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MINUTES - 11142006 - D.6
TO: BOARD OF SUPERVISORS Contra FROM: DENNIS M. BARRY, AICP 7 Costa COMMUNITY DEVELOPMENT DIRECTOR,- �� County • rq ioon'{'; DATE: NOVEMBER 14, 2006 SUBJECT: PROGRESS REPORT AND UPDATE ON THE EVALUATION OF POTENTIAL REGULATION OF MEDICAL MARIJUANA DISPENSARIES. (ALL SUPERVISORIAL DISTRICTS) SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION I. RECOMMENDATION A. ACCEPT the attached progress report and update on the evaluation of potential regulation of medical marijuana dispensaries. CONTINUED ON ATTACHMENT: X YES SIGNATURE RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S): ACTION OF BOARD ON I L( I a 0 (40 APPROVED AS RECOMMENDED ZC OTHER St Se e TE OF SUPERVISORS �V I HEREBY CERTIFY THAT THIS IS A TRUE AND UNANIMOUS(ABSENT) CORRECT COPY OF AN ACTION TAKEN AND AY NOES: ENTERED ON THE MINUTES OF THE BOARD OF ABSENT: ABSTAIN: SUPERVISORS ON THE DATE SHOWN Contact: Ruben Hernandez(925)335-1339 ATTESTED WPLAAo�(/l 0 JOHN CULLEN, CLERK OF TH BOAR OF Orig: Community Development Department SUPERVISORS AND COUNTY.ADMINI TRATOR cc: Sheriff-Coroner Office County Counsel Building Inspection Dept., Property Conservation Division BY Ax- 0 EPUTY Health Services Department District Attorney's Office Alcohol&Other Drugs Advisory Board via Health Services Dept. November 14, 2006 Board of Supervisors Evaluation on Permanent Regulation of Medical Marijuana Dispensaries Page 2 II. FISCAL IMPACT None. III. BACKGROUND In 1996, the voters of the State of California approved Proposition 215, the Compassionate Use Act of 1996, codified at Health and Safety Code Section 11362.5. The purpose of the Compassionate Use Act of 1996 is to enable persons with certain illnesses to obtain and use medical marijuana without fear of criminal prosecution. Subsequently, in 2003 the State Legislature adopted Senate Bill 420, which requires county health departments to establish a program for the issuance of identification cards to qualified patients and establish procedures under which a qualified patient with an identification card may use marijuana for medical purposes. In response to the opening of dispensaries within unincorporated Contra Costa County, the Board of Supervisors, at the March 7, 2006 hearing, directed the Community Development Department, in conjunction with the Office of County Counsel, the Sheriff- Coroner's Office, the Health Services Department, and the District Attorney's Office to begin researching and making recommendations regarding marijuana dispensaries. Pursuant to the provisions of Government Code Section 65858, on April 11, 2006, the Board of Supervisors adopted an urgency interim ordinance prohibiting the establishment of medical marijuana dispensaries in the unincorporated areas of the County (Ord. No. 2006-12). As an urgency measure, the ordinance became effective immediately and was effective for forty-five days, until May 26, 2006. Subsequently, as allowed by State law, on May 23, 2006, the Board of Supervisors adopted Ordinance No. 2006-17, which extended the period of the original Urgency Interim Ordinance an additional ten months and 15 days, to April 10, 2007. If additional time were needed to adopt permanent regulations, state law does permit the County the opportunity to extend the ordinance an additional year to April 10, 2008. The Board also requested that the Community Development Department return with a progress report. IV. MEDICAL MARIJUANA TASK FORCE Following the initial hearing on medical marijuana dispensaries (February 22, 2006), the Board directed Supervisor Piepho's office to work with Supervisor DeSaulnier's office, the Community Development Department, the District Attorney's Office, County Counsel, the Sheriffs Department, the Health Services Department, and other related departments to develop recommendations for permanent regulation of medical marijuana dispensaries within Contra Costa County. Since then the medical marijuana November 14, 2006 Board of Supervisors Evaluation on Permanent Regulation of Medical Marijuana Dispensaries Page`3 "Task Force" has held two meetings to discuss permanent regulation of medical marijuana dispensaries. Members of the medical marijuana community attended one of the meetings in order to provide input. Supervisor Piepho's office anticipates that the next "Task Force" meeting will be scheduled for December. V. ADDRESSING MEDICAL MARIJUANA DISPENSARIES Throughout the State a number of cities and counties have taken action regarding medical marijuana dispensaries. Many jurisdictions have adopted urgency interim ordinances prohibiting the establishment of dispensaries similar to the ones adopted by the Board in April and May of this year. Other jurisdictions have adopted permanent language or ordinances prohibiting or regulating the establishment of medical marijuana dispensaries. Within Contra Costa County, the only city that has adopted an ordinance allowing the establishment of dispensaries is the City of Martinez. According to staff at the Martinez Planning Department, no applications have been filed. Four cities have adopted permanent regulations prohibiting the establishment of dispensaries, and four other cities have adopted interim ordinances prohibiting dispensaries. A chart identifying the actions taken by the various cities within Contra Costa County has been attached as Attachment 'A'. A. Prohibiting Dispensaries - In response to the increased activity regarding the establishment of marijuana dispensaries throughout California, a number of jurisdictions throughout the State and within Contra Costa County have adopted permanent regulations addressing the issue of medical marijuana dispensaries. Jurisdictions have used different methods for permanently prohibiting the establishment of dispensaries. ➢ Some jurisdictions, such as the cities of Walnut Creek and San Ramon, have not taken any formal action, but have made a determination that a medical marijuana dispensary is a use that is not permitted within any zoning district and is a violation of Federal law, and is therefore prohibited. ➢ Other jurisdictions, such as the City of Concord, the City of Richmond and the City of San Pablo have adopted permanent zoning regulations prohibiting the establishment of medical marijuana dispensaries, or have added language to their existing ordinances prohibiting the establishment of any uses that are in violation of State and/or Federal law. ➢ Numerous concerns have been used by jurisdictions as the basis for prohibiting the establishment of dispensaries, including; November 14, 2006 Board of Supervisors Evaluation on Permanent Regulation of Medical Marijuana Dispensaries Page 4 ■ Higher crime rate, including robbery of facility and patrons, ■ Loitering near facility, ■ Increased drug use near facility, ■ Increased street sales of marijuana, ■ Cardholder fraud, ■ Abuse of medical marijuana, ■ Increased traffic, and ■ Potentially offensive odor. B. Regulating Dispensaries - In response to the passing of Proposition 215 and Senate Bill 420, a number of jurisdictions throughout the State have opted to regulate the establishment of medical marijuana dispensaries instead of prohibit them. As of November 1, 2006, eight (8) counties and twenty-three (23) cities within the State have adopted ordinances regulating the establishment of dispensaries. Locally, San Francisco, Santa Clara and Alameda Counties and cities such as Martinez, Oakland, Berkeley and San Jose have adopted permanent ordinances regulating the establishment of medical marijuana dispensaries. In order to obtain some input on how existing ordinances have been performing, staff contacted a few of the jurisdictions with adopted dispensary ordinances. According to those involved with the implementation of dispensary ordinances, the overall effectiveness of the regulations has been mostly positive, with minimal drawbacks. In some instances, such as in Oakland and San Francisco, the ordinances have been modified in order to address issues such as over concentration of medical marijuana facilities or the establishment of dispensaries in undesirable locations. In Alameda County, the Sheriff's Deputy responsible for approving and overseeing the establishment of the facilities, informed staff that there has been a slight increase in the amount of crime around one of the three facilities in Alameda County, mostly theft related. C. Existing Ordinances - All of the existing ordinances regulating dispensaries require approval of a conditional use permit prior to establishment. The application process, approval requirements and regulations vary between jurisdictions, but overall the existing ordinances are very similar. 1. Application Process - The application process, requirements and department responsible for review, approval and oversight of dispensaries varies between jurisdictions. ➢ Typical application procedures for dispensaries are similar to conditional use permit applications or alcohol sales permits, but November 14, 2006 Board of Supervisors Evaluation on Permanent Regulation of Medical Marijuana Dispensaries Page 5 some application requirements are more extensive than others (eg. background checks for owners/employees of dispensaries). ➢ Almost all of the existing ordinances require public notification and/or a public hearing, but some ordinances only require administrative approval. ➢ The lead department responsible for approval of the medical marijuana dispensary applications varies between jurisdictions. In some jurisdictions, such as Alameda County, the Sheriffs Department is responsible for processing, approving and regulating the dispensaries. In other jurisdictions, the Planning or Health Services Department is responsible for approval and regulation of dispensaries. Most of the existing ordinances require approval from more than one department. 2. Requirements/Restrictions - Most ordinances share similar requirements/restrictions for establishing dispensaries. For example, almost all of the existing dispensary ordinances have location restrictions and recently many jurisdictions have limited the total number of dispensaries allowed. ➢ Alameda County and the City of Berkeley allow only three dispensaries within their respective jurisdictions. ➢ All of the existing ordinances identify the specific zoning districts in which dispensaries can be established. Typically, dispensaries are permitted in commercial and industrial zoning districts and prohibited in residential, multi-family and agricultural zoning districts. ➢ In general, most existing ordinances restrict establishment of dispensaries within a certain distance (typically between 300 and 1,000 feet) of the following uses: • Schools (K-12) • Parks and Public Playgrounds • Religious Facilities • Other Dispensaries ➢ Other common conditions placed on dispensaries include restricted hours of operation, age restrictions, prohibition of November 14, 2006 Board of Supervisors Evaluation on Permanent Regulation of Medical Marijuana Dispensaries Page 6 smoking on-site and prohibition of retail sale of other goods such as pipes or paraphernalia. ➢ Some require special ventilation systems and allow little or no outdoor advertising. VI. ADDITIONAL INFORMATION Staff has provided a copy of this report to those members of the public who spoke at the previous Board hearings for the adoption of the medical marijuana urgency interim ordinance. ATTACHMENT IN STATUS OF MEDICAL MARIJUANA REGULATION FOR CITIES WITHIN CONTRA COSTA COUNTY* AS OF 10/31/06 gg 9 The� follo05ing cit es, hsae ado3pte�clpermanent ordinances g MIT 33 $ y a r 1 �bann►nq the establishment of�medicahman�uanad�spensanes • Richmond San Pablo • EI Cerrito Concord The ;follouungl c�#ies have adopted permanent ordinances e Matin. the estabhshrnent`ofined�cal Mari uana des ens'ar�es,' • Martinez z� AlT� �The�following c�t�es have adopted interim ord►nances prohi,b�ting theme estabtishrnento�f�med�`cal man uana dis ensaries. `' ' • Antioch Brentwood • Pleasant Hill Pinole 6`1 dw i n'gcine haven'ot takeany formal action regarding; ul 'wa RM the establishment of smed�calman�uana Adis ensarfesbut havelr. 7 � 3 ,� a3 r < indicatedthat rneducalmar�Juana d�spens�anes air=e note ra`� Federale�aWsern any�of their zoningd�stnctsanda�violaton of rfRomn- 1071 1,0 • Clayton Walnut Creek • San Ramon *Some cities have not been included because they have not taken any action or did not provide a response. ADDENDUM TO ITEM D.6 November 14, 2006 On this day, the Board of Supervisors considered accepting a progress report and update on the evaluation of potential regulation of medical marijuana dispensaries. Catherine Kutsuris, Community Development Department (CDD),presented this item, stating the County extended an interim Ordinance in May 2006 which restricted setting up new marijuana facilities in the unincorporated area of the County until the County evaluates the issue and decides on the adoption of regulations. She summarized progress on outstanding issues to consider regulating marijuana dispensaries. Supervisor Uilkema asked when this item would return to the Board again. Ms. Kutsuris said CDD would return to the Board in May 2007, and noted Supervisors from District III and IV had also held two meetings and that more meetings are proposed. She noted no time table has been set to return to the Board other than in May 2007. She said if there is no decision from that point State Law allows one more extension of the moratorium. Chair Gioia suggested replacing Supervisor DeSaulnier with another member on the Committee, as today is Supervisor DeSaulnier's last meeting as the acting Supervisor for District IV. Supervisor Piepho suggested the Body could appoint Susan Bonilla, Supervisor Elect District IV, to fill in for District IV. She said findings are being compiled within the Task Force for their next meeting to return to the Board with recommendations for further activity in the next month. Chair Gioia opened the meeting to public comment. The following people spoke: Lauren Unruh, Pleasant Hill resident, said she is representing minority religious groups and requested to be invited to the Task Force meetings. She spoke of medical marijuana being prohibited as a religious prohibition and said she is deeply hurt by this proposal; Joseph Partansky, Concord resident, requested handouts to be given to members of the Task Force and urged the Board to use the County of Marin as a model when finalizing the regulations for a marijuana dispensary; Armando Soto, Richmond resident, cited several areas where marijuana dispensaries are recognized as legal entities and said regulated dispensaries benefit the community by providing access for the seriously ill and injured. He handed the Board literature on Medical Cannabis Dispensing Collectives and Local Regulation by Americans for Safe Access; James Anthony, former Oakland City Attorney, noted the report quoted Richmond as an establishment banning medical marijuana dispensaries. He said Richmond failed to renew their moratorium and remains in the last category of cities that have not taken any action. Mr. Anthony encouraged the Task Force to take public and expert participation in the early stages of drafting marijuana regulation for cities within Contra Costa County. Chair Gioia said there could be two approaches that would dictate the detail - (a) prohibiting dispensaries; (b)regulating dispensaries with some form of land use permit process. He said the Task Force would discuss those two approaches and bring back to the Board analogous tracks but eventually it would be a policy decision of the Board. By a unanimous vote with District IV absent,the Board of Supervisors took the following action: ACCEPTED the progress report and update on the evaluation of potential regulation of medical marijuana dispensaries. REQUEST TO SPEAK FORM (THREE (3} MINUTE LIMIT) Complete this form and!place it in the box near the speakers' rostrum before addressing the Board. Name: I-et of 2l Phone: �T57 -9,?o Address: (t)Ql city: pre-66�4� (Address and phone number are optional;please note that this card will become a public record kept on-file— with the Clerk of the Board in association with this meeting) I am speaking for myself or organization: CHECK ONE: ❑ 1 wish to speak on Agenda Item # Date: My comments will be: VGeneral F] For 0 Against El I wish to speak on the subject of: 0 1 do not wish to speak but would like to leave these comments for the Board to consider: Please see reverse for instructions and important information REQUEST TO SPEAK FORM (THREE (3) MINUTE LIMIT) Comp to this form 'place it in the box near the speakers' rostrum before addressing the Board. Name: t Phoria: 2 _.2 �fi Address: U - / $ r City: dt� ._l (Address and hone number are optional,, le a note that this card will become a ublic r�ke t on 'le with the Clerk of the Board in'association with this meeting) I am speaki or myself or organization: CHE flNE: I wish to speak on Agenda Item it Date: My comments will be: ❑ General ❑ For ❑Against ❑ i wish to speak on the subject of: C1 1 do not wish to speak but would like to leave these comments for the Board to consider: Please see reverse for instructions and important information REQUEST TO SPEAK FORM (THREE (3) MINUTE LIMIT) Complete this form and `place it in the box near the speakers' rostrum before addressing the Board. Name: , r, W\E�,dt `; rte, Phone: Address: City: vn, tc�, (Address and phone number are optional;please note that this card will become-a public record kept on file with the Clerk of the Board in association with this meeting) I am speaking for myself_ or organization: CHECK ONE: I wish to speak on Agenda Item # Date: . t 1 t tf-n(,., My comments will be: l-General ❑ For ❑ Against ❑ I wish to speak on the subject of: ❑ I do not wish to speak but would like to leave these comments for the Board to consider: _.__ _ Plea,se see reverse for instructions and important information REQUEST TO SPEAK FORM (THREE (3) MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum before addressing the Board. Name: I dU rJ�gc>Ll Phone: 2 7— , �� j Address: `�`� city: CA <l—& (Address and phone number are ptional;please note that this card will become a public record kept on file with the Clerk of the Board in association with this meeting) /} I am speaking for myself or organization: 149A1 1 A1Q,6— CHEC . NE: / UK I wish to speak on Agenda Item # Date: 1 l 0 My comments will be: ❑ General L( For ❑ Against I I ❑ 1 wish to speak on the subject of: C❑ I do not wish to speak but would like to leave these comments for the Board to consider: i Please see reverse for instructions and important information REQUEST TO SPEAK FORM (THREE (3) MINUTE LIMIT) �7 ' Complete this form andplace it in the box near the speakers' rostrum before addressing the Board. Name: /�'/� '�` Phone: " ,✓ �_ ,`� Address::3City: (Address and phone number bre optional;please note that this card will become a public record kept on file with the Clerk of the Board in lassociation with this meeting) . I am speaking for myself or organization: _/ CHECK ONE: I ❑ 1 wish to speak on Agenda Item # Date: My comments will be: XGeneral ❑ For ❑ Against F1I wish to speak on the subject of: I do not wish to speak but would like to leave these comments for the Board to consider: Please see reverse for instructions and important information Americ fe Access • For • AN ORGANIZATION OF MEDICALPROFESSIONALS, 1 PATIENTS HELPING PATIENTS MEDICAL CANNABIS DISPENSING COLLECTIVES AND LOCAL REGULATION ii is lI �i } 9 (hy 1�f7{f i+ { 1 I LN AmericansFor SafeAccess Advancing Legal Medical Marijuana Therapeutics and Research Headquarters 1322 Webster Street,Suite 402,Oakland,California,94612 PHONE:510.251.1856 FAX:510.251.2036 National Office 1906 Sunderland Place,NW,Washington DC 20036 PHONE:202.857.4272 FAX:202.857.4273 WEB:www.AmericansForSafeAccess.org TOLL FREE:1.888.929.4367 MEaD,ICAL .CANI01I DISPENSING COLLECTIVES AND LOCAL REGULATION 2f0 O EXECUTIVE SUMMARY Introduction....................................................................................................................1 OVERVIEW Aboutthis Report...........................................................................................................3 About Americans for Safe Access..................................................................................3 The National Political Landscape...................................................................................3 History of Medical Cannabis in California....................................................................4 What is a Medical Cannabis Dispensing Collective......................................................4 Rationale for Medical Cannabis Dispensing Collectives ..............................................5 Medical Cannabis Dispensing Collectives are Legal Under State Law........................5 Why Patients Need Convenient Dispensaries...............................................................6 What Communities are Doing to Help Patients...........................................................6 IMPACT OF DISPENSARIES AND REGULATIONS ON COMMUNITIES Dispensaries Reduce Crime and Improve Public Safety...............................................7 Why Diversion of Medical Cannabis is Typically Not a Problem .................................8 Dispensaries Can Be Good Neighbors............................................................................8 BENEFITS OF DISPENSARIES TO THE PATIENT COMMUNITY Dispensaries Provide Many Benefits to the Sick and Suffering ................................10 Research Supports the Dispensary Model...................................................................11 Many Dispensaries Provide Key Social Services..........................................................11 Conclusion.....................................................................................................................13 APPENDIX A Recommendations on Dispensary Regulations...........................................................14 APPENDIX B Ordinance Evaluation Survey Questions.....................................................................18 APPENDIX C Survey Answer and Data Analyses..............................................................................19 APPENDIX D Mapsof Ordinances .....................................................................................................20 For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. fe Access Americans For • AN ORGANIZATION OF MEDICALPROFESSIONALS, 1 PATIENTS d \ California's original medical cannabis law, • offering a safer environment for patients the Compassionate Use Act (Prop. 215), than having to buy on the illicit market directs local officials to implement ways for • improving the health of patients through qualified patients to access their medicine. social support With the passage of state legislation (SB 420) • helping patients with other social in 2003, and the 2005 court ruling in People services, such as food and housing v. Urziceanu, medical cannabis dispensing • having a greater than average customer collectives (or dispensaries) are now satisfaction rating for health care recognized as legal entities. Since most of the more than 150,000 cannabis patients in Creating dispensary regulations combats I California (NORML 2005 estimate) rely on crime because: dispensaries for their medicine, communities . dispensary security reduces crime in the across the state are facing requests for vicinity business licenses or zoning decisions related . street sales tend to decrease to the operation of dispensaries. • patients and operators are vigilant • any criminal activity gets reported to Americans for Safe Access, the leading police ` national organization representing the interests of medical cannabis patients and Regulated dispensaries are: their doctors, has undertaken a study of the . legal under California state law experience of those communities that have . helping revitalize neighborhoods dispensary ordinances. The report that • bringing new customers to neighboring follows details those experiences, as related businesses by local officials; it also covers some of the • not a source of community complaints political background and current legal status of dispensaries, outlines important issues to This report concludes with a section consider in drafting dispensary regulations, outlining the important elements for local and summarizes a recent study by a officials to consider as they move forward University of California, Berkeley researcher with regulations for dispensaries. ASA has on the community benefits of dispensaries. worked successfully with officials in Kern In short, this report describes why: County, Los Angeles, San Francisco and elsewhere to craft ordinances that meet the Regulated dispensaries benefit the state's legal requirements, as well as the community by: needs of patients and the larger community. • providing access for the most seriously ill Please contact ASA if you have questions: and injured 888-929-4367. For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 1 OVERVIEW OF MEDICALDISPENSARIES "As the number of patients in the state of California who rely upon medical cannabis for their treatment continues to grow, it is increasingly imperative that cities and counties address the issue of dispensaries in our respective communities. In the city of Oakland we recognized this need and adopted an ordinance which balances patients'need for safe access to treatment while reassuring the community that these dispensaries are run right.A tangential benefit of the dispensaries has been that they have helped to j stimulate economic development in the areas where they are located." a —Desley Brooks, Oakland City Councilmember ABOUT THIS REPORT city and county officials are also considering Land-use decisions are now part of the imple- how to arrive at the most effective regulations for their community, ones that respect the mentation of California's medical marijuana, . or cannabis, laws. As a result, medical cannabis rights of patients for safe and legal access dispensing collectives (dispensaries) are the within the context of the larger community. subject of considerable debate by planning and other local officials. Dispensaries have ABOUT AMERICANS FOR SAFE ACCESS been operating openly in many communities Americans for Safe,Access (ASA) is the largest since the passage of Proposition 215 in 1996. national member-based organization of j As a compassionate, community-based patients, medical professionals, scientists and response to the problems patients face in try- concerned citizens promoting safe and legal ing to access cannabis, dispensaries are cur- access to cannabis for therapeutic uses and rently used by more than half of all patients in research. ASA works in partnership with state, the state and are essential to those most seri- local and national legislators to overcome bar- ously ill or injured. Since 2003, when the legis- riers and create policies that improve access to lature further implemented state law by cannabis for patients and researchers. We expressly addressing the issue of patient col- have more than 30,000 active members with lectives and compensation for cannabis, more chapters and affiliates in more than 40 states. dispensaries have opened and more communi- ties have been faced with questions about business permits and land use options. THE NATIONAL POLITICAL LANDSCAPE , A substantial majority of Americans support In an attempt to clarify the issues involved, safe and legal access to medical cannabis. Americans for Safe Access has conducted a public opinion polls in every part of the coun- t survey of local officials in addition to continu- try show majority support cutting across politi- ously tracking regulatory activity throughout cal and demographic lines. Among them, a the state. (safeaccessnow.org/regulations.) The Time/CNN poll in 2002 showed 80% national report that follows outlines some of the support; a survey of AARP members in 2004 j underlying questions and provides an showed 72% of older Americans support legal overview of the experiences of cities and access, with those in the western states polling counties around the state. In many parts of 82% in favor. California, dispensaries have operated respon- sibly and provided essential services to the This broad popular consensus, combined with most needy without local intervention, but an intransigent federal government which x For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 2 refuses to acknowledge medical uses for supported Proposition P, a ballot initiative cannabis, has meant that Americans have which recommended a non-enforcement poli- turned to state-based solutions. The laws vot- cy for the medical use, cultivation and distri- ers and legislators have passed are intended bution of marijuana. In 1992, citing both the to mitigate the effects of the federal govern- interests of their constituency and the ment's prohibition on medical cannabis by endorsement of therapeutic use by the allowing qualified patients to use it without California Medical Association, the San state or local interference. Beginning with Francisco Board of Supervisors adopted a res- California in 1996, voters passed initiatives in olution urging the mayor and district attorney eight states plus the District of Columbia— to accept letters from recommending physi- Alaska, Colorado, Maine, Montana, Nevada, cians (Resolution No. 141-98). In 1993, the Oregon, and Washington. State legislatures Sonoma Board of Supervisors approved a res- followed suit, with elected officials in Hawaii, olution mirroring a Senate Joint Resolution Maryland, Rhode Island, and Vermont taking passed earlier that year, noting that a UN action to protect patients from criminal penal- committee had called for cannabis to be ty, and the California legislature amending its made available by prescription and calling on voter initiative in 2003. "Federal and State representatives to support Momentum for these state-level provisions for returning [cannabis] preparations to the list of compassionate use and safe access has contin- available medicines which can be prescribed ued to build as more research on the thera- by licensed physicians" (Resolution No.93-1547). peutic uses of cannabis is published. And the Since 1996 when 56% of California voters public advocacy of well-known cannabis approved the Compassionate Use Act (CUA), patients such as the Emmy-winning talkshow public support for safe and legal access to host Montel Williams has also increased public medical cannabis has only increased. A awareness and created political pressure for statewide Field poll in 2004 found that "three compassionate state and local solutions. in four voters (74%) favors implementation of Twice in the past decade the U.S. Supreme the law. Voter support for the implementa- Court has taken up the question. In the most tion of Prop. 215 cuts across all partisan, ideo- recent case, Gonzales v. Raich, a split court logical and age subgroups of the state." upheld the ability of federal officials to prose- (field.com/fieldpolionlinetsubscribers/Rls2105.pdf) cute patients if they so choose, but did not Even before the release of that Field poll, overturn state laws. In the wake of that deci- state legislators recognized that there is both sion, the attorneys general of California, strong support among voters for implement- Hawaii, Oregon, and Colorado all issued legal ing the safe and legal access promised by the opinions or statements reaffirming their Compassionate Use Act (CUA) and little direc- state's medical cannabis laws. The duty of tion as to how local officials should proceed. state and local law enforcement is to the This led to the drafting and passage of Senate enforcement and implementation of state,- Bill 420 in 2003, which amended the CUA to not federal, law. spell out more clearly the obligations of local officials for implementation. HISTORY OF MEDICAL CANNABIS IN CALIFORNIA WHAT IS A CANNABIS DISPENSARY? Local officials and voters in California have The majority of medical marijuana (cannabis) recognized the needs of medical cannabis patients cannot cultivate their medicine for patients in their communities and have taken themselves or find a caregiver to grow it for action, even before voters made it legal in them. Most of California's estimated 200,000 1996. In 1991, 80% of San Francisco voters patients obtain their medicine from a Medical 1 For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 3 Cannabis Dispensing Collective (MCDC), often state, the California legislature enacted referred to as a "dispensary." Dispensaries are Senate Bill 420 in 2004, which expressly states typically storefront facilities that provide med- that qualified patients and primary caregivers ical cannabis and other services to patients in may collectively or cooperatively cultivate need.There are more than 200 dispensaries cannabis for medical purposes (Cal. Health & operating in California as of August 2006. Safety Code section 11362.775). This provision Dispensaries operate with a closed member- has been interpreted by the courts to mean ship that allow only patients and caregivers to that dispensing collectives, where patients obtain cannabis and only after membership is may buy their medicine, are legal entities approved (upon verification of patient docu- under state law. California's Third District mentation). Many dispensaries offer on-site Court of Appeal affirmed the legality of col- consumption, providing a safe and comfort- lectives and cooperatives in 2005 in the case able place where patients can medicate. An of People v. Urziceanu, which held that SB increasing number of dispensaries offer addi- 420, which the court called the Medical tional services for their patient membership, Marijuana Program Act (MMPA), provides col- including such services as: massage, acupunc- lectives and cooperatives a defense to mari- ture, legal trainings, free meals, or counseling. juana distribution charges. Drawing from the Research on the social benefits for patients is Compassionate Use Act's directive to imple- discussed in the last section of this report. ment a plan for the safe and affordable distri- bution of medical marijuana, the court found RATIONALE FOR CANNABIS DISPENSARIES that the MMPA and its legalization of collec- While the Compassionate Use Act does not tives and cooperatives represented the state government's initial response to this mandate. explicitly discuss medical cannabis dispen- By expressly providing for reimbursement for saries, it calls for the federal and state govern- marijuana and services in connection with col- lectives and cooperatives, the Legislature has the safe and affordable distribution of marl- abrogated earlier cases, such as Trippett, juana to all patients in medical need of mari- Peron, and Young, and established a new juana. (Health & Safety Code § 11362.5) This defense for those who form and operate col- portion of the law has been the basis for the lectives and cooperatives to dispense marijua- development of compassionate, community- na. (See People v. Urziceanu (2005) 132 based systems of access for patients in various Cal.App.4th 747, 33 Cal.Rptr.2d 859, 881.) parts of California. In some cases, that has meant the creation of patient-run growing This new case law parallels the interpretation collectives that allow those with cultivation of SB 420 provided to the League of Cities last expertise to help other patients obtain medi- year by Berkeley Assistant City Attorney cine. In most cases, particularly in urban set- Matthew J. Orebic, in his presentation tings, that has meant the establishment of "Medical Marijuana: The conflict between medical cannabis dispensing collectives, or dis- California and federal law and its effect on pensaries. These dispensaries are typically local law enforcement and ordinances." As he organized and run by groups of patients and states in that report: their caregivers in a collective model of patient- In the 2004 legislation, Section 11362.775 directed health care that is becoming a model ... expressly allow[s] medical marijuana to for the delivery of other health services. be cultivated collectively by qualified patients and primary caregivers, and by MEDICAL CANNABIS DISPENSARIES ARE necessary implication, distributed among LEGAL UNDER STATE LAW the collective's members... Under the col- In an effort to clarify the voter initiative of lective model, qualified patients who are 1996 and aid in its implementation across the unwilling or unable to cultivate marijuana For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 4 on their own can still have access to mari- Officials recognize their duty to implement juana by joining together with other quali- state laws, even in instances when they may fled patients to form a collective. not have previously supported medical Orebic also notes that the law allows for cannabis legislation. Duke Martin, mayor pro tem of Ridgecrest said during a city council those involved to "receive reimbursement for hearing on their local dispensary ordinance, services rendered in supplying the patient "it's something that's the law, and I will with medical marijuana." uphold the law." WHY PATIENTS NEED CONVENIENT DISPENSARIES "Because they are under strict city regulation, While some patients with long-term illnesses there is less likelihood of theft or violence and or injuries have the time, space, and skill to less opposition from angry neighbors. It is no cultivate their own cannabis, the majority in the state, particularly those in urban settings, longer a controversial issue in our city. i do not have the ability to provide for them- —Mike Rotkin, Santa Cruz selves. For those patients, dispensaries are the only option for safe and legal access. This is all the more true for those individuals who are This understanding of civic obligation was suffering from a sudden, acute injury or illness. echoed at the Ridgecrest hearing by Councilmember Ron Carter, who said, "I want Many of the most serious and debilitating to make sure everything is legitimate and injuries and illnesses require immediate relief. above board. It's legal. It's not something we A cancer patient, for instance, who has just can stop, but we can have an ordinance of begun chemotherapy will typically need regulations." immediate access for help with nausea, which is why a Harvard study found that 45% of Similarly, Whittier Planning Commissioner R.D. oncologists were already recommending McDonnell spoke publicly of the benefits of cannabis to their patients, even before it had dispensary regulations at a city government ( been made legal in any state. It is unreason- hearing. "It provides us with reasonable pro- able to exclude those patients most in need tections," he said. "But at the same time pro- simply because they are incapable of garden- vides the opportunity for the legitimate ing or cannot wait months for relief. operations." Whittier officials discussed the possibility of an i WHAT COMMUNITIES ARE DOING TO outright ban on dispensary operations, but Greg Nordback said, "It was the opinion of HELP PATIENTS our city attorney that you can't ban them; it's Many communities in California have recog- against the law. You have to come up with an i nized the essential service that dispensaries area they can be in." Whittier passed its dis- provide and have either tacitly allowed their pensary ordinance in December 2005. creation or, more recently, created ordinances or regulations for their operation. Dispensary Placerville Police Chief George Nielson com- regulation is one way in which the city can mented that, "The issue of medical marijuana exert local control over the policy issue and continues to be somewhat controversial in ensure the needs of patients and the commu- our community, as I suspect and hear it nity at large are being met. As of August remains in other California communities. The I 2006, twenty-six cities and seven counties issue of 'safe access' is important to some and have enacted regulations, and many more are not to others. There was some objection to considering doing so soon. See appendix D.) the dispensary ordinance, but I would say it was a vocal minority on the issue." For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 5 I IMPACT OF DISPENSARIES AND REGULATORY ORDINANCES CALIFORNIA ,.ON COMMUNITIES� IN DISPENSARIES REDUCE CRIME AND for their members and staff more seriously IMPROVE PUBLIC SAFETY than many businesses. Security cameras are Some reports have suggested that dispen- often used both inside and outside the prem- saries are magnets for criminal activity or ises, and security guards are often employed other behavior that is a problem for the com- to ensure safety. Both cameras and security munity, but the experience of those cities with guards serve as a general deterrent to crimi- dispensary regulations says otherwise. Crime nal activity and other problems on the street. - statistics and the accounts of local officials sur- Those likely to engage in such activities will veyed by ASA indicate that crime is actually tend to move to a less-monitored area, there- reduced by the presence of a dispensary. And by ensuring a safe environment not only for complaints from citizens and surrounding dispensary members and staff but also for businesses are either negligible or are signifi- neighbors and businesses in the surrounding cantly reduced with the implementation of area. local regulations. Residents in areas surrounding dispensaries This trend has led multiple cities and counties have reported improvements to the neighbor- E to consider regulation as a solution. Kern hood. Kirk C., a long time San Francisco resi- County, which passed a dispensary ordinance dent, commented at a city hearing, "I have in July 2006, is a case in point. The sheriff lived in the same apartment along the there noted in his staff report that "regulato_ Divisadero corridor in San Francisco for the ry oversight at the local levels helps prevent past five years. Each store that has opened in crime directly and indirectly related to illegal my neighborhood has been nicer, with many operations occurring under the pretense and new restaurants quickly becoming some of protection of state laws authorizing Medical the city's hottest spots. My neighborhood's Marijuana Dispensaries." Although dispensary- crime and vandalism seems to be going down related crime has not been a problem for the Year after year. It strikes me that the dispen- county, the regulations will help law enforce- saries have been a vital part of the improve- ment determine the legitimacy of dispensaries ment that is going on in my neighborhood." and their patients. Oakland's city administrator for the ordinance i The sheriff specifically pointed out that, regulating dispensaries, Barbara Killey, notes "existing dispensaries have not caused notice- that "The areas around the dispensaries may able law enforcement of secondary effects be some of the most safest areas of Oakland and problems for at least one year. Asa now because of the level of security, surveil- result, the focus of the proposed Ordinance lance, etc...since the ordinance passed." is narrowed to insure Dispensary compliance Likewise, Santa Rosa Mayor Jane Bender with the law" (Kern County Staff Report, noted that since the city passed its ordinance, Proposed Ordinance Regulating Medical there appears to be "a decrease in criminal Cannabis Dispensaries, July 11, 2006). activity. There certainly has been a decrease in The presence of a dispensary in the neighbor- complaints. The city attorney says there have hood can actually improve public safety and been no complaints either from citizens nor reduce crime. Most dispensaries take security from neighboring businesses." For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 4 6 Those dispensaries that go through the per- members are to behave in and around the mitting process or otherwise comply with dispensary. Many have "good neighbor" local ordinances tend, by their very nature, to trainings for their members that emphasize be those most interested in meeting commu- sensitivity to the concerns of neighbors, and nity standards and being good neighbors. all absolutely prohibit the resale of cannabis Cities enacting ordinances for the operation to anyone. Anyone violating that prohibition of dispensaries may even require security is typically banned from any further contact measures, but it is a matter of good business with the dispensary. practice for dispensary operators since it is in their own best interest. Many local officials surveyed by ASA said dispensaries operating "The areas around the dispensaries may be in their communities have presented no prob- lems, or what problems there may have been some of the most safest areas of Oakland now significantly diminished once an ordinance or because of the level of security, surveillance, other regulation was instituted. etc. since the ordinance passed." Mike Rotkin, fifth-term councilmember and —Barbara Killey, Oakland former four-term mayor in the City of Santa Cruz, says about his city's dispensary, "It pro- vides a legal (under State law) service for peo- As Oakland's city administrator for the regula- ple in medical need. Because it is well run and tory ordinance explains, "dispensaries them- well regulated and located in an area accept- selves have been very good at self policing able to the City, it gets cooperation from the against resale because they understand they local police. Because they are under strict city can lose their permit if their patients resell." regulation, there is less likelihood of theft or In the event of street or other resale, local law violence and less opposition from angry enforcement has at its disposal all the many .neighbors. It is no longer a controversial issue legal penalties the state provides. This all adds in our city." up to a safer street environment with fewer Regarding the decrease in complaints about drug-related problems than before dispensary existing dispensaries, several officials said that operations were permitted in the area. The ordinances significantly improved relations experience of the City of Oakland is a good with other businesses and the community at example of this phenomenon. The city's leg- large. An Oakland city council staff member islative analyst, Lupe Schoenberger, stated noted that they, "had gotten reports of break that, "...[P]eople feel safer when they're ins. That kind of activity has stopped . That walking down the street. The level of marijua- danger has been eliminated." na street sales has significantly reduced." Dispensaries operating with the permission of WHY DIVERSION OF MEDICAL CANNABIS the city are also more likely to appropriately IS TYPICALLY NOT A PROBLEM utilize law enforcement resources themselves, One of the concerns of public officials is that reporting any crimes directly to the appropri- dispensaries make possible or even encourage ate agencies. And, again, dispensary operators 1 the resale of cannabis on the street. But the and their patient members tend to be more experience of those cities which have institut- safety conscious than the general public, ed ordinances is that such problems, which resulting in great vigilance and better pre- are rare in the first place, quickly disappear. In emptive measures. The reduction in crime in addition to the ease for law enforcement of areas with dispensaries has been reported monitoring openly operating facilities, dispen- anecdotally by law enforcement in several saries universally have strict rules about how communities. For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 7 DISPENSARIES CAN BE GOOD NEIGHBORS about establishing it or running it." Medical cannabis dispensing collectives are Mark Keilty, Planning and Building director of i typically positive additions to the neighbor- Tulare, when asked if the existence of dispen- hoods in which they locate, bringing addition- saries affected local business, said they had al customers to neighboring businesses and no effect or at least no one has complained." reducing crime in the immediate area. And Dave Turner, mayor of Fort Bragg, noted Like any new business that serves a different that before the passage of regulations there customer base than the existing businesses in were "plenty of complaints from both neigh- the area, dispensaries increase the revenue of boring businesses and concerned citizens," other businesses in the surrounding area sim- but since then, it is no longer a problem. ply because new people are coming to access Public officials understand that, when it services, increasing foot traffic past other comes to dispensaries, they must balance both establishments. In many communities, the the humanitarian needs of patients and the opening of a dispensary has helped revitalize concerns of the public, especially those of an area. While patients tend to opt for dis- neighboring residents and business owners. pensaries that are close and convenient, par- ticularly since travel can be difficult, many patients will travel to dispensary locations in "Dispensaries themselves have been very good parts of town they would not otherwise visit. Even if patients are not immediately utilizing at self policing against resale because they the services or purchasing the goods offered understand they can lose their permit if their by neighboring businesses, they are more like- ly to eventually patronize those businesses patients resell." --Barbara Killey, Oakland because of convenience. ASA's survey of officials whose cities have Oakland City Councilmember Nancy J. Nadel passed dispensary ry reguIati ns found that the wrote in an open letter to her fellow col- vast majority of businesses adjoining or near leagues across the state, "Local government has a responsibility dispensaries had reported no problems associ- p y to the medical needs of its ated with a dispensary opening after the people, even when it's not a politically easy implementation of regulation. choice to make. We have found it possible to build regulations that address the concerns of Kriss Worthington, longtime councilmember neighbors, local businesses law enforcement in Berkeley, said in support of a dispensary and the general public, while not compromis- there, "They have been a responsible neigh- ing the needs of the patients themselves. bor and vital organization to our diverse com- We've found that by working with all inter- munity. Since their opening, they have done ested parities in advance of adopting an ordi- an outstanding job keeping the building clean, nance while keeping the patients' needs neat, organized and safe. In fact, we have had foremost, problems that may seem inevitable E no calls from neighbors complaining about never arise." them, which is a sign of respect from the com- munity. In Berkeley, even average restaurants Mike Rotkin of Santa Cruz stated that since and stores have complaints from neighbors." Santa Cruz enacted an ordinance for dispen- sary operations, "Things have calmed down. Mike Rotkin, fifth term councilmember and The police are happy with the ordinance, and former four term mayor in the City of Santa that has made things a lot easier. I think the Cruz said about the dispensary that opened fact that we took the time to give people there last year, "The immediately neighboring who wrote us respectful and detailed expla- businesses have been uniformly supportive or nations of what we were doing and why neutral. There have been no complaints either made a real difference." For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 8 BENEFITS OF DISPENSARIES TO THE PATIENT COMMUNITY DISPENSARIES PROVIDE MANY BENEFITS obtaining their medicine." TO THE SICK AND SUFFERING Oakland's city administrator for ordinances, Safe and legal access to cannabis is the reason said safe access to cannabis is "very impor- dispensaries have been created by patients tant" for the community. "In the finding the and caregivers around the state. For many council made to justify the ordinance, they people, dispensaries remove significant barri- say 'have safe and affordable access'." ers to their ability to obtain cannabis. Patients in urban areas with no space to cultivate And Mike Rotkin, the longtime Santa Cruz cannabis, those without the requisite garden- elected official, said that this is also an impor- ing skills to grow their own, and, most critical- tant matter for his city's citizens: "The council ly, those who face the sudden onset of a considers it a high priority and has taken con- serious illness or who have suffered a cata- siderable heat to speak out and act on the strophic illness—all tend to rely on dispen- issue." saries as a compassionate, community-based It was a similar decision of social conscience solution that is an alternative to potentially that lead to Placerville's city council putting a dangerous illicit market transactions. regulatory ordinance in place. Councilmember Many elected officials around the state recog- Marian Washburn told her colleagues that "as nize the importance of dispensaries for their you get older, you know people with diseases constituents. As Nathan Miley, former who suffer terribly, so that is probably what Oakland City councilmember and now get down to after considering all the other Alameda County supervisor said in a letter to components." his colleagues, "When designing regulations, While dispensaries provide a unique way for it is crucial to remember that at its core this is patients to obtain the cannabis their doctors a healthcare issue, requiring the involvement have recommended, they typically offer far and leadership of local departments of public more that is of benefit to the health and wel- health. A pro-active healthcare-based fare of those suffering both chronic and acute approach can effectively address problems medical problems. before they arise, and communities can design methods for safe, legal access to med- Dispensaries are often called "clubs" in part ical marijuana while keeping the patients' because many of them offer far more than a needs foremost." clinical setting for obtaining cannabis. Recognizing the isolation that many seriously Likewise, Abbe Land, mayor of West ill and injured people experience, many dis- Hollywood says safe access is "very impor- pensary operators chose to offer a wider array tant" and long-time councilmember John of social services, including everything from a Duran agreed, adding, "We have a very high place to congregate and socialize to help with number of HIV-positive residents in our area. finding housing and meals. The social support Some of them require medical marijuana to patients receive in these settings has far- offset the medications they take for HIV." reaching benefits that is also influencing the Jane Bender, mayor of Santa Rosa, says, development of other patient-based care "There are legitimate patients in our commu- models. nity, and I'm glad they have a safe means of I E For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 9 RESEARCH SUPPORTS THE DISPENSARY and very friendly. I enjoy coming." . MODEL "This is the friendliest dispensary that I have A 2006 study by Amanda Reiman, Ph.D. of the ever been to and the staff is always warm and School of Social Welfare at the University of open. That's why I keep coming to this place. California, Berkeley examined the experience The selection is always wide." of 130 patients spread among seven different dispensaries in the San Francisco Bay Area. Dr. Reiman's study cataloged the patients' demo- MANY DISPENSARIES PROVIDE KEY graphic information, health status, consumer SOCIAL SERVICES satisfaction, and use of services, while also Dispensaries offer many cannabis-related serv- F considering the dispensaries' environment, ices that patients cannot otherwise obtain. staff, and services offered. The study found Among them is an array of cannabis varieties, . that "medical cannabis patients have created some of which are more useful for certain a system of dispensing medical cannabis that afflictions than others, and staff awareness of also includes services such as counseling, what types of cannabis other patients report 9 to be helpful. In other words, one variety entertainment and support groups, all impor- p Y of tant components of coping with chronic ill- cannabis may be effective for pain control s ness." She also found that levels of while another may be better for combating satisfaction with the care received at dispen- nausea. Dispensaries allow for the pooling of saries ranked significantly higher than those information about these differences and the reported for health care nationally. opportunity to access the type of cannabis likely to be most beneficial. Patients who use the dispensaries studied uni- formly reported being well satisfied with the services they received, giving an 80% satisfac- tion rating. The most important factors for "There are legitimate patients in our patients in choosing a medical cannabis dis- community, and I'm glad they have a safe pensary were: feeling comfortable and secure, means of obtaining their medicine." familiarity with the dispensary, and having a rapport with the staff. In their comments, —Jane Bender, Santa Rosa patients tended to note the helpfulness and kindness of staff and the support found in the Other cannabis-related services include the presence of other patients. availability of cannabis products in other Patients in Dr. Reiman's study frequently cited forms than the smokeable ones. While most ! their relationships with staff as a positive fac- patients prefer to have the ability to modu- tor. Comments from six different dispensaries late dosing that smoking easily allows, for include: others, the effects of edible cannabis products are preferable. Dispensaries typically offer edi- "I love this spot because of the love they give, ble products such as brownies or cookies for always! They treat everyone like a family those purposes. Many dispensaries also offer loved one!" classes on how to grow your own cannabis, "This particular establishment is very friendly classes on legal matters,trainings for health- for the most part and very convenient for care advocacy, and other seminars. me." Beyond providing safe and legal access to "The staff and patients are like family to me!" cannabis, the dispensaries studied also offer important social services to patients, including ; f "The staff are warm and respectful." counseling, help with housing and meals, hos- "The staff at this facility are always cordial pice and other care referrals, and, in one case, For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 10 i co jK PA MY co a L lt� 3O i f� 2 x N p m J T M c- cosA Wr o wr c m? >' 3 0• a' o --� ca 0 0 N ' -c oT coo 3 I '+3 Cn Y CAy s i; '�� � fY 3 Sir+ � � a, p G r• '' �L- V r +f}�� cs Orill Lei �� �, 'Z ►'�' sa ta Q _ 0 3 0 -0 O b Q -� {ZD �p C Q 3 O CD CD < 3 C to O rp+ " O Q 0 Q Z@ �-CD , " 0 C6 M..nH Ln 0 r rt a O Q N O CDD ( O CD Q N o . i W -e S < CD Z o N � 6 c � — _ O .�. G► o°`ar � � R; �` 0-0 �`; �, Qom 3 =r � . 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Another component of Among the broader services the study found this model ... is the possible benefit that in dispensaries are support groups, including social support has for one diagnosed with groups for women, veterans, and men; cre- a chronic and/or terminal physical or psy- ativity and art groups, including groups for chological illness. Beyond the support that writers, quilters, crochet, and crafts; and medical cannabis patients receive from entertainment options, including bingo, open services is the support received from fellow mike nights, poetry readings, internet access, patients, some of whom are experiencing libraries, and puzzles. Clothing drives and the same or similar physical/psychological neighborhood parties are among the activi- symptoms.... It is possible that the mental ties that patients can also participate in health benefits from the social support of through their dispensary. fellow patients is an important part of the Social services such as counseling and support healing process, separate from the medici- groups were reported to be the most com- nal value of the cannabis itself. monly and regularly used service, with two- Several researchers and physicians who have thirds of patients reporting that they use studied the issue of the patient experience social services at dispensaries 1-2 times per with dispensaries have concluded that there week. Also, life services, such as free food are other important positive effects stemming and housing help, were used at least once or from a dispensary model that includes a com- twice a week by 22% of those surveyed. ponent of social support groups. Dr. Reiman notes that, "support groups may have the ability to address issues besides the "Local government has a responsibility to the illness itself that might contribute to long- medical needs of its people, even when it's not term physical and emotional health outcomes, a politically easy choice to make.We have found such as the prevalence of depression among the chronically ill." it possible to build regulations that address the For those who suffer the most serious illness, concerns of neighbors, local businesses law such as HIV/AIDS and terminal cancer, these enforcement and theeneral public,while not groups of like-minded people with similar compromising the needs off the patients g conditions can also help patients through the grieving process. Other research into the themselves.We've found that by working with patient experience has found that many all interested parities in advance of adopting an patients have lost or are losing friends and partners to terminal illness. These patients ordinance while keeping the patients needs report finding solace with other patients who foremost, problems that may seem inevitable are also grieving or facing end-of-life deci- never arise." —Nancy Nadel, Oakland sions. A medical study published in 1998 con- cluded that the patient-to-patient contact associated with the social club model was the Dispensaries offer chronically ill patients even best therapeutic setting for ill people. more than safe and legal access to cannabis and an array of social services. The study found that dispensaries also provided other social benefits for the chronically ill, an impor- tant part of the bigger picture: [T]he multiple services provided by the For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 11 i ,,,_CONCLUSION Dispensaries are proving to be an asset to the medicine their doctors recommend: the most communities they serve, as well as the larger seriously ill and injured. Many dispensaries community within which they operate. also offer essential services to patients, such as ASA's survey of local officials and monitoring help with food and housing. of regulatory activity throughout the State of Medical and public health studies have also California has shown that, once working reg- shown that the social-club model of most dis- ulatory ordinances are in place, dispensaries pensaries is of significant benefit to the over- are typically viewed favorably by public off i- all health of patients. The result is that cials, neighbors, businesses, and the communi- cannabis patients rate their satisfaction with ty at large, and that regulatory ordinances dispensaries as far greater than the customer- can and do improve an area, both socially and satisfaction ratings given to health care agen- economically. cies in general. Dispensaries - now expressly legal under Public officials across the state, in both urban California state law- are helping revitalize and rural communities where dispensary reg- neighborhoods by reducing crime and bring- ulatory ordinances have been adopted, have ing new customers to surrounding businesses. been outspoken in praise of what. Their com- They improve public safety by increasing the ments are consistent on and favorable to the security presence in neighborhoods, reducing regulatory schemes they enacted and the illicit market marijuana sales, and ensuring benefits to the patients and others living in that any criminal activity gets reported to the their communities. appropriate law enforcement authorities. As a compassionate, community-based More importantly, dispensaries benefit the response to the medical needs of more than community by providing safe access for those 150,000 sick and suffering Californians, dis- who have the greatest difficulty getting the pensaries are working. For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 12 ,,,APPENDIX A RECOMMENDATIONS ON DISPENSARY adopts a motion approving the nomination or on REGULATIONS the 41st day following the date the mayoral nomi- Cannabis dispensaries have been operating suc- nation was transmitted to the Clerk of the City cessfully around California for a decade with very Council if the City Council fails to act upon the few problems. But since the legislature and courts nomination prior to such date. have acted to make their legality a matter of state Of the three members nominated by the Mayor, law more than local tolerance,the question of the Mayor shall nominate one member to repre- how to implement appropriate zoning and busi- sent the interests of City neighborhood associa- ness licensing is coming before local officials all tions or groups, one member to represent the across the state.What follows are recommenda- interests of medical marijuana patients, and one tions on matters to consider, based on adopted member to represent the interests of the law code as well as ASA's extensive experience work- enforcement community. ing with community leaders and elected officials. Of the four members of the commission appoint- ed by the City Council, two members shall repre- COMMUNITY OVERSIGHT sent the interests of City neighborhood In order to appropriately resolve conflict in the associations or groups, one member shall repre- community and establish a process by which com- sent the interests of the medical marijuana com- plaints and concerns can be reviewed, it can often munity, and one member shall represent the be helpful to create a community oversight com- interests of the public health community. mittee. Such committees, if fair and balanced, can provide a means for the voices of all affected par- DISPENSARIES REGULATIONS ARE BEST ties to be heard, and to quickly resolve problems. HANDLED THROUGH THE HEALTH OR The Ukiah City Council created such a task force in PLANNING DEPARTMENTS, NOT LAW 2005;what follows is how they defined the group: ENFORCEMENT AGENCIES The Ukiah Medical Marijuana Review and Reason:To ensure that qualified patients, care- Oversight Commission shall consist of seven mem- givers, and dispensaries are protected, general reg- bers nominated and appointed pursuant to this ulatory oversight duties—including permitting, section.The Mayor shall nominate three members record maintenance and related protocols— to the commission, and the City Council shall should be the responsibility of the local depart- appoint, by motion, four other members to the ment of public health (DPH) or planning depart- commission. Each nomination of the Mayor shall ment. Given the statutory mission and be subject to approval by the City Council, and responsibilities of DPH, it is the natural choice and shall be the subject of a public hearing and vote best-suited agency to address the regulation of within 40 days. If the City Council fails to act on a medical cannabis dispensing collectives. Law mayoral nomination within 40 days of the date enforcement agencies are ill-suited for handling the nomination is transmitted to the Clerk of the such matters, having little or no expertise in health City Council, the nominee shall be deemed and medical affairs. approved. Appointments to the commission shall become effective on the date the City Council For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 13 Examples of responsible agencies and RESTRICTIONS ON WHERE DISPENSARIES officials: CAN LOCATE ARE OFTEN UNNECESSARY •Angels Camp—City Administrator AND CAN CREATE 13ARRIERS TO ACCESS •Atascadero—Planning Commission Reason:As described in this report, regulated dis- • Citrus Heights—City Manager pensaries do not generally increase crime or bring • Los Angeles—Planning Department • Plymouth—City Administrator other harm to their neighborhoods, regardless of • San Francisco—Department of Public Health where they are located.And since for many • Selma—City Manager patients travel is difficult, cities and counties •Visalia—City Planner should take care to avoid unnecessary restrictions on where dispensaries can locate. Patients benefit ARBITRARY CAPS ON THE NUMBER OF from dispensaries being convenient and accessible, DISPENSARIES CAN BE COUNTER- especially if the patients are disabled or have con- PRODUCTIVE ditions that limit their mobility. Reason: Policymakers do not need to set arbitrary It is unnecessary and burdensome for patients and limitations on the number of dispensing collectives dispensaries,to restrict dispensaries to industrial allowed to operate because, as with other services, corners, far away from public transit and other competitive market forces and consumer choice services. Depending on a city's population density, will be decisive. Dispensaries which provide quality it can also be extremely detrimental to set exces- care and patient services to their memberships will sive proximity restrictions(to schools or other facil- flourish, while those that do not will fail. ities)that can make it impossible for dispensaries to locate anywhere within the city limits. It is Capping the number of dispensaries limits con- important to balance patient needs with neigh- sumer choice, which can result in both decreased borhood concerns in this process. quality of care and less affordable medicine. Limiting the number of dispensing collectives allowed to operate may also force patients with PATIENTS BENEFIT FROM ON-SITE limited mobility to travel farther for access than CONSUMPTION AND PROPER they would otherwise need to. VENTILATION SYSTEMS Artificially limiting the supply for patients can Reason: Dispensaries that allow members to con- result in an inability to meet demand, which in sume medicine on-site have positive psychosocial turn may lead to such undesirable effects as lines health benefits for chronically ill people who are outside of dispensaries, increased prices, and lower otherwise isolated. On-site consumption encour- quality medicine. ages dispensary members to take advantage of the support services that improve patients' quality Examples of cities and counties without of life and, in some cases, even prolong it. numerical caps on dispensaries: Researchers have shown that support groups like • Dixon those offered by dispensaries are effective for • Elk Grove patients with a variety of serious illnesses. • Fort Bragg Participants active in support services are less anx- • Placerville ious and depressed, make better use of their time • Ripon and are more likely to return to work than • Selma patients who receive only standardized care, •Tulare regardless of whether they have serious psychiatric • Calaveras County • Kern County symptoms. On-site consumption is also important • Los Angeles County for patients who face restrictions to off-site con- • City and County of San Francisco sumption, such as those, in subsidized or other housing arrangements that prohibit smoking. In addition, on-site consumption provides an oppor- For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 14 tunity for patients to share information about Health and Safety Code, a health care facility effective use of cannabis and to use specialized licensed pursuant to Chapter 2 of Division 2 of the delivery methods, such as vaporizers, which do not Health and Safety Code, a residential care facility require smoking. for persons with chronic life-threatening illness Examples of localities that permit on-site licensed pursuant to Chapter 3.01 of Division 2 of consumption (many stipulate ventilation require- the Health and Safety Code, residential care facili- ments): ty for the elderly licensed pursuant to Chapter 3.2 of Division 2 of the Health and Safety Code, a resi- • Berkeley dential hospice, or a home health agency licensed • San Francisco •Alameda County pursuant to Chapter 8 of Division 2 of the Health • Kern County and Safety Code, as long as any such use complies • Los Angeles County strictly with applicable law including, but not limit- ed to, Health and Safety Code Section 11362.5 et DIFFERENTIATING DISPENSARIES FROM PRIVATE seq., or a qualified patient's or caregiver's place of PATIENT COLLECTIVES IS IMPORTANT residence. Reason: Private patient collectives, in which sever- al patients grow their medicine collectively at a PATIENTS BENEFIT FROM ACCESS TO EDIBLES AND private location, should not be required to follow MEDICAL CANNABIS CONSUMPTION DEVICES the same restrictions that are placed on retail dis- Reason: Not all patients smoke cannabis. Many pensaries, since they are a different type of opera- find tinctures(cannabis extracts) or edibles(such as tion.A too-broadly written ordinance may baked goods containing cannabis)to be more inadvertently put untenable restrictions on individ- effective for their conditions.Allowing dispen- ual patients and caregivers who are providing saries to carry these items is important to patients either for themselves or a few others. getting the best level of care possible. For patients who have existing respiration problems or who Example: Santa Rosa's adopted ordinance, provi- otherwise have an aversion to smoking, edibles cion 10-40.030 (F): are essential. Conversely, for patients who do "Medical cannabis dispensing collective," here- choose to smoke or vaporize, they need to procure inafter "dispensary," shall be construed to include the tools to do so. Prohibiting dispensaries from any association, cooperative, affiliation, or collec- carrying medical cannabis consumption devices, tive of persons where multiple "qualified patients" often referred to as paraphernalia, forces patients and/or "primary care givers," are organized to to go elsewhere to procure these items. provide education, referral, or network services, Additionally, when dispensaries do carry these and facilitation or assistance in the lawful, "retail" devices, informed dispensary staff can explain their distribution of medical cannabis. "Dispensary" usage to new patients. means any facility or location where the primary Examples of localities allowing dispensaries purpose is to dispense medical cannabis(i.e., mari- to carry edibles and delivery devices • juana) as a medication that has been recommend- • ed by a physician and where medical cannabis is •Angels Camp made available to and/or distributed by or to two • Berkeley or more of the following: a primary caregiver • Citrus Heights • and/or a qualified patient, in strict accordance Santa Cruz• Sutter Creek with California Health and Safety Code Section .West Hollywood 11362.5 et seq. A "dispensary" shall not include •Alameda County dispensing by primary caregivers to qualified • Kern County patients in the following locations and uses, as • Los Angeles County long as the location of such uses are otherwise regulated by this Code or applicable law: a clinic licensed pursuant to Chapter 1 of Division 2 of the For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 15 ,.APPENDIX B MEDICAL CANNABIS DISPENSARY ORDINANCE EVALUATION SURVEY QUESTIONS 1. What is your name and position? 9. How many medical cannabis dispensaries are there now?What is the estimated popula- tion of the area that may utilize them? Do 2. How important is safe access to medical you think the current number of dispensaries marijuana in your community? is enough to address the needs of the com- munity? 3. On what date did your city/county pass its ordinance? 10. Has there been an increase or decrease in criminal activity related to dispensaries since the regulations were implemented? 4. Were there medical cannabis dispensaries in your district before the ordinance? How many? 11. How has the ordinance improved the public safety in your community? Has it wors- ened the public safety? How? 5. If any, were there any complaints against them before the ordinance was passed? If yes, who made the complaints?What were the 12. Has the existence of dispensaries affect- specific complaints that were made? How fre- ed local business? How do neighboring busi- quently were complaints made? nesses view dispensaries? 6. Were there any objections to passing an 13. What would you advocate be changed ordinance to regulate medical cannabis dis- in the current regulations? pensaries? 14. Do you have anything else you would 7. If so, what were the primary objections? like to say in evaluation of the medical Who were the main objectors? cannabis ordinance? 8. Has the ordinance implementation allayed or amplified those concerns? For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 16 „ .APPENDIX C SURVEY ANSWER AND DATA ANALYSIS • Objections to the ordinance were allayed Summary after implementation. • The majority of responses were positive. • Regulation improved public safety. • Safe access is important to every • Crime decreases or shows no effect affect after regulations community. • Most businesses are either supportive of • Complaints of dispensaries generally or neutral about neighboring dispensaries. decrease after regulation. o = o E E cu C o fn � -ffif N @ 8- O O _” 0 .O Z N N D N C CQ � � C O N N N � .D X N U N 7 (S3 o 'a o iu E E N N N M U N U 7 O C O O N = C C C t6 C t0 l9 00 -0 '0ao v � � r n v o CrtM a Fort Bragg Yes No Neutral Oakland Yes No Neutral Placerville Yes No Neutral San Francisco d Yes No Neutral Santa Cruz Yes No Neutral Santa Rosa Yes No Neutral Tulare Yes No Neutral West Hollywood Yes 14 1 No Neutral 17 California Cities Allowing for and Regulating Dispensaries - i I {. ------- i------------- Fort Bragg o ` r' Chrus,Heights tPlacerville -�—o-\ o Santa Rose(� o Dixon- Plyinoah,,_�,.Sutter Creek p i \�--•� l\ Elk Grove i 0 MartmeiN_ � Jackson Berkeley,-, Y� '���f..t o 1-'...., o— ?( Oakland Angels Camp `s \\oHaywardi /. Ripon San Francisco's - t oSan Jose —----` \ Santa Cruz `\ •\Z \ Selma o i •.,\ \� ----- oVisalia Tulare � \ oAtascadew", �\ t, 1 West Hollywood -----i o Whittier i As of October 2006 For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 18 California Cities with Dispensary Bans J \usanville t' Yuba Citj �� Lincoln-` f v\ 4,Davi �olsom \ \,Hercules, San Rafaek '1 •S •-�Cdncord IN \ EI Cerrito •' jInion City �•Mo\esto South San Francisco; ��• ��/ t \ ��,, \ r�-"�Fremont Newbrrk� l s Banos_,--" j /< Cmis 5 1 Rosedale �- RsrrrolBeach --' • \\ Hesperia `. Pasadena* r---� EI Cerrito__- !` Torrance• i • Costa Mea M Orieta ��� �\1' "�-•-Temecula-- � N \ As of October 2006 For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 19 California Cities with Dispensary Moratoriums I I Willits / • l v 1 Ukiah r �---•__ LClearlake7 • r_; HealdsbUrg\ s� -'� r r }\ \W dsdr l` \1•/'� Rancho Cordova Sebastopol, • --7. / • �• (Antioch yyf • Fairfield I—' Galt Rohnert Park "` \ • { �...• � San Pablo Pinole`-+3 _,Oakley 00- Mill Valley---- d •�t `P�asanCHiu Manteca .Riverbank Marin City.'.� 3anrl-eendr� `•• fryCeres Sausalito ��' '�_ 11 •♦ • Toi k • Patterson / f� Peasnton-- M�gpta -Newman'^lam'' \7 \ \ \ IL.ivermore� ` `\ •Marina 1 \ Seasid1`e \ �- �Ridgecrest \1 \ /Arroyo Grande San Luis Obispo - 1,., IndusVy /o . `} Santa Clarita EI Monte, I } Grover Beach Maria Mena.,,, J I Ontario ill Moorpark�;— i rPomona /Corona Redlands Lomp c• BBuellton \ j Solvang % - —_._._.,�`^•� /Palm Springs ) Carpinteria--- ��. ••Pico Rivera,) •' _ La Mirada Ii 0 I •r •„ ._ ...--.—.- Jlndian Wells '{ '__� "L•. _-,� ,�•• �--- r Simi Valley _-:_�-- - "- \, •--1�f e o �• Malibu--`-"�— Hawthorne /p„�•�, \ Placentia •Lawndale •\ I � Hermosa Beach L I \�\ ��"Lake Foresi'Sa n Jacinto Palm Desert N Redondo Beach. a `Mission Wiejo P J• 'Long Beach Newport Beach Hawalian Gardens As of October 2006 For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 20 California Counties with Moratoriums, Bans and Ordinances I 1 ----------- / 4 r.----- Sutter .• EI Dorado Sonoma Amador- �-\• Sacramento _J- \Calaveras \ \.� l Contra Costa �� M1 \Alameda /' 1 Santa Clara) - Merced ) �< -4 r� z ,ft A San Luis Obispo �- Kern 1 Santa Barbara Los Angeles Riverside Legend N 0 Bans Moratoria - 0 Ordinances — I As of October 2006 For more information,see www.AmericansForSafeAccess.org or contact the ASA office at 1-888-929-4367 or 510-251-1856. 21 e LAmericansFor SafeAccess F O U N D A T I O N Advancing legal Medical Marijuana Therapeutics and Research ©Copyright 2006 Americans for Safe Access.All rights reserved. www.AmericansForSafeAccess.org 1-888-929-4367 CANCER AND MEDICAL MARIJUANA =-4 9-s C.A N S z o aPxa s y SJJtl 0� Americans for Safe Access �r A Note from Americans for Safe Access We are committed to ensuring safe, legal availability of marijuana for medical uses. This brochure is intended to help doctors, patients and policymakers bet- ter understand how marijuana -- or "cannabis" as it is more properly called -- may be used as a treatment for people with serious medical conditions. This booklet contains information about using cannabis as medicine. In it you'll find information on: Why Cannabis is Legal to Recommend .. ....................3 Overview of the Scientific Research on Medical Cannabis ......4 Research on Cannabis and Cancer ..........................6 Comparison of Medications: Efficacy and Side-Effects ........10 Why Cannabis is Safe to Recommend ......................13 Testimonials of Patients and Doctors .......................14 History of Cannabis as Medicine ..........................20 Scientific and Legal References............................24 The federal prohibition on cannabis has limited modern clinical research. But the documented history of safe, medical use of cannabis dates to 2700 B.C. Cannabis was part of the American pharmacopoeia until 1942 and is currently available by prescription in the Netherlands, and soon in Canada. Testimonials from doctors and patients tell something of the experience of using cannabis therapies, and supporting statements from professional health organi- zations and leading medical journals testify as to its legitimacy. This brochure is intended to be a starting point for the consideration of applying cannabis therapies to specific conditions. It is not intended to,replace the train- ing and expertise of physicians or attorneys. But as patients, doctors and advo- cates who have been working intimately with these issues for many years, Americans for Safe Access has seen firsthand how helpful cannabis can be for a wide variety of indications. We know doctors want the freedom to practice med- icine and patients the freedom to make decisions about their healthcare. For more information about ASA and the work we do,please see our website at SAFEACCEssNow.oRG or call 1-888-929-4367. 2 i Is Cannabis Legal to Recommend? i In 2004, the United States Supreme Court upheld earlier federal court decisions that doctors have a fundamental Constitutional right to recommend cannabis to their patients. I The history. Within weeks of California voters.legalizing medical cannabis in 1996,federal officials had threatened to revoke the prescribing privileges of any physicians who recommended cannabis to their patients for medical use.' In response, a group of doctors and patients led by AIDS specialist Dr. Marcus Conant filed suit against the government, contending that such a policy violates the First Amendment? The federal courts agreed at first the district level,'then all the way through appeals to the Ninth Circuit and then the Supreme Court. j What doctors may and may not do. In Conant v. Walters,' the Ninth Circuit Court of Appeals held that the federal government could neither punish nor { threaten a doctor merely for recommending the use of cannabis to a patient! But it remains illegal for a doctor to "aid and abet" a patient in obtaining cannabis.' This means a physician may discuss the pros and cons of medical cannabis with any patient, and issue a written or oral recommendation to use cannabis without fear of legal reprisal.' This is true regardless of whether the physician antici- pates that the patient will,in turn,use this recommendation to obtain cannabis.' What physicians may not do is actually pre- scribe or dispense cannabis to a patient'or tell patients how to use a written recommendation to procure it from a cannabis club or dispen- sary.'° Doctors can tell patients they may be helped by cannabis.They can put that in writ- i ing. They just can't help patients obtain the - � s cannabis itself. F4� J Patients protected under state, not federal, law. In June 2005, the U.S. Supreme Court . overturned the Raich v Ashcroft Ninth Circuit i Court of Appeals decision. In reversing the lower court's ruling, Gonzales v Raich estab- lished stab lished that it is legal under federal law to pros- ecute patients who possess, grow, or consume Angel Raich &Dr. Frank Lucido medical cannabis in medical cannabis states.However,this Supreme Court decision does not overturn or supercede the laws in states with medical cannabis programs. For assistance with determining how best to write a legal recommendation for cannabis, or additional information about the Supreme Court's decision, please contact Americans for Safe Access at 1-888-929-4367. 3 3 Scientific Research Supports Medical Cannabis s Between 1840 and 1900, European and American medical journals published more than 100 articles on the therapeutic use of the drug known then as Cannabis indica(or Indian hemp)and now as cannabis.Today, new studies are being pub- lished in peer-reviewed journals that demonstrate cannabis has medical value in treating patients with such serious illnesses as AIDS,glaucoma,cancer,multiple sclerosis, epilepsy,and chronic pain. f i The safety of the drug has been attested to by numerous studies and reports, E including the LaGuardia Report of 1944, The Schafer Commission Report of 1972, the Institutes of Medicine report of 1999, a 1997 study conducted by the British House of Lords, research sponsored by Health Canada, and numerous studies conducted in the INSTITUTES OF I MEDICINE Netherlands, where cannabis has been quasi- "Nausea, appetite loss, pain and anxiety . . legal since 1976 and is cur- all can be m I itigated by marijuana.... For rently available from Phar- patients, such�as those with AIDS or under- macies by prescription. going chemotherapy, who suffer simultane- Recent published research ously from �severe pain, nausea, and on CD4 immunity in AIDS appetite loss, canna-binoid drugs might offer patients found no compro- broad spectrum relief not found in any other single medicat I ion.- mise to the immune sys- tems of patients undergoing Marijuana and Medicine: cannabis therapy in clinical As I sessing the Science Base, 1999 trials." The use of medical cannabis has been endorsed by numerous professional organizations, including the American Academy of Family Physicians, the American Public Health Association, and the American Nurses Association.Its use is supported by such leading medical publications as The New England Journal of Medicine and The Lancet. RECENT RESEARCH ADVANCES. While research has until recently been sharply limited by federal prohibition,the last few years have seen rapid change. The International Cannabinoid Research Society was formally incorporated as a - j scientific research society in 1991. Membership in the Society has more than tripled from about 50 members in the first year to over 230 in 2003. i I The International Association for Cannabis as Medicine(IACM)was founded in March 2000. It publishes a bi-weekly newsletter and the IACNf-Bulletin. For the last three years Haworth Press has published the peer-reviewed Journal of Cannabis Therapeutics. 4 The University of ----< California established the Center for Medicinal Cannabis - .-,i Studies in 2001.It cur- / E rently has 14 studies in progress and four others awaiting state f ) and federal approval, € t including studies of ° r cancer pain, nausea control in chemothera- py, general analgesia and a proposed study on refractory cancer pain. t LLQ, In the United King- dom, GW Pharma- ceuticals has been granted a clinical trial exemption certificate by the Medicines Control Agency to conduct clinical studies with cannabis-based medicines, including the sublingual spray Sativex®. The exemption includes investigations in the relief of pain of neurological origin and defects of neurological function in the following indications: multiple sclerosis(MS), spinal cord injury,peripheral nerve injury, central nervous system damage, neuroinvasive cancer, dystonias, cerebral vascular accident and spina bifida, as well as for the relief of pain and inflammation in rheumatoid arthritis and also pain relief in brachial plexus injury. Health Canada granted regulatory approval for Sativex®for the treatment of MS in April 2005, and the drug will soon be on the shelves in Canada. The phase II trials provided positive results and confirmed an excellent safety profile for cannabis-based medicines. In 2002, GW conducted five phase III trials of its cannabis derivatives, including a double-blind, placebo-controlled trial with a sublingual spray containing High THC in more than 100 patients with cancer pain. In total, more than 1,000 patients are currently involved in phase III trials in the UK. GW Pharmaceuticals received an IND approval to commence phase II clinical trials in Canada in patients with chronic pain,multiple sclerosis and spinal cord injury in 2002. Following meetings with the FDA,DEA,the Office for National Drug Control Policy, and the National Institute for Drug Abuse, GW was grant- ed an import license from the DEA and has imported its first cannabis extracts into the U.S. Pre-clinical research with these extracts in the U.S. is ongoing. 5 J CANNABIS AND CANCER Cannabis has been found to help cancer patients with pain and nausea,and recent E research indicates it has tumor-reducing properties as well. It has proven highly effective at controlling the nausea associated with chemotherapy, and its appetite-stimulation properties help combat wasting. Cannabis can help control the pain associated with radiation and chemotherapy,as well as the disease itself Also,cannabinoids have been shown to have tumor-reducing properties for many types of cancer. Cannabis and chemotherapy side effects Using cannabis and drugs made from the cannabinoids it contains to treat the side effects of cancer chemotherapy has been more widely studied than many other potential therapeutic applications. Numerous clinical studies have reported that the use of cannabis reduces nausea and vomiting and stimulates appetite, there- by reducing the severity of cachexia,or wasting syndrome, in patients receiving y chemotherapy treatment. The 1999 Institutes of Medicine report concluded: "In patients already experi- encing severe nausea or vomiting, pills are generally ineffective, because of the difficulty in swallowing or keeping a pill down,and slow onset of the drug effect. Thus an inhalation(but,preferably not smoking)cannabinoid drug delivery sys- tem would be advantageous for treating chemotherapy-induced nausea."" A 1997 inquiry by the British Medical Association found cannabis more effec- tive than Marinol, and a 1998 review by the House of Lords Science & Technology Select Committee concluded that "Cannabinoids are undoubtedly effective as anti-emetic agents in vomiting induced by anti-cancer drugs. Some users of both find cannabis In 2003 itself more effective.""'^ passed a resolution that supports those health care I providers who recommend In the last three years,there medicinal use, recognizes "the right of have been major advances patients to ha I ,Ve safe access to therapeutic in both cannabinoid phar- marijuana/ca6, nabis," and calls for more and in under- research and education, as well as a of the cancer dis- rescheduling of marijuana for medical use. process. In particular, research has demonstrated the presence of numerous cannabinoid receptors in the nucleus of the solitary tract, a brain center impor- tant in control of vomiting. 6 Although other recentlyn developed anti-emetics are � N as effective or more effec- tive than oral THC, nabilone or smoked cannabis, for certain indi- viduals unresponsive to conventional anti-emetic drugs, the use of smoked cannabis can provide relief more effectively than oral preparations which may be difficult to swallow or be vomited before taking effect, as the IOM report ' notes. The psychoactive/euphori- ant effects of THC or t + . inhaled cannabis may also Y provide an improvement in mood. By contrast, several conventional medications t . commonly prescribed for i cancer patients, e.g. phe- nothiazines such as ' haloperidol (known as "major tranquillizers"), may produce unwanted side effects such as excessive sedation, flattening of mood, and/or distressing physi- cal"extrapyramidal" symptoms such as uncontrolled or compulsive movements. While clinical research on using cannabis medicinally has been limited by gov- ernment prohibition until very recently and obstacles still exist. The accumulat- ed data speaks strongly in favor of considering it as an option for most cancer l patients, and many oncologists do. Survey data from a Harvard Medical School study in 1990, before any states had approved medical use, shows that 44% of oncologists had recommended cannabis to at least some of their patients.Nearly half said they would do so if the laws were changed. According the American Cancer Society's 2003 data,more than 1,300,000 Americans are diagnosed with cancer each year.15 At least 300,000 of them will undergo chemotherapy, mean- ing as many as 132,000 patients annually may have cannabis recommended to them to help fight the side effects of conventional treatments. { As the Institutes of Medicine report concluded, "nausea, appetite loss, pain and anxiety . . all can be mitigated by marijuana." 1 I 7 Research on cannabis and chemotherapy Cannabis is used to combat pain caused by various cancers and nausea induced by chemotherapy agents. Over 30 human clinical trials examining the effects of cannabis or synthetic cannabinoids on nausea, not including several U.S. state trials that took place between 1978 and 1986.16 In reviewing this literature,Hall et al. concluded that "... THC [delta-9-tetrahydrocannabinol] is superior to placebo, and equivalent in effectiveness_to other widely-used anti-emetic drugs, in its capacity to reduce the nausea and vomiting caused by some chemotherapy k regimens in some cancer patients."" A 2003 study found "Cannabinoids - the active components of Cannabis sativa and their derivatives - exert palliative effects in cancer patients by preventing nausea,vomiting and pain and by stim- ulating appetite. In addition, these compounds have been shown to inhibit the growth of tumor cells in culture and animal models by modulating key cell-sig- naling pathways.Cannabinoids are usually well tolerated,and do not produce the f generalized toxic effects of conventional chemotherapies."" f Authors of the Institute of Medicine report, "Marijuana and Medicine:Assessing the Science Base,"acknowledged that there are certain cancer patients for whom cannabis should be a valid medical option.19 A random-sample anonymous sur- vey was conducted in the spring of 1990 measuring the attitudes and experiences of oncologists concerning the antiemetic use of cannabis in cancer chemothera- py patients. Of the respondents expressing an opinion,a majority(54%)thought cannabis should be available by prescription.20 Cancer-fighting properties of cannabis More than eighteen major studies published between 2001 and 2003 showed that the chemicals in cannabis known as cannabinoids have a sig- nificant effect fighting cancer cells. We now know cannabinoids arrest many kinds of cancer growths (brain, breast, leukemic, melanoma, phaeochromocytoma, et al.) through promotion of apoptosis (pro- grammed cell death) that is lost in tumors, and by arresting angiogenesis j (increased blood vessel production). i Recent scientific advances in the study of cannabinoid receptors and endocannabinoids have produced exciting new leads in the search for anti-cancer treatments. F There is growing evidence of direct anti-tumor activity of cannabinoids, specifically CBl and C132 agonists, in a range of cancer types including brain(gliomas), skin,pituitary,prostate and bowel. The antitumor activ- ity has led in laboratory animals and in-vitro human tissues to regression s is m _ YS 5 N i of tumors, reductions in vascularisation (blood supply) and metastases (secondary tumors), as well as direct inducement of death (apoptosis) among cancer cells. Indeed, the complex interactions of endogenous j cannabinoids and receptors are leading to greater scientific understanding s of the mechanisms by which cancers develop. The findings of these studies are borne out by the reports of such patients as Steve Kubby and Irvin Rosenfeld, whose cannabis use is credited with keeping rare, terminal cancers in a state of remission for decades beyond conventional expectations. Research on tumor reduction Although cannabis smoke has been shown to have precancerous-causing effects in animal tissue, epidemiological studies have failed to link cannabis smoking with cancer."," If smoke inhalation is a concern, cannabis can be used with a vaporizer, orally in baked goods,and topically as a tincture or a suppository. { Cannabinoids, the active components of cannabis, have been shown to exhibit anti-tumor properties. Multiple studies published between 2001 and 2003 found 9 i that cannabinoids inhibit tumor growth in laboratory animals.-" In another study,injections of synthetic THC eradicated malignant brain tumors in one-third -i of treated rats, and prolonged life in another third by as much as six weeks.28 Other journals have also reported on cannabinoids' antitumoral potential...... Italian research teams reported in 1998 and 2001 that the endocannabinoid anan- damide,which binds to the same brain receptors as cannabis " p , potently and selec- tively inhibits the proliferation of human breast cancer cells in vitro"by interfer- DNA production cycle.36...Cannabis has been shown in recent stud- ing with their ies to inhibit the growth of thyroid,prostate and colorectal cancer cells.39-9 THC has a been found to cause the death of glioma cells.424And research on pituitary cancers t shows cannabinoids are key to regulating human pituitary hormone secretion."' r Now cannabis compares to other medications The American Cancer Society lists 269 medicines currently prescribed to treat cancer and its symptoms,and to treat the side effects of other cancer drugs. Some drugs are prescribed for pain caused by cancer, and cancer patients report pain relief with cannabis therapy.Many chemotherapy agents cause severe nausea and 13 drugs are currently prescribed to treat nausea, including Marinol, a synthetic form of delta-9-THC, one of the active ingredients in cannabis. The newer antiemetics,Anzamet,Kytril and Zofran,are serotonin antagonists, blocking the neurotransmitter that sends a vomiting signal to the brain.Rare side effects of these drugs include fever, fatigue, bone pain, muscle aches, constipa- tion, loss of appetite, inflammation of the pancreas, changes in electrical activi- ty of heart,vivid dreams,sleep problems,confusion,anxiety and facial swelling. ti i Reglan, a substituted benzamide, increases emptying of the stomach, thus decreasing the chance of developing nausea and vomiting due to food remaining in the stomach. When given at high doses, it blocks the messages to the part of the brain responsible for nausea and vomiting resulting from chemotherapy. Side effects include sleepiness,restlessness, diarrhea and dry mouth. Rarer side E effects are rash,hives and decreased blood pressure Haldol and Inapsine are tranquilizers that block messages to the part of the brain Gresponsible for nausea and vomiting. Possible side effects include decreased breathing rate, increased heart rate, decrease in blood pressure when changing position and,rarely, change in electrical activity of the heart. i r Compazine and Torecan are phenothiazines, the first major anti-nausea drugs. Both have tranquilizing effects. Common side effects include dry mouth and constipation. Less common effects are blurred vision, restlessness, involuntary muscle movements,tremors,increased appetite,weight gain,increased heart rate and changes in electrical activity of heart. Rare side effects include jaundice, rash,hives and increased sensitivity to sunlight. 10 i ' f � r c _ i Benadryl, an antihistamine, is given along with Reglan, Haldol, Inapsine, Compazine and Torecan to counter side effects of restlessness,tongue protrusion, and involuntary movements. Its side effects include sedation, drowsiness, dry mouth, dizziness, confusion, excitability and decreased blood pressure. Decadron (dexamethasone), a corticosteroid, is given with other chemotherapy drugs as an adjunct medication. Common side effects include increased appetite, irritation of stomach, euphoria, difficulty sleeping, mood changes, flushing, increased blood sugar, decreased blood potassium level. Possible side effects upon discontinuing the drug include adrenal insufficiency,weakness,aches,fever, dizziness, lowering of blood pressure when changing position, difficulty breath- ing, and low blood sugar. f Benzodiazepine drugs Ativan and Xanax are also prescribed to combat the i effects of chemotherapy. Ativan causes amnesia.Abruptly stopping the drug can cause anxiety,dizziness,nausea and vomiting,and tiredness.It can cause drowsi- ness, confusion, weakness, and headache when first starting the drug. Nausea, vomiting, dry mouth, changes in heart rate and blood pressure, and palpitations are possible side effects. In addition,in April 2003 the FDA approved the drug Emend(a re itant)to helpi control delayed-onset nausea. It isgiven along with two other anti-nausea drugs. A regimen of three pills costs $250. The most common side effects with Emend are fatigue,nausea, loss of appetite,constipation, diarrhea. ! Cannabis:By comparison, the side effects associated with cannabis are typically mild and are classified as"low risk." Euphoric mood changes are among the most frequent side effects. Cannabinoids can exacerbate schizophrenic psychosis in predisposed persons. Cannabinoids impede cognitive and psychomotor perform- ance, resulting in tem- AMERICAN ACADEMY OF porary impairment. "The American Academy of Family Physicians Chronic use can lead to the development of tol- [supports] the use of marijuana ... under med-_ erance. Tachycardia and ical supervision and control for cific medical hypotension frequently are documented as 1996-1997 AAFF`Reference Manual adverse events in the cardiovascular system. A few cases of myocar- dial ischemia have been reported in young and previously healthy patients. E Inhaling the smoke of cannabis cigarettes induces side effects on the respiratory system. Cannabinoids are contraindicated for patients with a history of cardiac ischemias.In summary,a low risk profile is evident from the literature available. Serious complications are very rare and were not reported after use of cannabi- noids for medical indications. Is cannabis safe to recommend? t "The smoking of cannabis, even long term, is not harmful to health. . . . " So began a 1995 editorial statement of Great Britain's leading medical journal,The Lancet.The long history of human use of cannabis also attests to its safety-near- ly 5,000 years of documented use without a single death.In the same year as the Lancet editorial, Dr. Lester Grinspoon, a professor emeritus at Harvard Medical i School who has published many influential books and articles on the medical use of cannabis,had this to say in an article in the Journal of the American Medical Association(June 1995): "One of marihuana's greatest advantages as a medicine is its remarkable safety. It has little effect on major physiological functions. There is no known case of a lethal overdose; on the basis of animal models,the ratio of lethal to effective dose is estimated as 40,000 to I.By comparison,the ratio is between 3 and 50 to 1 for secobarbital and between 4 and 10 to I 3 for ethanol. Marihuana is also far less addictive and far less subject to 3 abuse than many drugs now used as muscle relaxants, hypnotics, and analgesics. The chief legitimate concern is the effect of smoking on the { lungs. Cannabis smoke carries even more tars and other particulate mat- ter than tobacco smoke. But the amount smoked is much less, especially in medical use, and once marihuana is an openly recognized medicine, solutions may be found; ultimately a technology for the inhalation of cannabinoid vapors could be developed." The technology Dr. Grinspoon imagined in 1995 now exists in the form of "vaporizers," widely available through stores and mail-order, while pharmaceu- i 1s tical companies have been developing sublingual spray and tablet forms of i the drug. Patients and , doctors have found other M' ways to avoid the poten- tial problems associated with smoking, though , long-term studies of even the heaviest users in Jamaica, Turkey and the U.S. have not found .,`1 �. increased incidence of Angel Raich using a vaporizer in the hospital lung disease or other res- piratory problems.As Dr. Grinspoon goes on to say,"the greatest danger in med- ical use of marihuana is its illegality,which imposes much anxiety and expense on suffering people,forces them to bargain with illicit drug dealers,and exposes them to the threat of criminal prosecution." This was the same conclusion reached by the House of Lords report, which recommended rescheduling and decriminalization,both of which were enacted in Great Britain in 2004. Cannabis or Marinol? Those committed to the prohibition on cannabis frequently cite Marinol, a Schedule III drug,as the legal means to obtain the benefits of cannabis.However, Marinol,which is a synthetic form of THC,does not deliver the same therapeu- tic benefits as the natural herb, which contains at least another 60 cannabinoids y in addition to THC.Recent research conducted by GW Pharmaceuticals in Great Britain has shown that Marinol is simply not as effective for pain management as the whole plant; a balance of cannabinoids, specifically CBC and CBD with THC, is what helps patients most. In fact, Marinol is not labeled for pain, only appetite stimulation and nausea control. But studies have found that many severely nauseated patients experience difficulty in getting and keeping a pill down, a problem avoided by use of inhaled cannabis. Clinical research on Marinol vs. cannabis has been limited by federal restric- tions, but a New Mexico state research program conducted from 1978 to 1986 provided cannabis or Marinol to about 250 cancer patients for whom conven- tional medications had failed to control the nausea and vomiting associated with chemotherapy. At a DEA hearing, a physician with the program testified that cannabis was clearly superior to both Chlorpromazine and Marinol for these patients. Additionally, patients frequently have difficulty getting the right dose with Marinol, while inhaled cannabis allows for easier titration and avoids the negative side effects many report with Marinol. As the House of Lords report states, "Some users of both find cannabis itself more effective." 13 The Experience of Patients JUDITH CUSHNER, BREAST CANCER In 1989,I was diagnosed with breast cancer.After a brief period of recovery from the surgeries, I was placed on an aggressive protocol of chemotherapy, which lasted for eight months.That protocol was referred to as "CMF,"because it con- sisted of heavy doses of Cytoxan,methotraxate, and 5 fluorouracil. The treatment caused severe and persistent side effects which were thoroughly disabling: chronic nausea,joint pain and weakness; a debilitating lack of energy and motivation;loss of appetite and a resulting unwanted weight loss; sleep dis- ruption; and eventually my withdrawal from social situations and interpersonal relationships. The cumulative effect of these symptoms often rendered it impos- sible (or painfully difficult)to take the huge number of medications essential to my treatment regimen. Right from the start,I was given Compazine as part of my chemotherapy proto- col. I took it both orally(in pill form)and intravenously,but it too caused severe adverse side effects, including neuropathy. Moreover, the Compazine provided little, if any,relief from the nausea that had persisted since my treatment began. Hoping for better results,my doctor discontinued the Compazine and prescribed Reglan. That, too, had no effect on the nausea and we decided to discontinue it after a fairly short time.By then,I had developed chronic mouth sores(also from the chemotherapy),which made it extremely painful to take pills or swallow any- thing.Rather than providing relief,the Reglan increased my discomfort and pain. Yet another drug I tried was Marinol, which gave me no relief from the unre- lenting nausea.If anything,taking yet another pill increased my discomfort.The pills themselves irritated the sores in my mouth. It also made me quite groggy, yet my sleep disturbance persisted, in part because my nausea and anxiety were so distracting. My doctor prescribed Lorazepam to help me sleep,but it was just one more medication with unpleasant effects of its own. During this time, a friend of mine(who happened to be a nurse)gave me a mar- ijuana cigarette. She had seen my suffering and thought it might help. I took her advice and it worked. I took just a few puffs and within minutes,the nausea dis- sipated. For the first time in several months, I felt relief. I also felt hope. I smoked small amounts of marijuana for the remainder of my chemotherapy and radiation treatment. It was not a regular part of my day, nor did it become a habit. a Each time I felt nausea coming on,I inhaled just two or three puffs and it subsided. As my nausea decreased, my ability to eat and retain food increased. I saw a marked weight gain and my energy increased.As my general health improved, my sleeping habits also improved.In retrospect,one of the greatest benefits from 14 , the marijuana was that it decreased my use of other, more disabling and toxic medications, including the Compazine,Reglan and Lorazepam. My cancer has been in remission now for just under a year.I lived to see my son's Bar Mitzvah, and I am proud to say that the risks I took to save my life, while technically illegal, have earned me the respect of both my children. They have learned the difference between therapeutic treatment and substance abuse, and (unlike many of their peers) that knowledge has helped them resist the tempta- tions of recreational drugs. � My decision to use marijuana and save my own life has educated many, includ- ing my rabbi and my congregation. --Sworn testimony by Judith Cushner in Conant v. McCaffrey, 2/14/1997 JO DALY, COLON CANCER In 1980, 1 was appointed by Dianne Feinstein, then Mayor of San Francisco, to serve as police commissioner for the city of San Francisco,an office which I held for six years. On May 24, 1988, 1 was diagnosed with Phase IV cancer of the colon. By the time it was diagnosed, it had already spread to my ovaries and lymph nodes. My oncologist at the UCSF Hospital prescribed an aggressive reg- imen of chemotherapy, which lasted six months. I was given large doses of the chemicals, four hours a day, five days a week in the first week of each month. Each day, when I returned home from the hospital following treatment, at about 5:00 p.m.,my whole body turned quite warm,as if a fever were coursing through me. My fingernails even burned with heat. Invariably,I was overcome by a sud den wave of intense nausea-- like a nuclear implosion in my solar plexus--and 1 rushed desperately for the bathroom where I would remain for hours,clutching the toilet and retching my guts out.I had no appetite.I could not hold down what little food that I managed to swallow.And I could not steep at night. This intense nausea persisted for the two weeks following the treatment.By the third week after treatment,the side effects of the chemicals began to wear off,and I start- ed to el better.-- The next —week,however, -had—return ~the hospital where the / chemicals were administered once more,beginning"yhell all over again. . pri- mary chemicals found in marijuana. However,I was often unable to swallow the - - - - -------l------ ----- -- --�------------------'-------� I told my oncologist about how well marijuana quelled my nausea. My doctor was not surprised.in fact,he told me that many of his patients had made the same discovery. My doctor encouraged me to continue using marijuana if it worked. Although it occasionally produced a slight euphoria, it was not a painful sensa- tion and I was careful never to leave the house during those rare moments. My use of medical marijuana had a secondary,though by no means minor bene- fit: I was able to drastically reduce my dependence on more powerful prescrip- tion drugs that I was prescribed for pain and nausea. With the help of medical marijuana, which I ingest only occasionally and in small amounts, I no longer need the Compazine,Lorazepam,Ativan and Halcion. No combination of these medications provided adequate relief. They also caused serious side effects that I never experienced with marijuana. Jo Daly, former San Francisco Police Commissioner ANONYMOUS, BREAST CANCER I have used medicinal cannabis legally in California for a year,after being diag- nosed and treated for breast cancer.I have also been given prescription drugs that were not effective,that irritated my stomach,for which they wanted to prescribe more drugs. These medications were neither cost-effective nor useful, and I choose to use medicinal cannabis through a vaporizer as recommended by my physician,thereby bypassing the sometimes-harmful effects of smoking. I,personally,would rather the federal government use their resources to go after the true criminals and terrorists that we have in our country, as opposed to per- secuting the sick for whatever relief they may have from medical cannabis. —Anonymous patient LYN NOFZIGER, FATHER OF CANCER PATIENT When our grown daughter was undergoing chemotherapy for lymph cancer, she was sick and vomiting constantly as a result of her treatments. No legal drugs, including Marinol,helped her. We finally turned to marijuana. With it, she kept her food down, was comfortable and even gained weight. Those who say Marinol and other drugs are satisfactory substitutes for marijuana may be right in some cases but certainly not in all cases. If doctors can prescribe morphine and other addictive medicines, it makes no sense to deny marijuana to sick and dying patients when it can be provided on a carefully controlled,prescription basis. —Lyn Nofziger, Senior adviser to former-President Ronald Reagan 16 L__ PROFESSIONAL ORGANIZATION ENDORSEMENTS s AIDS Action`Council French Ministry of Health Alaska Nurses Association Hawaii Nurses Association American Academy ofFamily Physicians Health Canada American Medical Student Association Kaiser Permanente American Nurses Association Lymphoma Foundation of America American Preventive Medical Association Mississippi Nurses Association American Public Health Association Multiple Sclerosis Society(Canada) American Society of Addiction Medicine National Acad.of Sciences hist.of Medidne Arthritis Research Campaign(UnitedKingdom) National Association for Public Health Polity Australian Medical Association National Nurses Society on Addictions Australian National Task Force on Cannabis Netherlands Ministry of Health Belgian Ministry of Health New Jersey State Nurses Association British House of Lords Select Committee New Mexico Medical Society British Medical Associ tion New Mexico Nurses Association- ; California Academy of Family Physicians New York State Nurses Association California Nurses Association North Carolina Nurses Association California Pharmacists Association ' San Francisco Mayor's Summit an AIDS and HIV Colorado Nurses Association Son Francisco Medico)Society Federation of American;Scientists Virginia Nurses Association i Florida Governor's Red Ribbon Panel on AIDS whitman•walker Clinic Florida Medical Association Wisconsin Nurses Association The Experience of Doctors HOWARD D. MACCABEE, M.D. i In my practice, I commonly use radiation therapy to treat the whole spectrum of solid malignant tumors. Radiation therapy is often used after surgery or chemotherapy, as a second stage in treatment. Sometimes, however, radiation therapy is used concurrently with-chemotherapy, or even as the first or only modality of treatment. I treat approximately 20 patients each day and provide follow-up care and/or consultation with another 5 or so patients a day. I currently have approximately 2,000 patients in various stages of follow-up to their initial treatment. Most of these are long-term survivors. Because of the nature of some cancers,I must sometimes irradiate large portions of my patients' abdomens. Such patients often experience nausea,vomiting,and other side effects. Because of the severity of these side effects, some of my patients choose to discontinue treatment altogether, even when they know that i ceasing treatment could lead to death. 17 r During the 1980s,I participated in a state-sponsored study of the effects of mar- ijuana and THC (an active ingredient in marijuana)on nausea. It was my obser- vation during this time that some patients smoked marijuana while hospitalized, often with the tacit approval of physicians. I also observed that medical marijua- na was clinically effective in treating the nausea of some patients. During my career as a physician,I have witnessed cases where patients suffered from nausea or vomiting that could not be controlled by prescription anti-emet- ics. I frequently hear similar reports from colleagues treating cancer and AIDS patients.As a practical matter,some patients are unable to swallow pills because of the side effects of radiation therapy or chemotherapy,or because of the nature of the cancer(for instance,throat cancer). For these patients,medical marijuana can be an effective form of treatment. Howard D. Maccabee,M.D. DEBASISH TRIPATRY, M.D. Since 1993,1 have been a physician at the UCSF Mount Zion Breast Care Center in San Francisco. My practice is devoted exclusively to breast cancer patients. I treat more than 1,000 patients.Approximately 100 of these patients are current- ly undergoing chemotherapy,a treatment utilizing various combinations of medication we use pow- erful medications. In some cases,the therapeutic dose of the n is not far from the potentially lethal dose. Although chemotherapy is a widely used treatment in the treatment of many cancers,it can also cause severe adverse affects, which some patients are simply unable to tolerate. The most common adverse effects of chemotherapy are nausea and retching. The nausea and retching associated with chemotherapy are often disabling and intractable. The severity of the symptoms and their medical consequences vary from patient to patient. In many cases, the immediate results are weight loss, fatigue, and chronic discomfort. The consequences can be far graver in patients whose health and functioning is already compromised.For example,the dangers associated with weight loss and malnutrition are greater in patients whose cancer has metastasized and attacked other parts of the body. I have prescribed Marinol to some of my patients and it has proven effective in some cases. However, scientific and anecdotal reports consistently indicate that smoking marijuana is a therapeutically preferable means of ingestion. Marinol is available in pill form only. Moreover, Marinol contains only one of the many ingredients found in marijuana (THC). It may be that the beneficial effects of THC are increased by the cumulative effect of additional substances found in cannabis. That is an area for future research. For whatever reason, smoking appears to result in faster, more effective relief, and dosage levels are more easily titrated and controlled in some patients. is KATE SCANNELL, MD i Because I was a cancer patient receiving chemotherapy at the same hospital where I worked, the women with whom I shared the suite quickly surmised that I was also a doctor. The clues were obvious: the colleagues dropping by, NEW ENGLAND JOURNAL OF MEDICINE the "doctor" salutations "A federal policy that prohibits physicians from co-workers and the from alleviating suffering by prescribing mar- odd coincidence that one ijuana to seriously ill patients is misguided, of my suite mates was heavy-handed, and inhumane.... It is also also one of my patients. hypocritical to forbid physicians to prescribe I braced myself for this extrememarijuana while permitting them to prescribe woman's question, both morphine and mepericline to relieve wanting to make myself clyspnea and pain...there is no risk of death available to her but also from smoking marijuana.... To demand evi- wishing that the world dence of therapeutic efficacy is equally hypo- could forget that I was a doctor for the moment. Jerome P. Kassirer, MD, editor After receiving my can- cer diagnosis, dealing with surgery and chemo- therapy and grappling with insistent reminders of my mortality,I had no desire to think about medicine or to experience myself as a physician in that oncology suite. And besides, the chemotherapy, anti-nauseants, sleep medications and prednisone were hamper- ing my ability to think clearly. So, after a gentle disclaimer about my clinical capabilities,I said I'd do my best to answer her question. She shoved her IV line out of the way and, with great effort and discomfort, rolled on her side to face me. Her belly was a pendulous sack bloated with ovarian cancer cells,and her eyes were vacant of any light. She became short of breath from the task of turning toward me. "Tell me," she managed,"Do you think marijuana could help me?I feel so sick." j I winced. I knew about her wretched pain, her constant nausea and all the pre- scription drugs that had failed her - some of which also made her more consti- pated,less alert and even more nauseous.I knew about the internal derangements of chemotherapy, the terrible feeling that a toxic swill is invading your bones, { destroying your gut and softening your brain. I knew this woman was dying a !- prolonged and miserable death. And, from years of clinical experience, I - like many other doctors - also knew 19 ii that marijuana could actually help her. From working with AIDS and cancer patients,I repeatedly saw how marijuana could ameliorate a patient's debilitating fatigue, restore appetite, diminish pain, remedy FEDERATIONnausea, cure vomiting "Based on much evidence, from patients and and curtail down-to-the- doctors alike, on the superior effectiveness bone weight loss. I and safety of,� whole cannabis compared to could firmly attest to its other medications, ... the President should benefits and wager the likelihood that it would instruct the NIH and the Food and Drug decrease her suffering. Administration to make efforts to enroll seri- ously ill patients whose physicians believe that Still,federal law has for- whole cannabi I s would be helpful to their con- bidden doctors to...pre- ditions in clinical trials" (November 1994) scribe marijuana to patients [though doctors may legally recommend it.] In fact, in 1988 the Drug Enforcement Agency even rejected one of its own i administrative law judge's conclusions supporting medicinal marijuana,after two full years of hearings on the issue. Judge Francis Young recommended the change on grounds that"marijuana,in its natural form, is one of the safest therapeutically active substances known to man," and that it offered a"currently accepted medical use in treatment." 3 f { Doctors see all sorts of social injustices that are written on the human body, one person at a time.But this one-the rote denial of a palliative care drug like mar- ijuana to people with serious illness-smacks of pure cruelty precisely because it is so easily remediable,precisely because it prioritizes service to a cold political agenda over the distressed lives and deaths of real human beings. f Washington bureaucrats - far removed from the troubled bedsides of sick and dying patients - are ignoring what patients and doctors and health care workers are telling them about real world suffering. The federal refusal to honor public referendums like California's voter-approved Medical Marijuana Initiative is bewildering. Its refusal to listen to doctors groups like the California Medical Association that support compassionate use of medical marijuana is chilling. r In a society that has witnessed extensive positive experiences with medicinal marijuana, as long as it is safe and not proven to be ineffective, why shouldn't seriously ill patients have access to it?Why should an old woman be made to die a horrible death for a hollow political symbol? —Kate Scannell,MD Dr. Scannell is co-director of the Ethics Department of Kaiser-Permanente. 20 HISTORY OF CANNABIS AS MEDICINE The history of the medical use of cannabis dates back to 2700 B.C. in the phar- macopoeia of Shen Nung,one of the fathers of Chinese medicine. In the west,it has been recognized as a valued, therapeutic herb for centuries. In 1823, Queen Victoria's personal physician, Sir Russell Reynolds,not only prescribed it to her for menstrual cramps but wrote in the first issue of The Lancet, "When pure and administered carefully, [it is] one of the of the most valuable medicines we pos- sess." (Lancet 1; 1823). a The American Medical Association opposed the first federal law against cannabis with an article in its leading journal (108 J.A.M.A. 1543-44; 1937). Their representative, Dr. William C. Woodward, testified to Congress that "The American Medical Association knows of no evidence that marihuana is a dan- gerous drug,"and that any prohibition"loses sight of the fact that future investi- gation may show that there are substantial medical uses for Cannabis."Cannabis remained part of the American pharmacopoeia until 1942 and is currently avail- able by prescription in the Netherlands and soon Canada. Federal Policy is Contradictory Federal policy on medical cannabis is filled with contradictions. Cannabis is a Schedule I drug,classified as having no medicinal value and a high potential for abuse,yet its most psychoactive component,THC,is legally available as Marinol and is classified as Schedule 111. { At the turn of the century, cannabis was widely prescribed, even in America. Cannabis is now available by prescription in the Netherlands. Canada has been growing cannabis for patients there and plans to put it in pharmacies as well. Ironically, the U.S. federal government also grows and provides cannabis for a small number of patients today. In 1976 the federal government created the Investigational New Drug (IND) compassionate access research program to allow patients to receive medical cannabis from the government. The application process was extremely compli- cated,and few physicians became involved. In the first twelve years the govern- ment accepted about a half dozen patients.The federal government approved the distribution of up to nine pounds of cannabis a year to these patients,all of whom report being substantially helped by it. In 1989 the FDA was deluged with new applications from people with AIDS,and 34 patients were approved within a year.In June 1991,the Public Health Service =" announced that the program would be suspended because it undercut the admin- istration's opposition to the use of illegal drugs. The program was discontinued in March 1992 and the remaining patients had to sue the federal government on 21 f the basis of "medical DEA CHIEF ADMINISTRATIVE LAw JUDGE necessity" to retain access to their medicine. Today, "Marijuana, i� its natural form, is one of the eight surviving patients still receive medical known... It would be unreasonable, arbitrary cannabis from the federal DEA to continue to government, grown under stand betwee I n those sufferers and the bene- a doctor's supervision at fits of this sub I stance" the University of Miss- The Honorable Francis L.Young, issippi and paid for by federal tax dollars. g on DEA rescheduling hearings,1988 Despite this successful medical program and cen- turies of documented safe use, cannabis is still classified in America as a Schedule I substance. Healthcare'advocates have tried to resolve this contradic- tion through legal and administrative channels.In 1972,a petition was submitted i to reschedule cannabis so that it could be prescribed to patients. i The DEA stalled hearings for 16 years,but in 1988 their chief administrative law judge,Francis L.Young,ruled that, "Marijuana, in its natural form, is one of the safest therapeutically active substances known... It would be unreasonable,arbi- trary and capricious for the DEA to continue to stand between those sufferers and the benefits of this substance...." The DEA refused to implement this ruling based on a procedural technicality and continues to classify cannabis as a substance with no medical use. ( Widespread public support; state laws passed Public opinion is clearly in favor of ending the prohibition of medical cannabis. According to a CNN/Time poll in November 2002, 80% of Americans support medical cannabis. The refusal of the federal government to act on this support has meant that patients have had to turn to the states for action. Since 1996, voters in eight states plus the District of Columbia have passed favorable medical cannabis ballot initiatives, while the legislatures in Hawaii, Vermont and Maryland have enacted similar bills. a. As of June 2005, medical cannabis legislation is under consideration in several states. Medical marijuana initiatives passed in Montana and Detroit and Ann Arbor, Michigan. Currently, laws that effectively remove state-level criminal penalties for growing and/or possessing medical cannabis are in place in Alaska, Arizona, California, Colorado, Hawaii, Maine, Maryland, Montana, Nevada, Oregon,Vermont and Washington. i 22 Thirty-six states have symbolic medical cannabis laws (laws that support med- ical cannabis but do not provide patients with legal protection under state law). New U.S. Supreme Court ruling On June 6th, 2005, the US Supreme Court overturned a decision by a federal appeals court (Raich v.Ashcroft), once again making it legal under federal law to prosecute medical marijuana patients for possessing,consuming,and cultivat- ing medical cannabis. The decision, Gonzales v. Raich, does not affect individ- ual states'medical marijuana programs,and only applies to prosecution in feder- al, not state, court. Please call the ASA offices if you have any more questions concerning the Supreme Court ruling. Petitions for legal prescriptions pending The federal Department of Health and Human Services(HHS) and the FDA are currently reviewing two legal petitions with broad implications for medical mar- ijuana. The first, brought by ASA under the Data Quality Act, says HHS must correct its statements that there is no medical use for marijuana to reflect the many studies which have found it helpful for many conditions.Acknowledging legitimate medical use would then force the agency to consider allowing the pre- scribing of marijuana as they do other drugs,based on its relative safety. A separate petition, of which ASA is a co-signer, asks the Drug Enforcement Administration for a full, formal re-evaluation of marijuana's medical benefits, based on hundreds of recent medical research studies and several thousand years of documented human use. s` 4, 23 h LEGAL CITATIONS 1. See "The Administration's Response to the Passage of California Proposition 215 and Arizona Proposition 200" (Dec. 30, 1996). 2. See Conant v. McCaffrey, 172 F.R.D. 681 (N.D. Cal. 1997). 3. See id.; Conant v. McCaffrey, 2000 WL 1281174 (N.D. Cal. 2000); Conant v. Walters, 309 F.3d 629 (9th Cir. 2002). 4. 309 F.3d 629 (9th Cir.2002). 5. Id. at 634-36. 6. Criminal liability for aiding and abetting requires proof that the defendant "in some sort associate[d] himself with the venture, that he participate[d] in it as something that he wishe[d]to bring about,that he[sought]by his action to make it succeed." Conant v. McCaffrey, 172 F.R.D. 681, 700 (N.D. Cal. 1997) (quotation omitted). A conspiracy to obtain cannabis requires an agreement between two or more persons to do this,with both persons know- ing this illegal objective and intending to help accomplish it. Id. at 700-01. 7. 309 F.3d at 634&636. 8. Conant v.McCaffrey,2000 WL 1281174,at 16(N.D. Cal.2000). 9. 309 F.3d at 634. 10. See id.. at 635; Conant v. McCaffrey, 172 F.R.D. 681, 700-01 (N.D. Cal. 1997). RESEARCH CITATIONS 11. Abrams,Donald I.,et al [2003]. Short-Term Effects of Cannabinoids in Patients with HIV-1 Infection:A Randomized,Placebo-Controlled Clinical Trial.Ann Intern Med. 2003 Aug 19;139(4):258-66. 12. Joy,Janet E.; Stanley J.Watson,Jr.; John A. Benson, Jr.,Eds. Marijuana and Medicine:Assessing the Science Base. Washington,DC: Division of Neuroscience and Behavioral Health,Institute of Medicine. 1999. 13.-British Medical Association [1997]. Therapeutic Uses of Cannabis. Harwood Academic Pub. 14. House of Lords, Select Committee on Science and Technology, [1998]. Cannabis: The Scientific and Medical Evidence. London,England: The Stationery Office,Parliament. 15. American Cancer Society[2003]. Cancer Facts and Figures 2003. http://www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf 16. "Review of the Human Studies on the Medical Use of Marijuana," Dale Gicringer, Ph.D. (1996). bttp://norml.org/medical/inedmj.studies.shtml. See state studies at http://www.drugpolicy.org/ 24 ------------- i i 17. W. Hall, et al., The Health and Psychological Consequences of Cannabis Use, Canberra, Australian Government Publishing Service (1994): 189. http://www.druglibrary.org/ 18. Guzman M. [2003] Cannabinoids: potential anticancer agents. Nat Rev Cancer. 3(10): 745-55 19.Joy,op.cit.,259. (Chapter 4 of this report contains sections on nausea,vom- iting,wasting syndrome and anorexia) 20. Doblin, Richard; Kleiman, Mark A. R. "Marijuana as Antiemetic Medicine: A Survey of Oncologists' Experiences and Attitudes." J Clin Oncol, 1991; 9: 1275-1290. 21. Knox, Richard A. "Study may undercut marijuana opponents-Report says THC did not cause cancer." Boston Globe. January 30, 1997. p. 1(A). 22. James, John S. "Medical Marijuana: Unpublished Federal Study Found THC- Treated Rats Lived Longer, Had Less Cancer." AIDS Treatment News. 1997. 263. http://www.immunet.org/ 23. M. Guzman, "Cannabinoids: Potential Anticancer Agents,"Nature Reviews Cancer 3, (2003) 745 -755. 24. Blazquez C, Casanova ML, Planas A, Del Pulgar TG, Villanueva C, f Fernandez-Acenero MJ,Aragones J, Huffinan JW,Jorcano JL, Guzman M. j [2003] Inhibition of tumor angiogenesis by cannabinoids. FASEB J. 17(3): 529-31. Epub 2003 Jan 02. 25. Sanchez C, de Ceballos ML, del Pulgar TG, Rueda D, Corbacho C,Velasco Q Galve-Roperh I, Huffman JW, Ramon y Cajal S, Guzman M. [2001] Inhibition of glioma growth in vivo by selective activation of the CB(2) cannabinoid receptor. Cancer Res. 61(15): 5784-9. 25 26 Casanova ML, Blazquez C, Martinez-Palacio J, Villanueva C, Fernandez- Acenero MJ, Huffman JW, Jorcano JL, Guzman M. [2003] Inhibition of skin tumor growth and angiogenesis in vivo by activation of cannabinoid receptors. J Clin Invest. 111(1): 43-50 27. Jacobsson SO,Wallin T, Fowler CJ. [2001] Inhibition of rat C6 glioma cell proliferation by endogenous and synthetic cannabinoids. Relative involve- ment of cannabinoid and vanilloid receptors. J Pharmacol Exp Ther. 2001 Dec;299(3): 951-9. 28. L Galve-Roperph et al. "Antitumoral action of cannabinoids: involvement of sustained ceramide accumulation of ERK activation." Nature Medicine 6 (2000): 313-319; ACM Bulletin. "THC destroys brain cancer in animal research." http://www.acmed.org/english/2000/eb000305.html 29. J.Benard. "Cannabinoids,among others,send malignant tumors to nirvana." Bull Cancer 87(2000): 299-300. 30. Di Marzo V., et al. "Palmitoylethanolamide inhibits the expression of fatty acid amide hydrolase and enhances the anti-proliferative effect of anan- damide in human breast cancer cells." Biochem J. 2001. 15(358): 249-55. 31. J.Molnar et al. "Membrane associated with antitumor effects of crocine-gin- senoside and cannabinoid derivatives."Anticancer Res 20(2000): 861-867. 32. L. Ruiz et al. "Delta-9-tetrahydrocannabinol induces apoptosis in human prostate PC-3 cells via a receptor-independent mechanism." FEBS Letter 458 (1999): 400-404. 33. S. Back et al. "Antitumor activity of cannabigerol against human oral epith- eloid carcinoma cells."Arch Pharm Res 21 (1998): 353-356. 34. L. Harris et al., "Anti-tumoral Properties of Cannabinoids," The Pharmacology of Marihuana,ed.M.Braude et al.,2 vols.,New York: Raven Press (1976) 2: 773-776 as cited by L. Grinspoon et al., Marihuana: The Forbidden Medicine (second edition), New Haven, CT: Yale University Press(1997), 173. 35. "Toxicology and Carcinogenesis Studies of ltrans-delta-9-tetrahydro- cannabinol in F344N/N Rats and BC63F1 Mice," National Institutes of Health National Toxicology Program, NIH Publication No. 97-3362 (November 1996). 36. L. De Petrocellis et al., The endogenous cannabinoid anandamide inhibits human breast cancer cell proliferation, Proceedings of the National Academy of Sciences 95 (1998): 8375-8380. http://www.pnas.org/cgi/con- tent/abstract/95/14/8375 37. "Pot Chemicals Might Inhibit Breast Tumors, Stroke Damage," Dallas Morning News,July 13, 1998. 26 38. Di Marzo V,Melck D, Orlando P, Bisogno T,Zagoory O, Bifulco M,Vogel Z,De Petrocellis L. [2001]Palmitoylethanolamide inhibits the expression of fatty acid amide hydrolase and enhances the anti-proliferative effect of anan- damide in human breast cancer cells.Biochem J. 358(Pt 1):249-55 39. Portella G, Laezza C, Laccetti P, De Petrocellis L, Di Marzo V, Bifulco M [2003] Inhibitory effects of cannabinoid CBI receptor stimulation on tumor growth and metastatic spreading: actions on signals involved in angiogene- sis and metastasis.FASEB J. 17(12): 1771-3. Epub 2003 Jul 03. I 40. Mimeault M, Pommery N, Wattez N, Bailly C, Henichart JP. [2003] Anti- proliferative and apoptotic effects of anandamide in human prostatic cancer cell lines: implication of epidermal growth factor receptor down-regulation and ceramide production.Prostate. 56(1): 1-12. 41. Ligresti A, Bisogno T, Matias I, De Petrocellis L, Cascio MCS Cosenza V, i D'argenio Q Scaglione G, Bifulco M, Sorrentini I, Di Marzo V. [2003] Possible endocannabinoid control of colorectal cancer growth. Gastroenterology. 125(3):677-87. 42. Gomez del Pulgar T,Velasco G, Sanchez C, Haro A, Guzman M. [2002] De novo-synthesized ceramide is involved in cannabinoid-induced apoptosis. Biochem J. 363(Pt 1):183-8. i 43. Gomez Del Pulgar T, De Ceballos ML, Guzman M, Velasco G. [2002] Cannabinoids protect astrocytes from ceramide-induced apoptosis through the phosphatidylinositol 3-kinase/protein kinase B pathway. J Biol Chem. 277(39):36527-33. Epub 2002 Jul 19. 44. Gonzalez S, Mauriello-Romanazzi G, Berrendero F, Ramos JA, Franzoni MF,Fernandez-Ruiz J. [2000] Decreased cannabinoid CBI receptor mRNA levels and immunoreactivity in pituitary hyperplasia induced by prolonged exposure to estrogens. Pituitary. 3(4):221-6. 45. Pagotto U, Marsicano G, Fezza F, Theodoropoulou M, Grubler Y, Stalla J, Arzberger T, Milone A, Losa M, Di Marzo V, Lutz B, Stalla GK. [2001] Normal human pituitary gland and pituitary adenomas express cannabinoid receptor type I and synthesize endogenous cannabinoids: first evidence for a direct role of cannabinoids on hormone modulation at the human pituitary level. J Clin Endocrinol Metab. 86(6):2687-96 46. Rubovitch V, Gafni M, Same Y. [2002] The cannabinoid agonist DALN positively. modulates L-type voltage-dependent calcium-channels in N18TG2 neuroblastoma cells. Brain Res Mol Brain Res. 101(1-2):93-102. 47. Bifulco M, Laezza C, Portella G, Vitale M, Orlando P, De Petrocellis L, Di Marzo V. [2001]Control by the endogenous cannabinoid system of ras onco- gene-dependent tumor growth.FASEB J. 15(14):2745-7.Epub 2001 Oct 29. safeaccessnow.org i 27 CHIEF ADMINISTRATIVE LAw JUDGE .juana, in its natural form, is one of the safest therapeu active substances known... It would be unreasonable, .ary and capricious for the DEA to continue to stand een those sufferers and the benefits of this substance The Honorable Francis L.You ng, ruling on DEA rescheduling hearings,1,988 More Resources Americans for Safe Access maintains a website with more resources for doctors and patients. There you will find the latest information on legal and legislative developments, new medical research, and what you can do to help protect the rights of patients and doctors. A grassroots coalition of more than 10,000 patients, doctors and advocates,Americans for Safe Access works with lead- ing organizations around the United States to make cannabis legally available to those who need it. For assis- tance with how to write a legal recommendation for cannabis, contact us at 1-888-929-4367 or visit our website at SAFEACCESSNOW.ORG Q,1CQNS F o ¢ PxA SJ3tl a� Americans for Safe Access (888) 929-4367 www.SafeAccessNow.org 1322 Webster Street, Suite 208, Oakland, CA 94612 CANCER 'AND MEDICAL MARIJUANA i t4 r 6 i L*V A-nericansFor SafeAccess P O u N D A 7 1 O N Advancing Legal Medical Marijuana Therapeutics and Research i A Note from Americans for Safe Access We are committed to ensuring safe, legal availability of marijuana for medical uses. This brochure is intended to help doctors, patients and policymakers better understand how marijuana—or "cannabis" as it is more properly called—may be used as a treatment for people with seri- ous medical conditions. This booklet contains information about using cannabis as medicine. In it you'll find information on: Why Cannabis is Legal to Recommend . . . . . . . . . . . . „ . . . . . . . . .3 Overview of the Scientific Research on Medical Cannabis . . . . . .4 Research on Cannabis and Cancer . . . . . . . . . . . . . . . . .. . . . . . . . . .6 Comparison of Medications: Efficacy and Side-Effects . . . . . . . 10 Why Cannabis is Safe to Recommend . . . . . . . . . . . . . . . . . . . . . .12 Testimonials of Patients and Doctors . . . . . . . . . . . . . „ . . . . . . . .14 History of Cannabis as Medicine . . . . .. ... ... .. . . . „ . . . . . . . .21 Scientific and Legal References . . . . . . . . . . . . . . . . . . „ . . . . . . . .24 We recognize that information about using cannabis as imedicine has been difficult to obtain. The federal prohibition on cannabis has meant that modern clinical research has been limited, to the detriment of medical science and the wellness of patients. But the documented histo- ry of the safe, medical use of cannabis dates to 2700 B.C. Cannabis was part of the American pharmacopoeia until 1942 and is currently avail- able by prescription in the Netherlands and Canada. Testimonials from both doctors and patients reveal valuable informa- tion on the use of cannabis therapies, and supporting statements from professional health organizations and leading medical journals support its legitimacy as a medicine. In the last few years, clinical trials in Great Britain, Canada, Spain, Israel, and elsewhere have shown great promise for new medical applications. This brochure is intended to be a starting point for the consideration of applying cannabis therapies to specific conditions; it is not intended to replace the training and expertise of physicians with regard to medi- cine, or attorneys with regard to the law. But as patients, doctors and advocates who have been working intimately with these issues for many years, Americans for Safe Access has seen firsthand how helpful cannabis can be for a wide variety of indications. We know doctors want the freedom to practice medicine and patients the freedom to make decisions about their healthcare. For more information about ASA and the work we do, please see our website at AmericansForSafeAccess.org or call 1-888••929-4367. 2 Americans for Safe Access Is Cannabis Legal to Recommend? In 2004, the United States Supreme Court upheld earlier federal court decisions�jthat doctors have a fundamental Constitutional.:right,to_;rec ommend cannabis to their patients. The history. Within weeks of California voters legalizing medical, cannabis lin 1996, federal officials had threatened to revoke the pre scribing privileges of any physicians who recommended cannabis to their patients for medical use.' In response, a group of doctors and patients led by AIDS specialist Dr. Marcus Conant filed suit against the government, contending that such a policy violates the First Amend- ment.'The federal courts agreed at first the district level,'then all the way through appeals to the Ninth Circuit and then the Supreme Court. What doctors may and may not do. In Conant v. Walters,°the Ninth Circuit Court of Appeals held that the federal government could nei- ther punish nor threaten a doctor merely for recommending the use of cannabis to a patient':' But it remains illegal for a doctor to "aid and abet" a patient in obtaining cannabis.'This means a physi- cian may'',!discuss the pros and cons of medical cannabis with any patient, and issue a written or oral recommendation to use cannabis without fear of legal ' reprisal.'This is true regardless of whether the physician anticipates that the patient will, in turn, use this recom- mendation to obtain cannabis.'What `- physicians may not do is actually pre- scribe or dispense cannabis to a patient' Angel Raich&Dr.Frank Luddo or tell patients how to use a written recommendation to procure it from a cannabis club or dispensary." Doctors can tell patients they may be helped by cannabis. They can put that in writing. They just can't help patients obtain the cannabis itself. Patients protected under state,not federal,law. In June 2005, the U.S. Supreme';Court overturned the Raich v. Ashcroft Ninth Circuit Court of Appeals decision. In reversing the lower court's ruling, Gonzales v. Raich established that it is legal under federal law to prosecute patients who possess, grow, or consume medical cannabis in medical cannabis states. However,',this Supreme Court decision does not overturn or supersede the laws in states with medical cannabis programs. For assistance with determining how best to write a legal recommenda- tion for cannabis, please contact ASA at 1-888-929-4367. 888-929-4367 www.AmericansForSafeAccess.org 3 tic research Supports Medical Cannabis Aw.en 1840 and 1900, European and American medical journals pub- lished more than 100 articles on the therapeutic use of the drug known then as Cannabis Indica (or Indian hemp) and now simply as cannabis. Today, new studies are being published in peer-reviewed journals that demonstrate cannabis has medical value in treating patients with seri- ous illnesses such as AIDS, glaucoma, cancer, multiple sclerosis, epilepsy, and chronic pain. The safety of the drug has been attested to by numerous studies and reports, including the LaGuardia Report of 1944, the Schafer Commission Report of 1972, a 1997 study conducted by the British House of Lords, the Institutes of Medicine report of 1999, research sponsored by Health Canada, and numerous studies conducted in the Netherlands, where cannabis has been quasi-legal since 1976 and is cur- rently available from phar- macies by prescription. "Nausea,appetite loss,pain and anxiety Recent published research all can b e mitigated by marijuana.... on CD4 immunity in AIDS For patients,such as those with AIDS or patients found no compro- undergoing chemotherapy, who suffer. mise to the immune sys- simultaneously from severe pain, nau- of patients undergo- ' appetite loss,cannabinoid drugs ing cannabis therapy in might offet broad spectrum relief not clinical trials." found in any other single medication." Marijuana and Medicine: The use of medical cannabis Assessing the Science Base,1999 has been endorsed by numerous professional organizations, including the American Academy of Family Physicians, the American Public Health Association, and the American Nurses Association. Its use is supported by such leading medical publications as The New England Journal of Medicine and The Lancet. Recent Research Advances While research has until recently been sharply limited by federal prohi- bition, the last few years have seen rapid change. The International Cannabinoid Research Society was formally incorporated as a scientific research organization in 1991. Membership in the Society has more than tripled from about 50 members in the first year to over 300 in 2005. The International Association for Cannabis as Medicine (IACM) was founded in March 2000. It publishes a bi-weekly newsletter and the IACM-Bulletin, and holds a bi-annual symposium to highlight emerging research in cannabis therapeutics. The University of California estab- 4 Americans for Safe Access lished the Center for Medicinal Cannabis Research in'2001.146 6,5 2006, the CMCR has 17 approved studies, including research on ce cec pain, nausea control in chemotherapy, general analge's'ia a,nd'a posed study on refractory cancer pain. In the United Kingdom, GW Pharmaceuticals has been'granted'a clinical trial exemption certifi- cate by the Medicines Control Agency to con- duct clinical studies with cannabis-based medicines. The exemp- tion includes investiga- tions in the relief of _ E pain of neurological origin and defects of • neurological function in the fofJowing indica- tions: multiple sclerosis (MS), spinal cord injury, peripheral nerve injury, central nervous system damage, neuroinvasive cancer, dystonias, cerebral vascular accident and spina bifida, as well as for the relief of pain and inflammation in rheumatoid arthritis and also pain relief in brachial plexus injury. GW has completed Phase III studies in patients with MS neuropathic pain and spasticity, and Phase II trials on perioperative pain, rheuma- toid arthritis, peripheral neuropathy secondary to diabetes mellitus or AIDS, and patients with neurogenic symptoms. These trials have provided positive results and confirmed an excellent safety profile for cannabis-based medicines. In 2002, GW conducted five Phase III trials of its cannabis derivatives, including a double-blind, placebo-controlled trial with a sublingual spray containing THC in more than 100,patients with cancer pain. In total, more than 1,000 patients are currently involved in phase III trials in the UK. In 2002 GW Pharmaceuticals received an IND approval to commence phase II clinical trials in Canada in patients with chronic pain, multiple sclerosis and spinal cord injury, and in April 2005 GW received regulato- ry approval to distribute Sativex in Canada for the relief of neuropathic pain in adults with Multiple Sclerosis. Following meetings with the FDA, DEA, thelOffice for National Drug Control Policy, and the National Institute for Drug Abuse, GW was granted an import license from the DEA and has imported its first cannabis extracts into the U.S., and in 888-929-4367 www.AmericansForSafeAccess.org 5 s anuary of 2006 was granted permission to begin Phase III clinical trials =nto cancer pain. CANNABIS AND CANCER Cannabis has been found to help cancer patients with pain and nausea, and recent research indicates it has tumor-reducing and anti-carcino- genic properties properties as well. It has proven highly effective at controlling the nausea associated with chemotherapy, and its appetite- stimulation properties help combat wasting. Cannabis can also help control the pain associated with some cancers, as well as that resulting from radiation and chemotherapy treatment. Cannabis and chemotherapy side effects One of the most widely studied therapeutic applications for cannabis and the pharmaceutical drugs derived from cannabinoids is in the treatment of nausea and vomiting associated with cancer chemothera- py.. Numerous clinical studies have reported that the use of cannabis reduces nausea and vomiting and stimulates appetite, thereby reducing the severity of cachexia, or wasting syndrome, in patients receiving „ chemotherapy treatment. The 1999 Institutes of Medicine report concluded: "In patients already experiencing severe nausea ® or vomiting, pills are generally inef- fective, because of the difficulty in swallowing or keeping a pill down, a and slow onset of the drug effect. Thus an inhalation (but, preferably not smoking) cannabinoid drug #\ delivery system would be advanta- geous for treating chemotherapy- ' induced nausea."12 A 1997 inquiry by the British Medical Association found cannabis more effective than Marinol, and a 1998 review by the House of Lords Science &Technology Select Committee concluded that "Cannabinoids are undoubtedly effective as anti-emetic agents in vomiting induced by anti-cancer drugs. Some users of both find cannabis itself more effective."13.14 In the last three years, there have been major advances in both cannabinoid pharmacology and in understanding of the cancer disease 6 Americans for Safe Access r process. In particular, research has demon strated.the,p,resen,ce_tof, numerous cannabinoid receptors in the nucleus of the solitary tract, a, brain center important in control of vomiting. Although other recently developed anti-emetics are as effective or more effective than oral THC, nabilone or smoked cannabis, for certain individuals unresponsive to conventional anti-emetic drugs, the use of smoked cannabis can provide relief more effectively than oral prepara- tions which may be difficult to swallow or be vomited before taking effect, as'the IOM report notes. The psychoactive/euphoriant effects of THC or inhaled cannabis may also provide an improvement in mood. By contrast, several convention- al medications commonly prescribed for cancer patients, e.g. phenoth- iazines such as haloperidol (known as "major tranquillizers") may pro- duce unwanted side effects such as excessive sedation, flattening of mood, and/or distressing physical "extrapyramidal" symptoms such as uncontrolled or compulsive movements. While clinical research on using cannabis medicinally has been severely limited by federal prohibition,the accumulated data speaks strongly in favor of considering it as an option for most cancer patients, and many oncologists do. Survey data from a Harvard Medical.School study in 1990, before any states had approved medical use, shows that 44% of oncologists had recommended cannabis to at least some of their patients. Nearly half said they would do so if the laws were changed. According the American Cancer Society's 2003 data, more than 1,300,000 Americans are diagnosed with cancer each year.15 At least 300,000 of them will undergo chemotherapy, meaning as many as 132,000 patients annually may have cannabis recommended to them to help fight the side effects of conventional treatments. As the Institutes of Medicine report concluded, "nausea, appetite loss, pain and lanxiety ... all can be mitigated by marijuana." Research on cannabis and chemotherapy Cannabis;is used to combat pain caused by various cancers and nausea induced by chemotherapy agents. Over 30 human clinical trials have examined the effects of cannabis or synthetic cannabinoids on nausea, not including several U.S. state trials that took place between 1978 and 1986.16 In reviewing this literature, Hall et al. concluded that ". . . THC [delta-9-tetrahydrocannabinol] is superior to placebo, and equivalent in effectiveness to other widely-used anti-emetic drugs, in its capacity to reduce the nausea and vomiting caused by some chemotherapy regi- mens in some cancer patients.""A 2003 study found "Cannabinoids— the active components of cannabis sativa.and their derivatives—exert 888-929-4367 www.AmericansForSafeAccess.org 7 i i.ve effects in cancer patients by preventing nausea, vomiting and ' p ., and by stimulating appetite. In addition, these compounds have been shown to inhibit the growth of tumor cells in culture and animal models by modulating key cell-signaling pathways. Cannabinoids are usually well tolerated, and do not produce the generalized toxic effects of conventional chemotherapies."" Authors of the Institute of Medicine report, "Marijuana and Medicine: Assessing the Science Base," found that there are certain cancer patients for whom cannabis should be a valid medical option.19 A ran- dom-sample anonymous survey conducted in the spring of 1990 meas- ured the attitudes and experiences of oncologists concerning the antiemetic use of cannabis in cancer chemotherapy patients. Of the respondents expressing an opinion, a majority (54%)thought cannabis should be available by prescription." Cancer-fighting properties of cannabis More than twenty major studies published between 2001 and 2006have shown that the chemicals in cannabis known as cannabinoids have a significant effect fighting cancer cells.We now know cannabinoids arrest many kinds of cancer growths (brain, breast, leukemic, melanoma, phaeochromocytoma, et al.) through promotion of apopto- sis (programmed cell death) that is lost in tumors, and by arresting angiogenesis (increased blood vessel production). Recent scientific advances in the study of cannabinoid receptors and endocannabinoids have produced exciting new leads in the search for anti-cancer treatments. There is growing evidence of direct anti-tumor activity of cannabinoids, specifically CB1 and CB2 agonists, in a range of cancer types including brain (gliomas), skin, pituitary, prostate and bowel. The antitumor activ- ity has led in laboratory animals and in-vitro human tissues to regres- sion of tumors, reductions in vascularisation (blood supply) and metas- tases (secondary tumors), as well as direct inducement of death (apop- tosis) among cancer cells. Indeed, the complex interactions of endoge- nous cannabinoids and receptors are leading to greater scientific under- standing of the mechanisms by which cancers develop. The findings of these studies are borne out by the reports of such patients as Steve Kubby, whose cannabis use is credited with keeping a rare, terminal cancer in a state of remission for decades beyond conven- tional expectations. 8 Americans for Safe Access Research on tumor reduction i4 :,1 Although cannabis smoke has been shown to have precancerous-taus-,-. ing effects in animal tissue, epidemiological studies on humans have:.,, failed to link cannabis smoking with cancer."," If smoke inhalation,is-a, concern, cannabis can be used with a vaporizer, orally in baked goods, and topically as a tincture or a suppository. Cannabinoids, the active components of cannabis, have been shown to exhibit anti-tumor properties. Multiple studies published between 2001 and 2006 found that cannabinoids inhibit tumor growth in laboratory animals.23-z.' In another study, injections of synthetic THC eradicated malignant brain tumors in one-third of treated',rats, and prolonged, life in another third by as much as x weeks.28 journals ournals have - also reported on cannabinoids' antitu- moral potential.2935 Italian research teams reported in 1998 and ` 2001 that,the endo- cannabinoid anan- damide, which binds ° to the same brain receptors as cannabis, "potently and selectively inhibits the prolifera- tion of human breast cancer cells in vitro" by interfering with their DNA production cycle.36-"Cannabis has been shown in recent studies to inhibit the growth of thyroid, prostate and colorectal cancer cells 11-41 THC has been found to cause the death of glioma cells.42,43 And research on pituitary cancers shows cannabinoids are key to regulating human pituitary hormone secretion."-4' In 2004 an Italian research team demonstrated that the administration of the nor-psychoactive cannabinoid cannabidiol (CBD) to nude mice significantly inhibited the growth of subcutaneously implanted U87 human glioma cells. The authors of the study concluded that "... CBD was able to produce a significant antitumor activity both in vitro and in vivo, thus'suggesting a possible application of CBD as an antineoplastic agent (an'.agent that inhibits the growth of malignant cells.)"48 More recently, investigators at the California Pacific Medical Center Research Institute reported that the administration of THC on human glioblastoma multiforme cell lines decreased the proliferation of malig- 888-929-4367 www.AmericansForSafeAccess.org 9 rnant cells and induced apoptosis (programmed cell death) more rapidly than did the administration of an alternative synthetic cannabis recep- tor agonist." How:,cannao s compares to other medications The;Am`erican Cancer Society lists 269 medicines currently prescribed to treat'tancer and its symptoms, and to treat the side effects of other cancer drugs. Some drugs are prescribed for pain caused by cancer, and cancer patients report pain relief with cannabis therapy. Many chemotherapy agents cause severe nausea and 13 drugs are currently prescribed to treat nausea, including Marinol, a synthetic form of delta- 9-THC, one of the active ingredients in cannabis. The newer antiemetics, Anzamet, Kytril and Zofran, are serotonin antagonists, blocking the neurotransmitter that sends a vomiting signal to the brain. Rare side effects of these drugs include fever, fatigue, bone pain, muscle aches, constipation, loss of appetite, inflammation of the pancreas, changes in electrical activity of heart, vivid dreams, sleep problems, confusion, anxiety and facial swelling. Reglan, a substituted benzamide, increases emptying of the stomach, thus decreasing the chance of developing nausea and vomiting due to food remaining in the stomach. When given at high doses, it blocks the messages to the part of the brain responsible for nausea and vomiting resulting from chemotherapy. Side effects include sleepiness, restless- ness, diarrhea and dry mouth. Rarer side effects are rash, hives and decreased blood pressure Haldol and Inapsine are tranquilizers that block messages to the part of the brain responsible for nausea and vomiting. Possible side effects include decreased breathing rate, increased heart rate, decrease in blood pressure when changing position and, rarely, change in electrical activity of the heart. Compazine and Torecan are phenothiazines, the first major anti-nausea drugs. Both have tranquilizing effects. Common side effects include dry mouth and constipation. Less common effects are blurred vision, rest- lessness, involuntary muscle movements, tremors, increased appetite, weight gain, increased heart rate and changes in electrical activity of heart. Rare side effects include jaundice, rash, hives and increased sensi- tivity to sunlight. Benadryl, an antihistamine, is given along with Reglan, Haldol, Inapsine, Compazine and Torecan to counter side effects of restlessness, tongue protrusion, and involuntary movements. Its side effects include sedation, drowsiness, dry mouth, dizziness, confusion, excitability and 10 Americans for Safe Access M; decreased!blood pressure. Decadron'i(dexamethasone), a corticosteroid, is given with other chemotherapy drugs as an adjunct medication. Common side effects include increased appetite, irritation of stomach, euphoria, difficulty sleeping, mood changes, flushing, increased blood sugar, decreased blood potassium level. Possible side effects upon discontinuing the drug include adrenal insufficiency, weakness, aches, fever, dizziness, lowering of blood pressure when changing position, difficulty breathing, and low blood sugar. Benzodiazepine drugs Ativan and Xanax are also prescribed to combat the effects of chemotherapy. Ativan causes amnesia. Abruptly stopping the drug can cause anxiety, dizziness, nausea and vomiting, and tired- ness. It can cause drowsiness, confusion, weakness, and headache when first starting the drug. Nausea, vomiting, dry mouth, changes in heart rate and blood pressure, and palpitations are possible side effects. In addition, in April 2003 the FDA approved the drug Emend (aprepi- tant) to help control delayed-onset nausea. It is given along with two other anti-nausea drugs. A regimen of three pills costs $250. The most common side effects with Emend are fatigue, nausea, loss of appetite, constipation, diarrhea. Cannabis: By comparison, the side effects associated with cannabis are typically mild and are classified as "low risk." Euphoric mood changes are among the most frequent side effects. Cannabinoids can exacer- bate schizophrenic psychosis in predisposed persons. Cannabinoids 888-929-4367 www.AmericansForSafeAccess.org 11 impede cognitive and psychomotor performance, resulting in tempo- rary impairment. Chronic use can lead to the development of tolerance. Tachycardia and hypotension are frequently documented as adverse evens in the cardiovascular system. A few cases of myocardial ischemia have been reported in young and previously healthy patients. Inhaling the smoke of cannabis cigarettes induces side effects on the respiratory system. Cannabinoids are contraindicated for patients with a history of cardiac ischemias. In summary, a low risk profile is evident from the lit- erature available. Serious complications are very rare and are not usual- ly reported during the use of cannabinoids for medical indications. Is cannabis safe to recommend? "The smoking of cannabis, even long term, is not harmful to health...." So began a 1995 edi- torial statement of ` Great Britain's leading '! medical) journal, The Lancet. The long his- - tory of human use of ' cannabis also attests t � ! to its safety—nearly 31 5,000 years of docu- mented use without a mow, ) single death. In the f same year as the Lancet editorial, Dr. Lester Grinspoon, a professor emeritus at Harvard Medical School who has published many influential books and articles on med- ical use of cannabis, had this to say in an article in the Journal of the American Medical Association (1995): "One of marihuana's greatest advantages as a medicine is its remarkable safety. It has little effect on major physiological func- tions. There is no known case of a lethal overdose; on the basis of animal models, the ratio of lethal to effective dose is estimated as 40,000 to 1. By comparison, the ratio is between 3 and 50 to 1 for secobarbital and between 4 and 10 to 1 for ethanol. Marihuana is also far less addictive and far less subject to abuse than many drugs now used as muscle relaxants, hypnotics, and analgesics. The chief legitimate concern is the effect of smoking on the lungs. Cannabis smoke carries even more tars and other particulate mat- ter than tobacco smoke. But the amount smoked is much less, especially in medical use, and once marihuana is an openly recog- nized medicine, solutions may be found; ultimately a technology 12 Americans for Safe Access for the inhalation of cannabinoid vapors cou,ld,be,deyeloped, The technology Dr. Grinspoon imagined in 1995 now exists in the form of "vaporizers," (which are widely available through stores.and by;mail- order) and;recent research attests to their efficacy and safety.35 Additionally, pharmaceutical companies have developed sublingual. sprays and',tablet forms of the drug. Patients and doctors have found other ways to avoid the potential problems associated with smoking, though long-term studies of even the heaviest users in Jamaica, Turkey and the U.S. have not found increased incidence of lung disease or other respiratory problems. As Dr. Grinspoon goes on to say, "the greatest danger in medical use of marihuana is its illegality, which imposes much anxiety and expense on suffering people, forces them to bargain with illicit drug dealers, and exposes them to the threat of criminal prosecu- tion." This'was the same conclusion reached by the House of Lords report, which recommended rescheduling and decriminalization, both of which were enacted in Great Britain in 2004. Cannabis or Marinol? Those committed to the prohibition on cannabis frequently cite Marinol, a Schedule III drug, as the legal means to obtain the benefits of cannabis. However, Marinol, which is a synthetic form of THC, does not deliver the same therapeutic benefits as the natural herb, which con- tains at least another 60 cannabinoids in addition to THC. Recent research conducted by GW Pharmaceuticals in Great Britain has shown that Marinol is simply not as effective for pain management as the whole plant; a balance of cannabinoids, specifically CBC and CBD with THC, is what helps patients most. In fact, Marinol is not labeled for pain, only appetite stimulation and nausea control. But studies have found that many"severely nauseated patients experience difficulty in getting and keeping a pill down, a problem avoided by use of inhaled cannabis. Clinical research on Marinol vs. cannabis has been limited by federal restrictions, but a New Mexico state research program conducted from 1978 to 1986 provided cannabis or Marinol to about 250 cancer patients for whomconventional medications had failed to control the nausea and vomiting associated with chemotherapy. At a DEA hearing, a physi- cian with the program testified that cannabis was clearly superior to both Chlorpromazine and Marinol for these patients. Additionally, patients frequently have difficulty getting the right dose with Marinol, while inhaled cannabis allows for easier titration and avoids the nega- tive side effects many report with Marinol. As the House of Lords report states, "Some users of both find cannabis itself more effective." 888-929-4367 www.AmericansForSafeAccess.org 13 '. THE EXPERIENCE OF PATIENTS Judith Cushner, Breast Cancer In 1989, I''Was diagnosed with breast cancer. After a brief period of recovery from the surgeries, I was placed on an aggressive protocol of chemotherapy, which lasted for eight months. That protocol was referred to as "CMF," because it consisted of heavy doses of Cytoxan, methotraxate, and 5 fluorouracil. The treatment caused severe and persistent side effects which were thoroughly disabling: chronic nausea, joint pain and weakness; a debili- tating lack of energy and motivation; loss of appetite and a resulting unwanted weight loss; sleep disruption; and eventually my withdrawal from social situations and interpersonal relationships. The cumulative effect of these symptoms often rendered it impossible (or painfully dif- ficult) to take the huge number of medications essential 'to my treat- ment regimen. Right from the start, I was given Compazine as part of my chemothera- py protocol. I took it both orally (in pill form) and intravenously, but it too caused severe adverse side effects, including neuropathy. Moreover, the Compazine provided little, if any, relief from the nausea that had persisted since my treatment began. Hoping for better results, my doc- tor discontinued the Compazine and prescribed Reglan. That, too, had no effect on the nausea and we decided to discontinue it after a fairly short time. By then, I had developed chronic mouth sores (also from the chemotherapy), which made it extremely painful to take pills or swal- low anything. Rather than providing relief, the Reglan increased my dis- comfort and pain. Yet another drug I tried was Marinol, which gave me no relief from the unrelenting nausea. If anything, taking yet another pill increased my discomfort. The pills themselves irritated the sores in my mouth. It also made me quite groggy, yet my sleep disturbance persisted, in part because my nausea and anxiety were so distracting. My doctor pre- scribed Lorazepam to help me sleep, but it was just one more medica- tion with unpleasant effects of its own. During this time, a friend of mine (who happened to be a nurse) gave me a marijuana cigarette. She had seen my suffering and.thought it might help. I took her advice and it worked. I took just a few puffs and within minutes, the nausea dissipated. For the first time in several months, 1 felt relief. I also felt hope. I smoked small amounts of mari- juana for the remainder of my chemotherapy and radiation treatment. It was not a regular part of my day, nor did it become a habit. Each 14 Americans for Safe Access time I felt nausea coming on, I inhaled just two or three`puffs and its subsided.' As my nausea decreased, my ability to eat and retain food increased. I saw a marked weight gain and my energy increased. As my general health improved, my sleeping habits also improved. In retrospect, one of the greatest benefits from the marijuana was AMERICAN NURSES ASSOCIATION that it decreased my use of other, more disabling and In 2003 the American Nurses Association toxic medications, including passed a resolution that supports those the Compazine, Reglan and health care providers Lorazepam. medicinal use, recognizes "the right of My cancerpatients to have safe access to therapeu- has been inmar , calls for remissions;now for just more research and education, under a year. I lived to see rescheduling of marijuana for medical my son's Bar Mitzvah, and I am proud to say that the risks I took to save my life, while technically illegal, have earned me the respect of both my children. They have learned the difference between therapeutic treatment and substance abuse, and (unlike many of their peers) that knowledge has helped them resist the temptations of recre- ational drugs. My decision to use marijuana and save my own life has educated many, including my rabbi and my congregation. -Sworn testimony by Judith Cushner in Conant v. McCaffrey, 2/14/1997 Jo Daly;Colon Cancer In 1980, 1 was appointed by Dianne Feinstein, then Mayor of San Francisco, to serve as police commissioner for the city of San Francisco, an office which I held for six years. On May 24, 1988, 1 was diagnosed with Phase IV cancer of the colon. By the time it was diagnosed, it had already spread to my ovaries and lymph nodes. My oncologist at the UCSF Hospital prescribed an aggressive regimen of chemotherapy, which lasted six months. I was given large doses of the chemicals, four hours a day, five days a week in the first week of each month. Each day, when I returned home from the hospital following treatment, at about 5:00 p.m., my whole body turned quite warm, as if a fever were coursing through me. My fingernails even burned with heat. Invariably, I was overcome by a sudden wave of intense nausea—like a nuclear implosion in my solar plexus—and I rushed desperately for the bathroom'where I would remain for hours, clutching the toilet and 888-929-4367 www.AmericansForSafeAccess.org is retching my guts out. I LIERATION OF AMERICAN SCIENTISTShad no appetite. I could "Bas'04:',o'n much evidence, from patients not hold down what lit- and-d6dors alike,on the superior effective- tle food that I managed ness and safety of whole cannabis com- to swallow. And I could pared President not sleep at night. should instr I uct the NIH and the FDA to make efforts to enroll seriously ill patients whose This intense nausea per- physicians I believe that whole cannabis sisted for the two weeks would be helpful to their conditions in clin- following -the treat- ical trials" By the third week FAS Peti tion on Medical Marijuana,1994 after treatment, the side effects of the chemicals began to wear off, and I started to feel better. The next week, however, I had to return to the hospital where the chemicals were administered once more, beginning my hell all over again. To combat the nausea, I tried Marinol, a synthetic version of THC, one of the primary chemicals found in marijuana. However, I was often unable to swallow the Marinol capsule because of my severe nausea and retching. A friend then gave me a marijuana cigarette, suggesting that it might help quell my nausea. I took three puffs from the ciga- rette. One-half hour later, I was calm, my nausea had disappeared, my appetite returned, and I slept that evening. I told my oncologist about how well marijuana quelled my nausea. My doctor was not surprised. In fact, he told me that many of his patients had made the same discovery. My doctor encouraged me to continue using marijuana if it worked. Although it occasionally produced a slight euphoria, it was not a painful sensation and I was careful never to leave the house during those rare moments. My use of medical marijuana had a secondary, though by no means minor benefit: I was able to drastically reduce my dependence on more powerful prescription drugs that I was prescribed for pain and nausea. With the help of medical marijuana, which I ingest only occasionally and in small amounts, I no longer need the Compazine, Lorazepam, Ativan and Halcion. No combination of these medications provided adequate relief. They also caused serious side effects that I never expe- rienced with marijuana. Jo Daly, former San Francisco Police Commissioner Anonymous, Breast Cancer I have used medicinal cannabis legally in California for a year, after 16 Americans for Safe Access being diagnosed and treated for breast cancer. I have also been,giv 1 prescription drugs that were not effective, that irritated my stomach;;; for which they wanted to prescribe more drugs. These medications"' were neither cost-effective nor useful, and I choose to use med'i(fMal cannabis through a vaporizer as recommended by my physician, there- by bypassing the sometimes-harmful effects of smoking. I, personally, would rather the federal government use their resources to go after the true criminals and terrorists that we have in our country, as opposed to persecuting the sick for whatever relief they may have from medical cannabis. —Anonymous patient Lyn Nofziger, Father of Cancer Patient When our grown daughter was undergoing chemotherapy for lymph cancer, she was sick and vomiting constantly as a result of her treat- ments. No legal drugs, including Marinol, helped her. We finally turned to marijuana. With it, she kept her food down, was comfortable and even gained weight. Those who say Marinol and other drugs are satis- factory su."bstitutes for marijuana may be right in some cases but cer- tainly not in all cases. If doctomcan prescribe morphine and other addictive medicines, it makes no sense to deny marijuana to sick and dying patients when it can be provided on a carefully controlled, prescription basis. —Lyn Nofziger, former senior adviser to President Ronald Reagan THE EXPERIENCE OF DOCTORS Howard D. Maccabee, M.D. In my practice, I commonly use radiation therapy to treat the whole spectrum of solid malignant tumors. Radiation therapy is often used after surgery or chemotherapy, as a second stage in treatment. Sometimes, however, radiation therapy is used concurrently with chemotherapy, or even as the first or only modality of treatment. I treat approximately 20 patients each day and provide follow-up care and/or consultation with another 5 or so patients a day. I currently have approximately 2,000 patients in various stages of follow-up to their ini- tial treatment. Most of these are long-term survivors. Because of the nature of some cancers, I must sometimes.irradiate large portions of my patients' abdomens. Such patients often experience nau- 888-929-4367 www.AmericansForSafeAccess.org 17 . l sea, vomiting, and other side effects. Because of the severity of these side'effects, some of my patients choose to discontinue treatment alto- gether, even when they know that ceasing treatment could lead to death. During the 1980s,'l participated in a state-sponsored study of the effects of marijuana and THC (an active ingredient in marijuana) on nausea. It was my observation during this time that some patients smoked marijuana while hospitalized, often with the tacit: approval of physicians. I also observed that medical marijuana was clinically effec- tive in treating the nausea of some AMERICAN ACADEMY OF FAMILY PHYSICIANS I patients. "The American Academy of Family Physicians [supports]t I he use of marijuana...under med-- During my career as a ical supervi I sioncontrol p• -d physician, I have wit- ical indications." nessed cases where patients suffered from 1996 1997 AAFP Reference Manual nausea or vomiting that could not be con- trolled by prescription anti-emetics. I frequently hear similar reports from colleagues treating cancer and AIDS patients. As a practical matter, some patients are unable to swallow pills because of the side effects of radiation therapy or chemotherapy, or because of the nature of the cancer (for instance, throat cancer). For these patients, medical marijuana can be an effec- tive form of treatment. —Howard D. Maccabee, M.D. Debasish Tripathy, M.D. Since 1993, 1 have been a physician at the UCSF Mount Zion Breast Care Center in San Francisco. My practice is devoted exclusively to breast can- cer patients. I treat more than 1,000 patients. Approximately 100 of these patients are currently undergoing chemotherapy, a treatment uti- lizing various combinations of powerful medications. In some cases, the therapeutic dose of the medication we use is not far from the poten- tially lethal dose. Although chemotherapy is a widely used treatment in the treatment of many cancers, it can also cause severe adverse affects, which some patients are simply unable to tolerate. The most common adverse effects of chemotherapy are nausea and retching. The nausea and retching associated with chemotherapy are often dis- abling and intractable. The severity of the symptoms and their medical consequences vary from patient to patient. In many cases, the immedi- ate results are weight loss, fatigue, and chronic discomfort. The conse- quences can be far graver in patients whose health and functioning is 18 Americans for Safe Access r already compromised. For example, the dangers associated with,weig'ht loss and malnutrition are greater in patients whose cancer has metasta- sized andattacked other parts of the body. have prescribed Marinol to some of my patients and it has proven effective in some cases. However, scientific and anecdotal reports con- sistently indicate that smoking marijuana is a therapeutically preferable means of ingestion. Marinol is available in pill form only. Moreover, Marinol contains only one of the many ingredients found in marijuana (THC). Itmay be that the beneficial effects of THC are increased by the cumulative effect of additional substances found in cannabis. That is an area for future research. For whatever reason, smoking appears to result in faster, more effective relief, and dosage levels are more easily titrated and controlled in some patients. Kate Scannell, MD Because I was a cancer patient receiving chemotherapy at the same hos- pital where I worked, the women with whom I shared the suite quickly surmised that I was also a doctor. The clues were obvious: the col- leagues dropping by, the "doctor" salutations from co-workers and the odd coincidence that one of my suite mates was also one of my patients. I braced myself for this woman's question, both wanting to make myself available to her but also wishing that the world could forget that I was',a doctor for the moment. After receiving my cancer diagno- sis, dealing with surgery and chemo-therapy and grappling with insis- tent reminders of my mortality, I had no desire to think about medicine or to experience myself as a physician in that oncology suite. And besides, the chemotherapy, anti-nauseants, sleep medications and pred- nisone were hampering my ability to think clearly. So, after a gentle disclaimer about my clinical capabilities, I said I'd do my best to answer her question. She shoved her IV line out of the way and, with igreat effort and discomfort, rolled on her side to face me. Her belly was a pendulous sack bloated with ovarian cancer cells, and her eyes were vacant of any light. She became short of breath from the task of turning toward me. "Tell me, she managed, "Do you think marijuana could help me? I feel so sick." I winced. I knew about her wretched pain, her constant nausea and all the prescription drugs that had failed her—some of which also made her more constipated, less alert and even more nauseous. I knew about the internal derangements of chemotherapy, the terrible feeling that a 888-929-4367 www.AmericansForSafeAccess.org 19