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Public Health Implications of

the Legalization of Marijuana in

the State of North Dakota Fall 2014 Nursing 456 Public Health Class

Minot State University

Running Head: PUBLIC HEALTH IMPLICATIONS 1

Public Health Implications of the Legalization of

Marijuana in the State of North Dakota

Fall 2014 Nursing 456 Public Health Class

Minot State University

PUBLIC HEALTH IMPLICATIONS

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Table of Contents

Positive Outcomes of Marijuana Legalization……………………………………………pg. 4-19

Jennifer Chevalier, Janelle Ramirez, and Jill Meyer

Negative Outcomes of Marijuana Legalization…………………………………………..pg. 19-42

Teri Alderson, Jamie Harris, and Kristin Kjelshus

Distribution of Marijuana………………………………………………………………...pg. 42-60

Hannah Lewis, Shelby LaBonte, and Kelsey Wunderlich

Regulation of Marijuana…………………………………………………………………pg. 60-77

Sarah Rimatzki, Sarah Majerus, and Mary Lukasik


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Abstract

The research was conducted in four separate sections. Each section conducted their own

research and developed interventions specific to their topic. The sections include: Positive

outcomes of marijuana legalization, negative outcomes of marijuana legalization, distribution of

marijuana, and regulation of marijuana. The effects of both medical and recreational marijuana

use were addressed in every section. Furthermore, a resolution was drafted to reflect the findings

of the research conducted. It was concluded that with proper education, regulation, and

distribution, medical marijuana can have a positive impact on the state of North Dakota.

Keywords: marijuana, positive outcomes, negative outcomes, regulation, and distribution


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Public Health Implications of the Legalization of

Marijuana in the State of North Dakota

Marijuana legalization has become a popular topic in recent years, and with 23 states as

well as the District of Columbia legalizing the substance in some manner the benefits as well as

the risks will continue to be debated. The following paper explores the public health

implications in the state of North Dakota. Research was divided into four main sections

including: positive outcomes of marijuana legalization, negative outcomes of marijuana

legalization, distribution of marijuana, and regulation of marijuana. Each section explores both

the medical and recreational use of marijuana, and proposes specific interventions relevant to the

section topic. The goal of the research conducted is to determine the impact of legalization both

positive and negative on the state of North Dakota.

Positive Outcomes of Marijuana Legalization

For years marijuana has been thought to have medicinal value and also viewed as a safe

for use recreationally. The two components of marijuana, delta-9-tetrahydrocannabinol (THC)

and Cannabidiol (CBD), can be separated from marijuana and used specifically for medicinal

purposes. The components may also be weakened or regulated for recreational usage. The

advocates of marijuana usage cite the potential for marijuana to be used as treatment for

countless medical conditions and show that it is a safer alternative compared with other

pharmaceutical drugs. Medical marijuana has shown to be beneficial in relieving different types

of pain without the risks of interacting with other pharmaceuticals or serious adverse reactions.

Further research has demonstrated marijuana’s effectiveness on symptom reduction for multiple

autoimmune disorders. Additionally, medical marijuana has been shown useful in the treatment

of Tourette’s syndrome, Alzheimer’s disease, epilepsy, and cancer. Marijuana, as a reactional


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drug, has fewer negative consequences as the available alternatives both illegal and legal. While

marijuana is currently regarded as a very dangerous substance by the United States government,

it remains one of the least physiologically toxic (Bostwick, 2012). Interventions for the safe

implementation of marijuana include education of healthcare professionals and the public and

repealing the Schedule 1 classification at the federal level. This would allow safe effective

implemention of marjiuana legalization.

Marijuana has two main components that have differing effects on the body. The most

well-known component is delta-9-tetrahydrocannabinol (THC), which causes the psychoactive

effects of marijuana. The second component Cannabidiol (CBD), is a non-psychoactive plant

cannabinoid and demonstrates the most promising outcomes with treating various medical

conditions. The two components can be separated from marijuana and used specifically for

medicinal purposes. The components may also be weakened or regulated for recreational usage.

The advocates of marijuana usage cite the potential for marijuana to be used as treatment for

countless medical conditions and show that it is a safer alternative compared with other

pharmaceutical drugs. One potential obstacle lies in the lack of research due to marijuana’s

classification as a Schedule 1 substance by the United States government. The classification

designates marijuana as highly addictive with no medicinal value; therefore, it is difficult to

obtain permission to research the effects of marijuana on various medical conditions (Bostwick,

2012). Furthermore, the label limits potential research participants to those individuals with

previous marijuana exposure. Due to this obstacle most current research is limited to animal

studies or small sample size. Another obstacle is the bias that accompanies the subjective nature

of individuals’ experiences making it difficult to obtain objective assessment data.


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Medical Use

The fact remains that breakthroughs in isolating the components of marijuana as well as a

better understanding of the human body’s pre-existing endocannabinoid system has led to

pharmaceutical progress. Specifically, four pharmaceutical cannabinoids are available for

treatment of various disorders; two (dronabinol and nabilone) have been approved for use in the

United States and a third (nabiximols) is available in Canada (Bostwick, 2012). Clearly, the

approval of such drugs indicates that marijuana and its components have therapeutic value. A

review of literature suggests that marijuana has the potential to treat many diseases and to benefit

millions of patients.

Pain often proves difficult to treat due to its subjective and the countless options for

management. However, the majority of the traditional pain relief medications are accompanied

by the risk for drug-to-drug interaction, and the potential for fatal drug overdose. Medical

marijuana has shown to be beneficial in relieving different types of pain without the risks of

interacting with other pharmaceuticals or serious adverse reactions. Evidence shows that

cannabinoids have been useful in blocking the transmission in pain pathways (Kogan &

Mechoulam, 2007). It is particularly useful in chronic and neuropathic pain, which has been

proven to be one of the most challenging types of pain to treat.

Neuropathic pain is characterized as a chronic pain state that affects the somatosensory

system. When traditional neuropathic pain medications are unsuccessful in relieving pain,

marijuana has been shown to be a reliable alternative. Additionally, marijuana has less drug-to-

drug interactions as well as less serious adverse effects than traditional pharmaceutical pain

medications. This point is specifically useful when thinking about patient safety and is a great

way to avoid unnecessary further hospital treatment. This is particularly important since many


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patients have additional comorbidities requiring additional interventions. Pain intensity was

significantly lower on THC treatment for patients experiencing neuropathic pain (Kogan &

Mechoulam, 2007). In another study, individuals who smoked 25mg of herbal marijuana with a

THC level of 9.4% reported a mean reduction in pain from 6.1 to 5.4 on a 10-cm scale visual

analog scale; furthermore the participants exhibited no serious signs of adverse effects (Ware, et

al., 2010).

In a study conducted by Abrams et al. (2007), inhaled marijuana was preferred as an

alternative pain relieving treatment for patients who had HIV-associated sensory neuropathy due

to fewer drug to drug interactions with the antiretroviral therapy. Traditional treatment for pain

associated with neuropathy includes anticonvulsants, such as gabapentin or lamotrigine, which

interacts with the antiretroviral therapy required to treat HIV; this renders anticonvulsants useless

for the treatment of HIV-associated sensory neuropathy. Marijuana limits potential

complications that may arise from using other pharmaceutical agents to treat HIV-associated

sensory neuropathy. Having a safer pain-relieving alternative, like medical marijuana, would

help these patients to manage their pain as well as the appropriate therapy that the antiretroviral

mediation would provide. In the Abrams et al. (2007) study, participants reported a 72%

reduction in chronic pain ratings after smoking just one marijuana cigarette and an additional

51% reduction in pain after completion of the study. These findings suggest that marijuana is a

useful tool for long-term pain relief as well as instantaneous pain management. Furthermore,

improvement was seen with marijuana-treated AIDS patients in muscle pain, nerve pain, and

paresthesia; it has also been shown to be effective in the treatment of central pain (Kogan &

Mechoulam, 2007).


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Further research has demonstrated marijuana’s effectiveness on symptom reduction for

multiple autoimmune disorders. Multiple sclerosis causes inflammation, demyelination, and

axonal damage. Spasticity is a known complication of multiple sclerosis, which is difficult to

treat. THC has been shown to improve motor coordination, spasticity, and rigidity resulting in

improved mobility. The use of THC has shown to be successful with persistent spasticity when

the traditional drugs used for MS are ineffective (Kogan & Mechoulam, 2007). These findings

are especially important for the patient because control over the spastic tendencies can improve

quality of life and overall ability to maintain adequate functioning. Not only can this affect the

patient socially, but it would also promote safety by allowing the patient to benefit from the

improved motor coordination. Corey-Bloom et al. (2012) utilized the Ashworth scale to measure

muscle tone intensity in individuals with multiple sclerosis while under the treatment of smoked

marijuana. This scale ranks the intensity of muscle tone from 0 to 5, zero being no increase in

tone and five being affected parts rigid in flexion and extension. The results showed smoking

marijuana reduced individuals’ scores by an average of 2.74 on the Ashworth scale. Furthermore

patients also reported a reduction in pain (Corey-Bloom, et al., 2012). This study demonstrates

marijuana is an effective treatment for relief of multiple symptoms of MS. In another

randomized, double blind, placebo-controlled study of nabiximols (Sativex) as an add-on therapy

in addition to other antispasmodics, results show that 74% of 272 subjects demonstrated an

improvement of 30% or more in spasticity caused by multiple sclerosis (Novotna, et al., 2011).

According to Kogan and Mechoulam (2007), patients on Sativex will not develop tolerance over

long-term use.

Amyotrophic-lateral-sclerosis (ALS) is characterized as fatal, resulting in a loss of motor

neurons in the brain and spinal cord. According to Kogen and Mechoulam (2007) some effects of


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THC include analgesia, muscle relaxation, bronchodilation, saliva reduction, appetite

stimulation, and improved sleep; a survey amongst patients with ALS reported a reduction in all

of the above named symptoms. One of the minor side effects of using smoked marijuana is

xerostomia (dry mouth), which benefits ALS patients because the reduction in salivation lowers

the risk of aspiration. Since patients ultimately succumb to respiratory failure the relieving

effects of THC, including bronchodilation and muscle relaxation, would be therapeutic palliative

care. Smoking marijuana may also have broader benefits for patients suffering from ALS.

Fascinatingly, mice that were administered THC showed delayed motor impairments as well as

prolonged survival when compared with control mice. Treatment was effective regardless of the

onset of symptoms and THC was found to delay the progression of the disease (Scotter, Abood,

& Glass, 2010).

There are a number of other neurological disorders that marijuana has been shown to

positively effect, like Tourette’s syndrome. Tourette’s syndrome is characterized by multiple

motor and vocal tics. In a clinical trial, conducted by Kogan and Mechoulam (2007), THC was

shown to reduce the tendency of tics in patients who suffer from Tourette’s syndrome without

leading to acute or long-term cognitive defects; the improvement of motor tics and in patients

being treated with THC was significant (Kogan & Mechoulam, 2007). The benefits of such

therapy include increased social interaction and self-confidence in individuals suffering from

Tourette’s syndrome.

Cannabinoids may also prove advantageous for the treatment of Alzheimer’s disease

(AD). “THC competitively inhibits acetylcholinesterase (AChE) and prevents AChE-induced

amyloid beta-peptide (Abeta) aggregation, the key pathological marker of AD” (Kogan &

Mechoulam, 2007, p. 420). Additionally THC treatment reduces behavioral disturbances, weight


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loss, and nighttime agitation symptoms associated with Alzheimer’s disease (Scotter, Abood, &

Glass, 2010). Reducing nocturnal activity amongst AD patients promotes safety and reduces the

risk of injury. AD often leads to decrease in weight as a consequence of nutritional deficits;

therefore, THC may prove a useful tool not only in disease management but also weight gain.

THC has been proven to be a more effective inhibitor of AChE-induced amyloid beta-peptide

aggregation than traditional pharmaceutical intervention including donepezil and tacrine

(Eubanks, et al., 2008). By inhibiting this aggregation, the disease process would ultimately slow

providing the patient with optimal, therapeutic effects.

Research has shown that cannabinoids have also been effective in treating convulsions in

epilepsy; cannabinoids were found to be more effective with anticonvulsants specificity than the

traditional pharmaceutical interventions used for seizures and it can reduce the induction of

status epilepticus-like activity (Kogan & Mechoulam, 2007). Since status epilepticus can lead to

oxygen deprivation episodes, using cannabinoids can help deter negative effects associated with

decreased oxygenation. Melisa et al. (2003) indicate for refractory seizures, seizure activity that

cannot be contained by traditional anticonvulsant, cannabinoids are more effective. This shows

that cannabinoids can be a safer alternative to seizures than the traditional drugs. Cannabinoids

can be a better substitute especially to those who have allergic tendencies toward the traditional

anticonvulsant therapy.

Regarding cancer, several studies have indicated a positive effect of cannabinoids on the

treatment and reduction of side effects as well as slowing the progression of cancer. Kogan and

Mechoulam (2007) found that cannabinoids suppressed angiogenesis and tumor invasion

decreasing growth, proliferation, and metastasis of the cancer; specifically, THC reduced breast

cancer cell proliferation by blocking the progression of the cell cycle and inducing programmed


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cell death. By decreasing the metastasis of cancer, a patient can obtain dominance over the

disease, making it maintainable. According to McAllister, Christian, Horowitz, Garcia, and

Deperez (2007) CBD has been shown to impede breast cancer metastasis in living mice. As an

early intervention for cancer patients, this programmed cell death can benefit before the negative

effects of metastasis occur. This would result in better response to treatment as well as avoiding

unnecessary additional treatment associated with metastasis.

Furthermore, evidence has demonstrated for some kinds of cancer, marijuana is

associated with risk reduction. Specifically moderate marijuana use diminishes the risk for

development of head and neck squamous cell carcinoma. Additionally marijuana usage seems to

counteract the probability of developing head and neck squamous cell carcinoma after alcohol

and tobacco usage (Liang, et al., 2009). Another cancer that has shown improvement through the

use of medical marijuana is Glioblastoma. Glioblastoma is an aggressive type of brain cancer

that has been shown to respond to THC therapy by prolonging the survival time of patients and

prohibiting tumor cell proliferation (Kogan & Mechoulam, 2007). According to Melamede

(2005), the components of marijuana have demonstrated destructive tendencies towards

numerous cancer types like lung, breast and prostate, leukemia and lymphoma, glioma, skin, and

pheochromromocytoma; patients often report smoking as the prefered route because the rapid

action allows self-titration. With the patient having the ability to self-titrate, it puts them in

control and allows them to stop medicating once relief is granted; this is similair to a patient

controlled analgesic pump used for opioid treatment.

There are a number of psychological disorders that medical marijuana has shown success

in treating. Bipolar disorder is characterized as a mental disorder that causes alternating phases

of elation and depression. According to Kogan and Mechoulam (2007), marijuana is commonly


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used with patients who suffer from bipolar disorder because it alleviates the mania and

depression associated with that disease. If a patient has the ability to manage the mania and

depression, they would be more likely to sustain regular relationships and develop a more stable

social life. Kogan and Mechoulam (2007) reported a woman found that marijuana not only

controlled her manic episodes but also reported better outcomes compared to the traditional

treatment of Lithium. Lithium has a small window of therapeutic effect and can result in toxicity

very easily, and has a number of unpleasant side effects. By substituting marijuana for Lithium,

avoidence of dangerous toxicity and unnecessary medical intervention is assured and patient

safety is maintained. Schizophrenia is another mental disorder shown to benefit from medical

marijuana. It is characterized by having a faulty perception and withdrawal from reality into

fantasies and delusions. Because CBD causes antipsychotic effects, marijuana has resulted in

improvements with schizophrenia and serves as a safer and well-tolerated alternative treatment to

traditional pharamceuticals (Kogan & Mechoulam, 2007).

Not only have cannabinoids been proven to be beneficial in neurological disorders but

also research shows that the active ingredients play a key role in the inflammatory process. The

discovery of the cannabinoid receptors CB1 and CB2 came with a vast advantage in studying the

use of marijuana to treat inflammatory diseases. While CB1 is mainly expressed in the brain and

central nervous system as well as peripheral nervous system, CB2 is found on cells of the

immune system suggesting that these receptors may play an important role in regulating immune

responses (Nagarkatti, Pandey, Rieder, Hedge, & Nagarkatti, 2009).

Apoptosis, also known as programmed cell death, is a natural cell process and essential to

human development. It is found that cannabinoids possess the mechanism to induce cell death in

some immune cells. Nagarkatti, Pandey, Rider, Hedge, and Nagarkatti (2009) stated that


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apoptosis in T cells as well as dendritic cells was triggered when administering THC to mice,

which then resulted in immunosuppression. Furthermore, it is important to note that

cannabinoids can be selective and protect from apoptosis in unspecified cells of the central

nervous system, unlike immune cells, which suggests a protective role in some autoimmune

diseases. In some kinds of cancer, for example breast cancer, cannabinoid receptors were often

found to be present in higher numbers in the tumor compared to normal cells that originated from

the same site. This results in an increased sensitivity to cannabinoids in the malignant cells

(Nagarkatti, Pandey, Rieder, Hedge, & Nagarkatti, 2009).

CB1 receptors were found to be present in the ileum and colon and CB1-repressing cells

increased significantly after inflammation. The pharmacological stimulation of cannabinoid

receptors has shown to be beneficial in treating colitis. Cannabinoids have been shown to control

the cellular pathways that lead to inflammation by decreasing smooth-muscle irritation and

suppressing cytokines. Furthermore, growing evidence suggests that CB1 and CB2 receptors are

increased during the early stages of liver injury. Endocannabinoids and their receptors may be

able to regulate the development of liver fibrosis and cirrhosis by regulating liver fibrogenesis


There are two additional ways in which cannabinoids are able to suppress inflammatory

response. One of them is the suppression of cytokines and chemokines at inflammatory sites and

the other one is increasing FOXP3+ regulatory T cells. Endocannabinoids are chemical

compounds that are naturally synthesized by humans and activate the same receptors as THC.

Their chief function is neuromodulation, however it is also an important modulator of the

autonomic nervous system and the immune system. Cytokines are secreted by immune cells


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upon stimulation and are the signaling proteins that maintain homeostasis of initiation and

resolution of inflammatory responses (Nagarkatti, Pandey, Rieder, Hedge, & Nagarkatti, 2009).

Nagarkatti, Pandey, Rider, Hedge, and Nagarkatti (2009) stated that some studies have

demonstrated that when THC was administered into mice, the cannabinoids would decrease

cytokine and chemokine production and increase T-regulatory cells subsequently suppressing

inflammatory responses and even showed recovery from immune-mediated damage to the liver.

Regarding rheumatoid arthritis, it was found that daily oral intake of (5mg/kg) of the non-

psychoactive component CBD inhibited disease progression in murine collagen-induced arthritis


Another important discovery was the connection between certain types of cancer and

inflammation. According to Balkwill and Mantovani (2001), inflammatory response is linked to

15-20% of all deaths from cancer worldwide. There are a lot of challenges that present when

wanting to implement the use of cannabinoids as an alternative to anti-inflammatory drugs, one

of which is the synthesis of the non-psychoactive cannabinoid receptor agonist with anti-

inflammatory activities. This suggests that further research should be conducted in order to

provide the best treatment possible.

According to Kimball, Wallace, Schneider, D'Andrea, and Hornby (2010), there is

overwhelming evidence that suggest cannabinoids in the gut control gastric secretion, GI

motility, visceral sensation, intestinal inflammation, and cell proliferation. Medical marijuana

has exhibited positive outcomes for patients diagnosed with Inflammatory Bowel Disease (IBD).

Inflammatory bowel disease involves all or part of the digestive tract that results in chronic

abdominal pain. According to Allegretti, Courtwright, Lucci, Korzenik, and Levine, (2013), a

study found that 10% of the patients that had this disease were using marijuana to cope with the


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pain and inflammation. The two cannabinoid receptors, CB1 and CB2, which make up part of the

endocannabinoid system and are stimulated by marijuana; this system is a regulatory system in

the gastrointestinal tract and is believed to control characteristics of intestinal inflammation

(Allegretti et al., 2013). According to Allegretti et al. (2013), a survey study was conducted with

patients who suffered from IBD and 32% of the patients who reported to be past or current users

of marijuana used it medicinally; some symptoms reported to be relieved were abdominal pain,

poor appetite, nausea, and diarrhea. These results are astounding and would help with other risk

factors that these patients would face without the marijuana, like meeting adequate nutritional

requirements and maintaining fluid balances. More than half of the past users (58%) reported

being interested in continuing the drug for their symptoms and only stopped due to lack of

availability and workplace drug testing; however, participants stated they would consider it for

treatment once it becomes legally available(Allegretti et al. , 2013). This demonstrates that the

therapeutic benefits are present and the only obstacle the patients are experiencing is legal

obtainment. The therapeutic benefits were so apparent that patients reported supplementing

narcotics with marijuana usage; however, if marijuana was utilized first the patients did not

express the need for any narcotics (Allegretti et al., 2013). This validates that marijuana can be

used alone for the abdominal pain associated with the inflammation of IBD.

Recreational Use

Marijuana, as a reactional drug, has fewer negative consequences as the available

alternatives both illegal and legal. While marijuana is currently regarded as a very dangerous

substance by the United States government it remains one of the least physiologically toxic

substances requiring 100 to 1,000 times the effective dose to cause death with no documented

deaths from smoked marijuana (Gable, 2006). In comparison, alcohol which is a legal and


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commonly used substance only requries 10 to 20 times the effective dose to result in death

(Gable, 2006). Futhermore, according to the National Institues on Drug Abuse (2014) 9% of

those who smoke marijuana will become addicted to the substance; whereas, 23% of individuals

who try heroin will become addicted.

According to Melamede (2005), tobacco has intense negative consequences for those

who smoke it such as high addiction potential. Tobacco has been associated with more than

400,000 yearly deaths in the United States with 140,000 lung-related deaths in 2001; marijuana,

however, is only casually linked with tobacco related cancers even when smoked. Marijuana

does not affect the lungs in the same manner as tobacco. For example, Nicotine receptors are

found in the epithelial cells lining the respiatory passages and marijuana receptors are widely

distrubuted and are not found in the respiratory epithelial cells (Melamede, 2005). This shows

that a person is more likely to develop an illness related to tobacco than they would to marijuana.

“THC inhibits the enzyme necessary to activate some of the carcinogens found in smoke”

(Melamede, 2005, p.5). This verifies that using marijuana recreationally would be a safer

alternative to smoking tobacco. Like tobacco, there are other routes that marijuana can be taken

that would eliminate the negative effects of smoke inhalation. According to Melamede (2005),

marijuana inhibits tumor angiogenesis while tobacco promotes it and that delivering marijuana

through a vaporizer eliminates the potential for carcinogens.

Interventions

In order for the positive effects of marijuana to be implemented government agencies,

healthcare professionals, and citizens must recognize a need for change. Firstly, the federal

government must eliminate the schedule 1 classification. Removal of the schedule 1

classification by the federal government will not result in legalization of the drug; rather it will


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allow states the authority to legalize marijuana without federal reprecussions and open the door

for more research to be conducted ensuring the safety and effectivenss of marijuana as a

pharmaceutical option. The research would allow the medical community to develop protocols

for dosaging and safe administration. Futhermore, it would allow the Food and Drug

Adminstration oversite of the prescribing practices of marijuana.

Secondly, education of government officials, healthcare professionals, and the public

must occur. Namely, that there are safe and effective uses for marijuana as well as potential for

misuse simliar to any other prescription or nonprescription substance available. Education will

allow the consumer and healthcare professional to understand who may benefit from its use and

who may be harmed. There are several obstacles that prevent healthcare providers from

considering the use of medical marijuana due to the disbelief that the benefit of using marijuana

for medical treatment outweighs the risks that is brings with it. Part of this is often due to

misconceptions about this very controversial topic, caused by erroneous information. However,

there are 23 States that implemented the use of medical marijuana for various health conditions,

which implies potential benefits to marijuana usage and it shows the need of clarification of

these misconceptions. To accomplish the task of education a coalition of professionals would

need to be formed including medical personal such as doctors, nurses, and pharmacists;

furthermore, individuals from the community including legislators, business owners, educators

should be involved to ensure a cohesive voice that represents the views of all members of the

community.

One of many of these misunderstandings include that marijuana is a schedule 1 drug and

must therefore be dangerous as previously mentioned. According to the Drug Enforcement

Administration (2014), a schedule 1 substance has no currently accepted medical use, has a high


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potential for dependence, and abuse. That being said, there is countless research out there that

proves that marijuana is not only highly effective for some diseases but sometimes the only

treatment that alleviates pain when all other medications fail. Throughout this section of the

paper we mentioned that studies showed that cannabinoids have a lesser risk for abuse or

addiction than some opioids. For other misconceptions please refer to Appendix C.

In order for physicians, nurses, and other healthcare professionals to have an open mind

about the use of medical marijuana, we need to facilitate educational programs. One of the ways

we can do that is in providing credit hours for attending clinical conferences about marijuana

therapeutics. Physicians with previous experience with medical marijuana would be available

for consultation in assisting healthcare professionals that are inexperienced with medical

marijuana.

Appendix C includes a drug reference sheet associated with marijuana. It includes, the

synonyms, the source, drug classification, routes of administration, side effects, duration of

effects, interactions, and information associated with tolerance and withdrawal. This information

is useful for the education of the patient and provider as a reference guide when using marijuana

as a pharmaceutical option. This information can be readily available for pharmacists and health

care providers. Additionally, prescribers can provide this information to patients who may have

concerns with using marijuana as a therapeutic agent.

Other ways to educate the population is by using social media to clarify these

misconceptions. A Facebook page can be started with evidence based information about medical

marijuana that is always up to date with the most pertinent information. This can include a fact

sheet as well as a marijuana drug guide regarding side effects, dosage, and interactions. This


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website could also include relevant facts about the most frequently asked questions that arise

with the use of medical marijuana.

In Summary, marijuana offers many medical benefits with fewer drug-to-drug

interactions, and less serious adverse reactions, than many of the current available

pharmaceutical options. It is currently a schedule 1 substance resulting in the difficulty of

research that would allow safe, therapeutic practices be established. Clearly medical marijuana

has potential therapeutic value and should be explored as a viable treatment option.

Negative Outcomes of Marijuana Legalization

According to Barber et al. (2013), marijuana is the most widely used illicit drug of abuse

(p. 2327). In the United States in 2010, there were approximately 17.4 million people that had

reportedly used marijuana within the past month (Sevigny, Pacula, & Heaton, 2014). Within the

past two decades (1990-2010), statistics show an overall increase in drug usage in all age groups,

and the underlying question remains is there a direct correlation between the legalization of the

drug for medicinal purposes and the increase in overall usage. The focus of the paper is to look at

the overall health effects of marijuana on the human body (physiologically and psychologically);

the potency of the drug, the availability of the drug, and the “gateway drug” theory that proposes

marijuana is the gateway to other illicit drug use. Marijuana use among pregnant and/or

breastfeeding women has increased significantly. It is now one of the most common illicit drugs

used during pregnancy. Marijuana use by pregnant women can lead to several negative effects on

embryonic development including but not limited to, problems with fetal brain development; low

birth weight and small for gestational age infants; and long-term developmental and behavioral

disturbances. Adolescence begins a period of rapid biological, psychological, and social change

whose natural progression is necessary for favorable outcomes. Exposure to marijuana during


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this critical time of neural development could adversely affect cognitive, emotional, and

behavioral maturity. Research has found that long-term heavy use could lead to negative

consequences including early, pregnancy, poor health, educational underachievement, and

unemployment.

Overall Health Effects

According to Barber et al. (2013), marijuana is the most widely used illicit drug of abuse

(p. 2327). In the United States in 2010, there were approximately 17.4 million people that had

reportedly used marijuana within the past month (Sevigny, Pacula, & Heaton, 2014). Within the

past two decades (1990-2010), statistics show an overall increase in drug usage in all age groups,

and the underlying question remains is there a direct correlation between the legalization of the

drug for medicinal purposes and the increase in overall usage. Marijuana comes from the hemp

plant, or Cannabis sativa, and it is made by mixing the dried leaves, stems, seeds, and flowers

(National Institute on Drug Abuse, 2014). It has multiple modes of administration with three

main delivery methods: inhalation, oral, and topical (Leafly, 2014). The most common inhalation

delivery methods include smoking and vaporization which go directly to the lungs before

entering the bloodstream. There are various options to choose from when smoking marijuana,

including: hand pipes which are similar to tobacco pipes; water pipes (also known as bongs or

bubblers) which use water to cool the smoke before entering the body; joints which are

marijuana rolled in paper; blunts which are marijuana and nicotine rolled in cigar paper; hookah

pipes which are similar to bongs except tobacco is added; and various creative home-made

devices. Vaporization is the process of heating the herbs in the marijuana to remove the various

cannabinoids to decrease the health risks linked to smoking. An increasingly more common form

of ingestion is orally via tinctures, ingestible oils, and food/drinks. Tinctures are made by using


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extracts from marijuana and mixing it with a solvent such as alcohol, vinegar, or glycerol. Then,

a few drops of the mixture are placed under the tongue to be absorbed. Ingestible oils can be

swallowed by themselves or placed into capsules to be ingested and absorbed by the GI tract.

Marijuana can virtually be put in any food or drink, but it delivers different effects compared to

other methods of administration. It has a slower onset compared to an almost immediate effect

when absorbed by the bloodstream, but it usually causes more intense, full-body, psychoactive

effects. Topical administration includes various lotions and creams containing cannabinoid

extracts. The advantage of the topical route is it does not act on the brain; therefore, it provides

local pain relief without the psychoactive effects.

Many individuals are under the impression marijuana has very little to no harmful effects

because it is made from all “natural” ingredients, but the substance contains approximately 400

different chemicals that interact with each other as well as the chemicals in our own brain to

cause multiple physiological and cognitive impairments (NIDA, 2014). Presently, there are 23

states in the United States of America, as well as Washington D.C. that have legalized the use of

marijuana for medicinal purposes (ProCon, 2014). Also, there are now four states including

Colorado, Washington, Oregon, and Alaska that have legalized the drug for recreational use

(Governing, 2014). The impact of the legalization of marijuana on our healthcare system is huge,

and it is crucial to increase our healthcare workers’ as well as laypersons’ awareness and

education on the effects the drug can have on the body and on our society as a whole. This

section of the paper will focus on the overall health effects of marijuana on the human body

(physiologically and psychologically); the potency of the drug, the availability of the drug, and

the “gateway drug” theory that proposes marijuana is the gateway to other illicit drug use.


22

All medications and drugs have the potential to affect the body both positively and

negatively. However, it is well known that alcohol and illicit drugs cause more negative effects

and marijuana is no different. It affects many systems in the human body, including the

cardiovascular, cerebrovascular, and the respiratory systems, as well as the peripheral vascular

networks.

There is increasing evidence directly linking marijuana to various cardiovascular

conditions, including acute myocardial infarction, cardiomyopathy, increased angina,

dysrhythmias, and sudden cardiac death (Thomas, Kloner, & Rezkalla, 2014). Once the drug is

in the body, it stimulates the sympathetic nervous system and reduces parasympathetic nervous

system activity, causing an increased release of the catecholamine’s epinephrine and

norepinephrine (Frost, Mostofsky, Rosenbloom, Mukamal, & Mittleman, 2012). Epinephrine and

norepinephrine are potent vasoconstrictors which will increase heart rate, blood pressure, and

myocardial oxygen demand causing a reduction in the amount of oxygenated blood the heart

pumps out to the body’s tissues which can lead to orthostatic hypotension, syncope, ischemia and

cardiac dysrhythmias. The drug also takes an effect on the coronary microcirculation which is

the portion of the vascular system in between the arterioles and venules. Thomas, Kloner, and

Rezkalla (2014), assessed a 34-year-old man with no previous eventful medical history who had

developed syncope and ventricular tachycardia shortly after he had used marijuana. A coronary

angiography revealed a very significant reduction in coronary blood flow due to spasms

attributed to his usage of the drug. In relation to cardiac dysrhythmias, a correlation exists

between the usage of marijuana and the development of various lethal rhythms including

profound tachycardia, frequent premature ventricular beats, atrial fibrillation, ventricular

tachycardia (VT), and ventricular fibrillation (VF) (Aryana & Williams, 2007). The most lethal


23

of these rhythms, VT and VF are characterized by a widened QRS complex and quivering of the

ventricles, respectively (Sole, Klein, & Moseley, 2013). Both of these rhythms can cause a

significant reduction and/or total loss of cardiac output and pulse leading to cardiac arrest.

According to Thomas, Kloner, and Rezkalla (2014), Bachs and Morland examined 6 cases of

probable cardiac death in healthy young adults with no previous medical conditions ranging from

17 to 43 years of age that appeared to be related solely to marijuana use as evidenced by the

toxicological studies revealing only tetrahydrocannabinol (THC) in the blood and urine. The

research shows marijuana has a direct negative effect on the cardiovascular system; therefore, it

is important for cardiologists as well as other healthcare professionals to be aware of these

findings and have the proper knowledge to adequately treat their patients.

Studies have shown marijuana usage has been found to be the most important risk factor

for ischemic stroke (Thomas et al., 2014). A case was reported concerning a 37-year-old male

who reported to a healthcare facility with left-sided hemiparesis, left-sided hemihypesthesia, and

double vision 15 minutes after smoking a joint (Finsterer, Christian, & Wolfgang, 2004). The

symptoms subsided about one hour after onset. He did not take any regular medications, he had

no family history of stroke, he had no previous medical conditions, and no other risk factors for

stoke/embolism except for nicotine smoking and slightly elevated cholesterol levels. He reported

frequent usage of marijuana for about 10 years, smoking 1-2 joints per month, but within the last

year, he began smoking 1-2 joints per week because of stressful circumstances in his life. He

denied any other illicit drug use. After reviewing various diagnostics and labs, it was determined

the patient’s marijuana usage was the cause of the stroke. As previously stated, marijuana

increases the levels of catecholamines in the body which increase heart rate, blood pressure, and

cardiac output. In relation to cerebral perfusion, marijuana increases the cerebrovascular


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resistance, systolic velocity, and reduces cerebral blood flow. According to Sole, Klein, and

Moseley (2013), it also reduces the cerebral autoregulatory capacity which is the ability of

cerebral blood vessels to adjust their diameter to arterial pressure changes within the brain (p.

347). All of these factors, caused by marijuana, are interrelated to cause a decreased flow of

blood to the brain and the inability of the brain to adjust its vessel diameter to compensate

leading to an acute stroke or a transient ischemic attack. Once an individual has one stroke, the

risk of he or she having another one increases ten to twenty fold.

As stated above, marijuana has a direct effect on the cardiac and cerebral vasculature, so

it is not surprising it has an effect on the peripheral vasculature networks. Overall, the

vasoconstrictor effect occurs throughout the whole body leading to various adverse peripheral

effects including thromboangitis obliterans (Buerger’s disease), Raynaud’s phenomenon,

ischemic ulcer, and digital necrosis (Thomas, Kloner, & Rezkalla, 2014). A term was coined in

the 1960s, cannabis arteritis, a very rare peripheral vascular disease attributed to the usage of

marijuana. The disease is similar to Buerger’s disease which is characterized by the blockage of

the blood vessels in the hands and feet. Overall, the reduction of blood flow can cause acute

and/or progressive ischemia which, in severe cases, can ultimately lead to tissue necrosis,

gangrene, and amputations.

People may believe smoking marijuana is the same as smoking a cigarette, but they are

incorrect. Each year, the state of California publishes a document containing a list of chemicals

known to cause cancer or reproductive toxicity; and, in 2009, marijuana smoke was added to the

list. As previously stated, marijuana is made up of approximately 400 different chemicals, and

ammonia and hydrogen cyanide are two of them (United States Department of Justice, 2014).

Inhalation of ammonia at low concentrations can cause coughing, and nose/throat irritation,


25

while high concentrations can cause bronchiolar and alveolar edema which can lead to

respiratory distress (New York State Department of Health, 2005). Marijuana has an ammonia

concentration 20 times higher than a cigarette, and about 3-5 times more hydrogen cyanide

(USDOJ, 2014). According to the CDC (2014), hydrogen cyanide is a chemical asphyxiate

which interferes with the normal use of oxygen in nearly every organ system in the body,

especially the cardiovascular, respiratory, and central nervous systems. The inhalation of

marijuana involves inhaling the substance when the fumes are extremely hot, and it is inhaled up

to peak inspiration and held in the lungs for as long as possible before it is exhaled. The extended

period of time the fumes are held within the lungs leads to increased lung damage. Another

comparison between marijuana and cigarettes is the use of filters. It is well known cigarettes

contain carcinogen-containing tars, and marijuana contains much of the same carcinogens

cigarettes do. However, marijuana cigarettes are not filtered; therefore, they deposit more tar in

the lungs compared to cigarettes. An individual only has to smoke three marijuana joints to get

the same amount of toxic chemicals they would get from smoking a whole pack of cigarettes.

The smoke inhaled from marijuana contains a high level of carbon monoxide which attaches to

the hemoglobin molecules in the body to form carboxyhemoglobin, which decreases the amount

of oxygen that will be delivered to the organs and tissues of the body (Ignatavicius & Workman,

2013).

Marijuana not only affects the brain physiologically, but it also affects it cognitively.

Marijuana causes vasoconstriction in the body due to the release of catecholamines, but more

specifically, it narrows the arteries in the brain leading to decreased oxygen delivery. The

reduction in oxygen along with the other factors previously discussed leads to impaired memory,

decreased processing speed, impaired verbal fluency, difficulty paying attention, and a decrease


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in overall IQ (USDOJ, 2014). In relation to adolescents, marijuana can have detrimental effects

on their developing brains which will be discussed later on in the research. According to the U.S.

Department of Justice (2014):

A study done by a group of Australian researchers showed that long-term heavy

marijuana use is associated with structural abnormalities in certain areas of the brain

responsible for memory, emotion, and aggression. The brain scans revealed a reduction in

size of the hippocampus and the amygdala in men who smoked at least 5 marijuana

cigarettes daily for almost 10 years. The results of this study proved that there are adverse

effects for all users, not just individuals in the high-risk categories (young adolescents

and those susceptible to mental illness) (p. 11).

Mental illnesses are multifactorial in origin and are influenced by various genetic and

environmental factors including substance abuse. Research has shown marijuana can accelerate

the manifestations of psychotic illnesses by up to three years. The risks for the elderly population

developing schizophrenia while smoking marijuana doubles, while the risk for young people

increases from about 1% to 5%. For decades, marijuana has been described as the “feel-good

drug” to escape reality and relax, but a two-year study done by the National Cannabis Prevention

and Information Centre at the University of New South Wales in Sydney, Australia, showed

aggression in marijuana users was just as high as crystal methamphetamine users. The increased

rates of aggression and mental health issues (depression, risk for suicide, schizophrenia, etc.)

could correlate with the increased potency of the drug itself, which will be discussed next in the

research.

The chemical compound in marijuana responsible for its psychoactive properties is delta-

9-tetrahydrocannabinol, abbreviated THC (NIDA, 2014). Once the drug is inhaled, it enters the


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blood from the lungs and then travels directly to the brain. Then, the chemical binds to specific

receptors in the brain called the cannabinoid 1 and 2 receptors (CB1 and CB2) (Frost et al.,

2012). These two receptors have different effects on the body when they become activated with

the CB1 receptors increasing lipid resistance, and chronic cardiovascular function in certain

chronic diseases (obesity and diabetes), and the CB2 receptors have the potential to suppress the

inflammatory response. Overall, the two cannabinoid receptors are part of the endocannabinoid

system which is predominantly located in the hippocampus, cerebellum, basal ganglia, and

cerebral cortex of the brain which are influential in pleasure, memory, thinking, concentration,

sensory and time perception, and coordinated movement. Thus, when an individual smokes

marijuana to create a “high”, these are the areas of the brain most affected which can cause long-

term problems with learning, memory, coordination, and judgment. According to the U.S.

Department of Justice (2014):

This is not the marijuana of the 1970s: today’s marijuana is far more powerful. On May

14, 2009, analysis from the NIDA-funded University of Mississippi’s Potency

Monitoring Project revealed that marijuana potency levels in the U.S. are the highest ever

reported since the scientific analysis of the drug began. This trend continues (p. 6).

The drug has reportedly tripled in potency from what it was in the early 1980’s (about 4%) to an

average potency of 12.55%. There are so many variations in the drug itself due to different

strains, and cultivation/processing techniques that it is hard to accurately predict potency levels

(Sevigny, Pacula, & Heaton, 2014). Also, there is no way to know how much THC an individual

is smoking because the product is not regulated by the FDA.

As previously stated, the drug is not regulated by the FDA or the individual state, but

evidence has shown medical marijuana has higher potency levels compared to marijuana used


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for recreational purposes (Sevigny, Pacula, & Heaton, 2014). Evidence also shows there is a

crossover of medicinal marijuana into the black market for recreational purposes. In Colorado,

the Rocky Mountain High Intensity Drug Trafficking Program has found increasingly more cases

of medicinal marijuana being sold by the patient, caregiver, or dispensary to individuals for

recreational purposes. Currently, in 13 states, medical marijuana dispensary systems are in the

process of being created. These dispensaries will most likely produce more potent marijuana

because of higher quality controls compared to the black market. Also, decriminalization of the

possession of marijuana may lead to greater potency levels. According to Sevigny, Pacula, and

Heaton (2014), decriminalization may lead to a higher and a more stable market which may lead

to growers investing in advanced production technologies to facilitate the cultivation of higher-

potency marijuana. All of the previous factors influence the increased potency of the drug.

A study done by Sevigny, Pacula, and Heaton (2014) hypothesized that there is a direct

correlation between the medical marijuana laws and the increase in potency of marijuana over

the past two decades. The researchers analyzed potency levels from state to state from 1990-

2010 using data from the University of Mississippi’s Potency Monitoring Program (PMP), which

forensically analyzes the marijuana samples that have been seized by local, state, or federal law

enforcement. The study does have limitations because the samples provided are nonrandom

samples seized by law enforcement; however, the researchers did find data supporting their

hypothesis. The mean potency of marijuana was 3.5 percentage points higher in states with a

medical marijuana law. Overall, the increasing potency levels have a direct effect on how

marijuana affects the body systems (as previously mentioned in the sections above), and it

suggests the increasing need for federal regulatory efforts for the drug.


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The same hypothesis for the potency levels can be used when pertaining to the

availability of marijuana: Will the increased rates of the legalization of marijuana increase the

availability and the use of the drug among high-risk individuals such as adolescent teens? An

article by Freisthler and Gruenewald (2014), examined how laws affect access and use to

marijuana within specific communities in California where marijuana outlets are located. The

dispensaries are regulated on a local community basis, and the banning of these dispensaries in

certain communities has led to a new way of accessing marijuana via online medical marijuana

delivery services (Freisthler & Gruenewald, 2014). The study was conducted through a telephone

survey of 8,790 individuals’ age 18 years and older across 50 different cities in California. The

survey looked at lifetime use, past year use, and frequency of past year use in relation to the

amount of storefront dispensaries and medical marijuana delivery services available in the area.

According to Freisthler and Gruenewald (2014), “the results indicate the density of delivery

services was related to a greater likelihood of current use and more frequent use; also, the density

of storefront dispensaries were positively related to the frequency of marijuana use” (p. 248).

Medical marijuana availability in a city was directly related to the more individuals using

marijuana and the frequency of their use. The underlying question in relation to these various

dispensaries is whether they are being regulated properly, and are they ensuring the customers

buying their products have a legitimate medical marijuana card. With the increasing prevalence

of state legislatures voting for the legalization of medical and recreational marijuana, all

dispensaries in the country need to be strictly regulated not at the local community level, but at

the federal level.

Throughout the years, marijuana has acquired the nickname of the “gateway drug”

because it has been said that once an individual uses marijuana, they will most likely move on to


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using more illicit drugs such as crack, cocaine, heroin, etc. According to the U.S. Department of

Justice (2014), there have been many studies proving this hypothesis, including one conducted

on 300 sets of twins revealing the twins using marijuana were four times more likely than their

sibling counterparts to use cocaine and crack cocaine, and five times more likely to use

hallucinogens such as LSD. Another study concluded that 62% of cocaine users ages 26 years

and older had started to use marijuana before the age of 15. Numerous experiments on rats

indicate experimentation with marijuana increases an individual’s vulnerability to heroin

addiction later on. Overall, there are a multitude of factors that can cause an individual to move

from marijuana to other illicit drugs, but the studies show a direct correlation between the

addictive properties of marijuana and increasing the risk of experimenting with other drugs.

Therefore, research indicates that legalization of marijuana will lead to an increasing rate of drug

abuse with other illicit drugs.

The section above has discussed all of the negative effects marijuana can have on the

body, mentally, and physically. Therefore, how can we as healthcare professionals intervene and

increase awareness and education on the subject, and improve the overall health in our

communities? Two crucial interventions are an increase in screening for drug abuse in clinical

settings and an increase in education to individuals of all ages, but especially those with an

increased vulnerability (adolescents, individuals with mental health disorders, etc.).

First, not only do healthcare professionals need to be aware of the importance of

screening for drug abuse, but they need to have the training to accurately assess their patients and

conduct the screenings. The National Institute on Drug Abuse has developed a tool, Screening

for Drug Use in General Medical Settings: A Resource Guide for Providers (2014) (see

Appendix D), which provides clinicians with a guideline to follow while conducting patient


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screenings. The guide begins with information for the clinician on the importance of conducting

drug screenings, and provides them with a useful framework to encourage patients to quit (the

five A’s: ask, advise, assess, assist, and arrange). The rest of the guide provides a multitude of

information including: screening for alcohol, tobacco, non-medical prescription drugs, and illicit

drugs; a framework of possible intervention strategies using the five A’s; recommendations to

address patient resistance; a sample progress note template, and additional resources.

Second, after the clinician has used the screening tool, if the patient states they use

marijuana or if they are considered to be part of the vulnerable group due to various risk factors,

a fact sheet from The National Institute on Drug Abuse (see Appendix D), can be given to them

with basic information on marijuana and the harmful effects (2014). It may also be beneficial to

have lung models similar to the ones created to simulate what nicotine does to the lungs for the

patients to see. Overall, education is critical to increase the patient’s knowledge and awareness

on the detrimental effects marijuana can have on the body.

Marijuana Use among Pregnant & Breastfeeding Women

The prevalence of marijuana use among pregnant women has increased over the last few

decades making it one of the most common illicit drugs used during pregnancy. However,

knowing the exact rate of marijuana use during pregnancy is hard to determine due to the

underreporting of drug use among these pregnant women. The use of marijuana during

pregnancy can have many effects not only on the mother but on her baby as well.

Marijuana use among pregnant women in North America has been reported at 4%,

making it the most commonly used illicit drug during pregnancy. Again, self-reporting of

marijuana use makes this actual rate difficult to determine (Morris et al., 2011). Prenatal health

and development are significantly affected by marijuana use among pregnant women. First of all,


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the main active ingredient in marijuana is delta-9-tetrahydrocannabinol (THC), which readily

crosses the placenta in pregnant women. This is of particular importance because of the health

effects of maternal marijuana use on the fetus. According to a brief in Midwives, 2012, the

increase in marijuana potency in recent years has led to increased negative effects on embryonic

development. The harmful effects to the fetus can take place as early as two weeks after

conception. Because of this, the chemicals within marijuana are capable of interfering with fetal

brain development which occurs within 2 weeks after conception. This means that the effects on

the fetus usually take place before the woman even knows she is pregnant. Research from recent

years shows that marijuana exposure to the fetus has resulted in a condition called anencephaly,

in which part of the skull or brain is missing (Midwives, 2012).

Results of the Ottawa Prenatal Prospective Study and the Maternal Health Practices and

Child Development Project show that marijuana use among pregnant women can lead to

impairments in fetal functional domains including cognitive deficits, difficulty with inhibitory

control, and increased sensitivity to illicit drugs later in life. Overall, research has shown that

exposure to marijuana in utero can result in long-term developmental and behavioral

disturbances of the offspring (Morris et al., 2011). It is also concluded that maternal marijuana

use can cause low birth weight and small for gestational age in infants (Keegan et al., 2010).

Given the health effects of maternal marijuana use on fetal development and well-being,

it is also important to examine the use of marijuana among mothers who are breastfeeding their

children postpartum. As of now, there have been very few studies done on maternal marijuana

use while breastfeeding. However, according to Garry et al. (2009), some mothers use marijuana

while breastfeeding because they believe that it will calm their colicky babies due to its sedative

effects. Research shows that maternal marijuana usage while breastfeeding can cause a decrease


33

in motor development from infancy through age 1. Moderate amounts of THC, the main

addictive ingredient in marijuana, passes through breast milk to the infant. During one

breastfeeding session, an infant can consume up to approximately 0.8% of the maternal intake of

one marijuana joint. Also, maternal marijuana intake can affect the quality and amount of breast

milk produced. Studies conducted in animals show that marijuana is capable of inhibiting milk

production due to inhibiting the production of prolactin which is the protein hormone that allows

a female mammal to produce milk. Also, these studies found that marijuana can have a direct

effect on mammary glands. Maternal marijuana use while breastfeeding can have many harmful

effects on infants. These include but are not limited to: sedation, delays in growth and

development, reduced muscle tone, and poor sucking reflex. Many animal studies have shown a

change in DNA and RNA synthesis along with an alteration in proteins. These proteins are

necessary for proper newborn growth. Because of these negative effects on infants, breastfeeding

is contraindicated for mothers who use marijuana. To ensure complete understanding of harmful

side effects on the infant, the mother needs to be educated in order to promote health and prevent

illness in both the mother and the infant. It is also important to keep in mind that mothers who

use marijuana are likely to use other illicit drugs as well, such as amphetamine, cocaine, and

heroine. These drugs also have significantly harmful effects on infants so it is crucial to assess

for concurrent maternal use of marijuana and these other substances (Garry et al., 2009).

Marijuana can also have several negative effects on children as well. Because THC

connects to brain receptors on nerve cells, it can affect a child’s thinking, memory, coordination,

and concentration. Some temporary side effects of marijuana use in children include but are not

limited to: difficulty with problem solving, thinking, and learning; loss of coordination; distorted

perception; increase in appetite; lightheadedness/drowsiness; and a decrease in inhibitions (The


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Nemours Foundation, 2014). Long-term effects consist of changes in the brain, respiratory

problems, immune system complications, emotional disturbances, and fertility issues in both men

and women later in life. Although some research shows benefits of marijuana use for children

with seizure disorders and cancers, not enough evidence is available to determine whether or not

this is entirely safe. Because of this, marijuana use among children is still considered harmful

and contraindicated at this point in time (The Nemours Foundation, 2014).

Due to the increase in legalization of medicinal marijuana within certain states in the

U.S., research has shown an increase in unintentional marijuana consumptions among children.

This is thought to be related to more homes containing medicinal marijuana, resulting in easier

access for children. In fact, according to a study conducted in Colorado by Wang in 2013,

between October 1st, 2009 and December 31st, 2011, 14 patients younger than 12 years old had

marijuana ingestion detected by urine toxicology screening. These children ranged from 8

months to 12 years old. The adverse effects on the children from the ingestion included lethargy

and respiratory complications. Of these 14 medicinal marijuana exposures, 7 of them were from

food products. This is thought to be closely related to the fact that medicinal marijuana use has

been legal in Colorado as of 2009 and it is now being packaged to increase product attractiveness

to young children. For example, medicinal marijuana is now being sold in edible forms such as

candy, soft drinks, and baked goods (Rollins, 2014). Because of this increased appeal to children,

medicinal marijuana needs to be closely regulated, especially in packaging. To prevent future

unintentional ingestions by children, products should be packaged in child-proof containers with

appropriate warning labels in place. Also, parents who are prescribed medicinal marijuana need

to be educated on proper storage of these products to ensure the safety of their children (Wang,

2014).


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Given all of the above information, it is very important for us as nurses to educate these

pregnant and breastfeeding clients about the harmful effects of marijuana on both the women and

their babies. Also, if any clients already use marijuana, it is just as important to advise them to

quit. This will result in better health outcomes for them and their babies.

There are many resources available that are applicable to the cessation of marijuana use

among pregnant and breastfeeding women. These include but are not limited to: health education

in Ob-Gyn clinics, including handouts, fact sheets, and verbal provider to client education;

marijuana cessation resources, including support groups and addiction services for expecting or

breastfeeding women. Below is a list of a few applicable resources available for these women:

Organization of Teratology Information Specialists (OTIS) Marijuana & Pregnancy Fact

Sheet Handout

BabyBlog: Clearing the Smoke About Marijuana Use During Pregnancy

Marijuana & Pregnancy Handout - The Fetal Infant Mortality Review (FIMR)

Community Action Team

For more information on any of these resources, please refer to Appendix E.

Marijuana Use among Adolescents

The UN Office on Drugs and Crime say that marijuana is the world’s most commonly

used drug and there are estimates between 119 and 224 million users worldwide (Resko, 2014).

According to the National Institute on Drug Abuse, marijuana is the most commonly used illegal

drug in the United States (NIDA Notes, 2014). They report, “After a period of decline in the last

decade, its use has been increasing among young people since 2007 along with a decreasing

perception of its risks which may correlate with the legalization debate in this country” (Resko,

2014). While the subject of marijuana legalization may still be open for argument and

interpretation, research shows many adverse consequences of marijuana use, especially in

adolescents. A recent study of people who began using as adolescents showed a significant


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decreased in brain connectivity in the learning and memory areas of the brain. In another long-

term study people who began using between ages 13 and 38 lowered their IQ on an average of 8

points. For those who quit in adulthood the loss was not fully returned. Interestingly, those who

started using as an adult did not show a significant decrease in IQ, which augments the argument

for decreasing the number of youth users by advocating for comprehensive school policy;

providing resources and support for users who want assistance quitting; ensuring representation

of local communities in the state on issues related to marijuana use; and last but most important,

providing parents with effective education and resources who courageously take responsibility

for teaching their children the truth about the highly deceptive effects of this drug.

Adolescence begins a period of rapid development biological, psychological, and social

change whose natural progression is necessary for favorable outcomes (Jacobus, Bava, Cohen-

Zion, Mahmood, & Tapert, 2009). Exposure to marijuana during this critical time of neural

development could adversely affect cognitive, emotional, and behavioral maturity. In a review of

cognitive functional consequences, adolescents who used marijuana on a regular basis were

found deficient in executive functioning and “demonstrated poorer performance on verbal

learning, memory, sequencing, and psychomotor speed compared to non-using adolescents after

approximately one month of abstinence” (Jacobus, Bava, Cohen-Zion, Mahmood, & Tapert,

2009). Younger users could be increasing their susceptibility to the consequences of toxicity on

their developing brain, which could lead to difficulty retaining information, risky decision-

making and impaired driving. Sleep is essential to healthy development and use may disrupt

sleep resulting in adolescents highly susceptible to sleep deprivation and neural development

alterations.


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A longitudinal cognitive study revealed that adolescent Marijuana use could interrupt

normal brain maturing leading to structure and functional alteration as evidenced by aberrant

patterns of activation on imaging studies (Hanson et al., 2010). This suggests that “once

cognitive deficits are no longer detectable, brain function may remain affected” requiring them to

use different learning strategies and the need to work even harder than those who abstain from

using Marijuana.

Research has found that long-term heavy use could lead to negative consequences

including early pregnancy, poor health, education underachievement, and unemployment (Green,

Doherty, Stuart, & Ensminger, 2010). Despite increasing evidence of these negative

consequences, only about half of the high school seniors in the US think marijuana use is risky

when used on a regular basis. This figure is decreased from almost 80% in the early 1990s.

Polls have also shown increasing positive attitudes for legalization.

One very concerning potential effect of adolescent use is the increased risk of criminal

behavior, such as economically driven or property crime, which also has negative health and

social effects (Green, Doherty, Stuart, & Ensminger, 2010). The strong link between use and

crime has similar risk factors including “poor family relations, low socioeconomic status, family

vulnerability to deviance, poor school achievement, behavioral problems, and a general

disposition to non-conformity”. The association of high school dropouts and adolescent heavy

Marijuana use partially explains the correlation between use and crime. Heavy adolescent users

had more arrests resulting in higher chances of incarceration, developing a drug-use disorder,

and the propensity toward using cocaine or heroin. In a meta-analysis of 30 studies the

relationship between drug use and criminal behavior showed the odds increased three to four

times greater than with non-users (Bennett, Holloway, & Farrington, 2008). The offence-type


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escalated to shoplifting, burglary, prostitution, and robbery. With this escalation of negative

consequences, it seems reasonable, even imperative, that preventing adolescent use in the first

place should be top priority.

There is a wide variety of herbal mixtures referred to as Spice marketed as safe and being

sold by names such as Skunk, fake weed, K2, and others that contain synthetic chemicals causing

psychoactive effects (National Institute on Drug Abuse, 2012). These products are popular with

young people because of their accessibility and the common misconception that they are a

natural product. This coupled with the fact that the chemicals are not easy to detect on a drug

test make it second only to the use of marijuana among high school seniors. It’s reported the

popular brand of Spice called K2, clearly marked Not for Consumption, is being sold as incense

resembling potpourri, which is smoked and is also infused for drinking as well.

Spice affects the brain much like marijuana causing experiences of mood elevation,

relaxation, and perception alteration (National Institute on Drug Abuse, 2012). Others have

reported extreme anxiety even paranoia and hallucinations, effects even stronger than with

marijuana. There are other serious effects reported to the Poison Control Center that include

tachycardia and high blood pressure. Regular use can lead to withdrawal and symptoms of

addiction. Use of this legal alternative to marijuana has lead to thousands being treated in the

emergency room, especially young men. This may be, in part, why usage was down from 11.3%

2012 to 7.9% in 2013.

According to The North Dakota Epidemiological Profile dated October 2012, community

members characterized drug use and abuse as a serious problem and a contributing factor of car

crashes and injuries in the statewide survey on community perceptions of alcohol and other drugs

(The North Dakota Epidemiological Profile, 2012)


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In the 2008-2009 National Survey on Drug Use and Health (NSDUH), marijuana use

prevalence for North Dakotans for adolescents included: aged 12 and older (8.3 percent) and

ages 12-17 (9.4 percent). The Youth Risk Behavioral Survey indicated that 6.4 percent of high

school students in 2011 tried marijuana for the first time before age 13 years. This compares to

the U.S. prevalence, which was 8.1 percent, and, in fact, the U.S. prevalence was higher than the

North Dakota prevalence across all years surveyed. North Dakota boys (8.2 percent) were more

than twice as likely than girls (4.0 percent) to have tried marijuana before age 13. This trend has

been consistent over the past ten years.

Finally, the subject of marijuana use is not a new subject to parents’, however the lack of

education and wisdom on how best to deal with it can be difficult if not horrifying for

responsible parents who want to be involved in talking with their adolescents. The school

district cannot be solely responsible for education and prevention of substance abuse, according

to the valuable resource, Marijuana and the Responsible Parent, “It is parents who can

absolutely make the most difference” in preventing harm that inevitable exposure will have

(Environmental Resource Center, 2014). They continue, “No drug speech by a police officer has

the influence of a caring parent. No counselor can ever have the powerful touch of family”.

While all these factors may influence and have their place, parenting is a very special and

dominant power in protecting adolescents. The need for strong resolve, a commitment to finding

accurate information, and a unique style that only parents have in context of their own family can

be key factors in successfully reaching and teaching adolescents on marijuana use.

A survey of 10,000 teens by the Partnership for a Drug-Free American found that the

risk of jail or failing health didn’t concern them as much as potentially disappointing their

parents (Environmental Resource Center, 2014). This is extremely important to understand in a


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society where there is increasing disrespect for authority by adolescents. Michael Resnick states,

“Many adolescents are very skillful in conveying the message that what parents say is irrelevant.

As parents, our mistake is to believe them”. On the surface, friends may seem as the most

important thing to them, in creatively helping them dig a little deeper, they may realize the

reality that parents and family are who matter most. Leaving this responsibility of education to

the school, police, or the church is dangerous. Parents must arm themselves’ because marijuana

is always available. Whether living in a small town or inner city, the exposure rates are similar.

Interestingly, “from ages 12-17, marijuana is two to four times easier to buy than beer, and has

been for years. Now, a cannabis high may be easier to access than ever with potentially legal

synthetic marijuana available over the counter and over the Internet.”

The recent increase in marijuana use “places teens at risk for other addiction, impairs

memory, judgment, and ability to learn” (NIDA Notes, 2010), which tends to endanger their

future. With the decline in perceived risk of using marijuana among young people, the

unfortunate result is increased use. Dr. Nora D. Volkow, Director of NIDA, “speculates that the

recent increase in teen use may be caused by the attention that the potential use of marijuana as a

medication has generated” (NIDA Notes, 2010). This attitude contributes to adolescents decline

in risk perception leading to increase use. These are all reasons advocating for comprehensive

school policy with a goal of decreasing the number of youth users, ensuring representation at the

local and state level on issues related to marijuana use, and making resources and support

available for those who seek assistance quitting is so important.

It takes courage to talk with teens about the facts and risks of marijuana use while

emphasizing a parents’ absolute concern for the good of their child, but both are necessary for

effective connection (Environmental Resource Center, 2014). This is a time when accepting


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parental values automatically is challenged by a variety of experiences and filling their

impressionable minds with a myriad of important life choices. Marijuana and the Responsible

Parent (see Appendix F), suggests many effective considerations such as the importance of

avoiding scare tactics, listening carefully, cautiously confronting personal use, and never trying

to talk to any youth while using. It also contains very helpful facts about types of natural and

synthetic marijuana, levels of intoxication, health risks involved, and some special concerns such

as potency, mixing drugs, and legal problems adolescents may face.

Additional resources can be found at the National Institute on Drug Abuse special

website devoted to adolescents NIDA for Teens with articles on issues such as potentially having

a breath test for marijuana similar to the one available to test alcohol; how scientists are trying to

see if the chemicals in marijuana are medically useful; and how the state of Colorado has

highlighted drug-driving laws with the use of humor. Adolescents need to have the realities of

marijuana use clearly, knowledgably and honestly explained by those in their lives they most

trust. This guide can help provide those essentials for parents who are willing to stand up and be

that trusted source of information for their children. One very important intervention a public

health nurse can use to effect positive change for patients, their families, and the communities

they live in is assisting them in identifying and accessing the necessary resources to prevent or

resolve problems or concerns they have. These adolescent-specific resources can help those in

the most trusted profession of nursing, who are faced with the challenge and privilege of

educating and referring clients, family, and friends on this sensitive subject to this vulnerable

population during a very pivotal stage in life.


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Distribution of Marijuana

The legalization of medical marijuana can be predicted as inevitable for all fifty states in

the United States of America in the future. With the legalization of medical marijuana, there is

going to be numerous concerns that would need to be addressed to assure complete safety for

consumers of the medical marijuana products. Looking at the distribution aspect of the

legalization of medical marijuana rising concerns include: packaging, the forms that medical

marijuana is provided in, and where medical marijuana products are being distributed from.

Interventions would need to be made that assure safety for all consumers and also the people that

are in close quarters with consumers.

With the current debate over the legalization of marijuana in different states around the

United States, there are many areas that are gray and not just black and white. One area that

would need to be researched further, either on a statewide or federal level is the distribution

aspect of marijuana. Looking specifically at medical marijuana being legalized, a decision should

be made on the licensed professional who can prescribe, handle, and dispense medical marijuana.

Other areas of concern about distribution that should be examined are how the dispensaries will

regulate the packaging so it is childproof, how to regulate the packaging so it is not easily

confused with regular food items, how to educate the consumer on the disposal of the used

packaging or any excess marijuana residue they may have, the different potencies of each form

the marijuana will be distributed in, regulations on advertisements for marijuana; medical

marijuana versus illegal and legal recreational marijuana costs, and whether or not there should

be taxes placed on medical and recreational marijuana products.


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Current State Distribution

According to NORML, as of November 4th, 2014, there are twenty-three states and the

District of Columbia that have passed the legalization of medical marijuana. Reasons for the

prescription and use of medical marijuana include, but are not limited to: chronic pain due to

cancer, HIV/AIDS, stimulation of appetite for individuals who suffer from anorexia and

cachexia, glaucoma, prevention of nausea and vomiting in individuals who are receiving

chemotherapy and radiation, seizures, epilepsy, amyotrophic lateral sclerosis, and multiple

sclerosis. In order to move forward in North Dakota with the debate on the legalization of

medical marijuana, it is necessary to look into how other states have come to their legislative

decisions and what they have included in their regulations. All of the following state information

was found by researching the state laws on norml.org/laws.

Alaska.

In Alaska, in order to qualify for medical marijuana, your physician would need to have

diagnosed a patient with cachexia, cancer, chronic pain, glaucoma, HIV/AIDS, multiple

sclerosis, nausea, or seizures. The patient is allowed to have one ounce of usable marijuana on

them at a time. They are allowed to grow plants at home. Alaska currently does not allow state

licensed dispensaries. If the patient who is prescribed the use of medical marijuana and he or she

is unable to administer it themselves they are allowed to have a primary or secondary caregiver.

The primary or secondary caregiver must be over the age of twenty-one, and they must not have

any felony charges of a controlled substance offense.

Arizona.

In Arizona, in order to qualify for medical marijuana, you need to be diagnosed with

Alzheimer’s disease, amyotrophic lateral sclerosis, cachexia, cancer, chronic pain, Crohn’s


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disease, glaucoma, hepatitis C, HIV/AIDS, multiple sclerosis, nausea, or seizures. As of January

1, 2015, post-traumatic stress disorder (PTSD) will be legalized for the use of medical marijuana.

Clients who are prescribed medical marijuana can grow their marijuana from home if they are

more than twenty-five miles away from any licensed state dispensary. Arizona has state licensed

dispensaries, but they must be non-profit facilities.

California.

In California, in order to qualify for medical marijuana, you need to be diagnosed by a

physician with arthritis, cancer, chronic pain, HIV/AIDS, epilepsy, chronic migraines, multiple

sclerosis, or any debilitating disease where the medical use of marijuana has been approved

and/or recommended by a physician. There are currently no restrictions on how much a patient

can possess at one time. California does not currently have any restrictions on the amount of

marijuana a patient can grow. Some cities in California regulate marijuana dispensaries, but

presently there are no state licensed dispensaries. A caregiver can administer marijuana to the

patient but the caregiver must be eighteen years of age, designated by a patient who is qualified

to make decisions and who has steadily provided priority care to the patient.

Colorado.

Colorado is one of the first states to have legalized medical and recreational marijuana.

In order to medically qualify for the use of marijuana, a physician needs to diagnose an

individual with cachexia, cancer, chronic pain, any chronic nervous system disorder, epilepsy,

glaucoma, HIV/AIDS, multiple sclerosis, or chronic nausea. The patient is only allowed to have

two ounces of usable marijuana in their possession at a time. A patient can only have one

primary caregiver who is over the age of eighteen.


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Recreational use of marijuana requires the buyer to be twenty-one years of age or older

and they can have up to one ounce of marijuana in their possession. A person can legally give

out one ounce or less of marijuana if there is no payment required. In other words, it is not legal

to sell marijuana for recreational use outside of state licensed dispensaries.

Connecticut.

In Connecticut, for a person to qualify for medical marijuana, a physician needs to

diagnose an individual with cachexia, cancer, Crohn’s disease, epilepsy, glaucoma, HIV/AIDS,

intractable spasticity, multiple sclerosis, Parkinson’s disease, or post-traumatic stress disorder

(PTSD). According to ProCon.org, patients are allowed to have a one-month supply of

marijuana in their possession at a time; this amount is determined by the physician who has

prescribed the marijuana, therefore a one month supply is not a standard weight or count. It is

based on a patient by patient basis. The state of Connecticut does not allow home cultivation of

marijuana. There are licensed state dispensaries and primary caregivers that are allowed to

administer the prescribed medical marijuana.

Delaware.

In Delaware, in order to qualify for medical marijuana, a physician needs to diagnose a

person with Alzheimer’s disease, amyotrophic lateral sclerosis, cachexia, cancer, chronic pain,

HIV/AIDS, nausea, PTSD, seizures, or severe and persistent muscle spasms. The patient may

possess up to six ounces without allowance to grow their marijuana at home. Although

Delaware has approved state dispensaries, there are currently no functioning dispensaries within

the state. Caregivers are not allowed to administer marijuana in the state of Delaware.


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District of Columbia.

District of Columbia allows the distribution of medical marijuana for HIV/AIDS,

glaucoma, multiple sclerosis, cancer, and other conditions that are chronic, long lasting,

debilitating, or that interfere with the basic functions of life. The Department of Health in the

District of Columbia states that “patients are permitted to purchase up to two ounces of dried

medical marijuana per month or the equivalent of two ounces of dried medical marijuana when

sold in any other form.” It is illegal for any patient to grow marijuana in their home. The

District of Columbia has licensed state dispensaries and primary caregivers are allowed to

administer the prescribed medical marijuana. Medical marijuana patients in District of Columbia

must choose one dispensary where they will receive their medical marijuana. They are not

allowed to visit more than one dispensary but they can change their dispensaries in the area if

need be. According to the Department of Health in District of Columbia, a patient can change

dispensaries by filling out a form. In addition to the form, a $90 fee is required from the state.

The $90 fee is to pay for a new registration card for the patient. The registration cards in District

of Columbia have the dispensaries name on them, therefore when a patient chooses to switch,

their registration card must be replaced.

Hawaii.

In Hawaii, medical marijuana is allowed to be prescribed for conditions including cancer,

glaucoma, or a positive HIV/AIDS status. Medical marijuana can also be prescribed for any

chronic and debilitating disease that can cause cachexia, severe pain, severe nausea, seizures, or

severe and persistent muscle spasms, which include the diseases multiple sclerosis or Crohn’s

disease. This supply may be possessed jointly between the patient and the primary caregiver.


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Illinois.

In the state of Illinois, medical marijuana can be legally prescribed for debilitating

medical conditions that include forty chronic diseases and conditions. Some of these diseases and

conditions include cancer, glaucoma, a positive HIV/AIDS status, and amyotrophic lateral

sclerosis, agitation of Alzheimer’s disease, cachexia, muscular dystrophy, severe fibromyalgia,

multiple sclerosis, Parkinson’s disease, and Myasthenia Gravis. The approved amount of

marijuana that is allowed to be in possession of a consumer is two and half ounces of usable

marijuana during a fourteen day period. It must be derived from a source within the state. On

July 20, 2014, the Compassionate Use of Medical Marijuana Act was signed by Illinois

Governor Quinn. This act allows children under the age of eighteen to be treated with non-

smokable forms of medical marijuana for the same conditions originally approved for adults.

Maine.

In Maine, the approved medical conditions that medical marijuana can be prescribed for

include cancer, hepatitis C, amyotrophic lateral sclerosis, Crohn’s disease, Alzheimer’s disease,

epilepsy, glaucoma, multiple sclerosis, post-traumatic stress disorder, cachexia, and nausea or

vomiting as a result from AIDS or chemotherapy. Patients may legally possess no more than one

and one quarter ounces of usable marijuana.

Maryland.

Maryland allows medical marijuana to be prescribed for conditions including cachexia,

anorexia, severe or chronic pain, severe nausea, seizures, and severe or persistent muscle spasms.

Patients are allowed a thirty day supply, with the amount being approved by the Maryland

Department of Health, in their possession.


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Massachusetts.

In the state of Massachusetts, medical marijuana can be prescribed for cancer, glaucoma,

a positive HIV/AIDS status, hepatitis C, amyotrophic lateral sclerosis, Crohn’s disease,

Parkinson’s disease, and multiple sclerosis. Patients may possess no more marijuana than is

necessary for their personal medical use, and it should not exceed the amount needed for sixty

days.

Michigan.

Michigan has approved medical marijuana to be prescribed for treatment of debilitating

medical conditions, including cancer, glaucoma, HIV, AIDS, hepatitis C, amyotrophic lateral

sclerosis, Crohn’s disease, agitation of Alzheimer’s disease, cachexia, severe and chronic pain,

severe nausea, seizures, epilepsy, muscle spasms, multiple sclerosis, and post-traumatic stress

disorder. Patients are allowed up to two and a half ounces of usable marijuana.

Minnesota.

In Minnesota, medical marijuana may be prescribed for cancer if the cancer is causing

severe or chronic pain, nausea, severe vomiting, or cachexia. It may be prescribed for glaucoma,

HIV/AIDS, Tourette’s syndrome, amyotrophic lateral sclerosis, seizures, epilepsy, multiple

sclerosis, Crohn’s disease, or terminal illness with a life expectancy of less than one year. There

will be two in-state manufacturers for producing all medical marijuana, registered by the

Commissioner of Health. The medical marijuana that will be distributed will not exceed a thirty-

day supply at one time, with the patient-specific dosage. The Legislature of the State of

Minnesota states in their bill that “Medical cannabis is defined as a species of the genus cannabis

plant delivered in the form of liquid, oils, pills, and a vaporized delivery method that does not

require the use of dried leaves or plant form. Smoking is not a method approved by the bill.”


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Montana.

In Montana, the conditions that are approved for the legal use of medical marijuana are

cancer, glaucoma, HIV/AIDS, a chronic or debilitating disease, cachexia, severe or chronic pain,

nausea, seizures, epilepsy, severe or persistent muscle spasms, multiple sclerosis, and Crohn’s

disease. A patient or their caregiver may possess up to six marijuana plants and may have up to

one ounce of usable marijuana in their possession at a time. A caregiver that is administering the

marijuana is not allowed to accept anything of value, including money, for any services or

marijuana products provided.

Nevada.

The conditions that are approved for the legal use of medical marijuana in the state of

Nevada include AIDS, cancer, glaucoma, cachexia, persistent muscle spasms, seizures, severe

nausea or pain, and PTSD. Patients or their caregivers can legally have no more than one ounce

of usable marijuana in their possession. This law was passed in the state of Nevada on October

1, 2001.

New Hampshire.

In the state of New Hampshire, the use of medical marijuana can be therapeutically used

for the physician determined conditions of cancer, glaucoma, HIV/AIDS, hepatitis C,

amyotrophic lateral sclerosis (ALS), muscular dystrophy, Crohn’s disease, agitation from

Alzheimer’s disease, multiple sclerosis, chronic pancreatitis, spinal cord injury or disease, or a

traumatic brain injury. Medical marijuana can be used for any condition that has caused

significant interference with activities of daily living such as; elevated intraocular pressure,

cachexia, chemotherapy, induced anorexia, severe pain that has not been relieved by previous

treatments and medications, constant or severe nausea and vomiting, persistent muscle spasms,


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and seizures. A person prescribed medical marijuana is not allowed to have more than two

ounces of usable marijuana in their possession or in their caregiver’s possession.

New Jersey.

In the state of New Jersey, with patients who suffer from debilitating medical conditions,

their prescribing physicians, primary caregivers, and those who are authorized to produce

medical marijuana are protected from arrest, prosecution, or any other criminal penalties from

the use of, prescribing of, or production of marijuana for medical purposes. Although these

people are safe from state prosecution they may not be protected from federal prosecution.

Federally, anyone could still be prosecuted for the possession of marijuana if the charges

violated federal law. If the patient, physician, and caregiver are still within rights of the state in

which they reside, they are protected. Medical conditions approved for the use of medical

marijuana are seizure disorders, epilepsy, intractable skeletal muscular spasticity, glaucoma,

severe or chronic pain, severe nausea or vomiting, cachexia due to HIV/AIDS or cancer,

amyotrophic lateral sclerosis, multiple sclerosis, terminal cancer, muscular dystrophy,

inflammatory bowel disease including Crohn’s disease, and any terminal illness that the

physician has determined to be fatal in less than twelve months. The patient is allowed to have

only two ounces in their possession for a thirty-day period.

New Mexico.

As of April 23, 2014, the approved medical conditions for the use of medical marijuana

are chronic pain, peripheral neuropathy, severe nausea and vomiting, induced anorexia, cachexia,

hepatitis C, Crohn’s disease, post-traumatic stress disorder, amyotrophic lateral sclerosis, cancer,

glaucoma, multiple sclerosis, damage to the nervous tissue or spinal cord, epilepsy, HIV/AIDS,

hospice patients, cervical dystonia, inflammatory autoimmune arthritis conditions, Parkinson’s


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disease, and Huntington’s disease. The patient is allowed to have up to six ounces of prescribed

marijuana in their possession.

New York.

New York approved the use of medical marijuana in fall of 2014 along with Maryland

and Minnesota. This approval allows for the distribution of medical marijuana for cancer,

epilepsy, HIV/AIDS, Huntington’s disease, inflammatory bowel disease, amyotrophic lateral

sclerosis, Parkinson’s disease, multiple sclerosis, neuropathy, and spinal cord damage. Medical

marijuana users are not allowed to possess whole-plant marijuana; they are only allowed to have

oils, pills, or extracts prepared from the plant. Home cultivation has been made very difficult in

the state because it only allows a patient to grow a thirty-day supply of non-smokable marijuana.

New York currently has five manufacturers of legal forms of marijuana-based preparations and

up to twenty dispensing centers that are approved and licensed by the state. Caregivers are not

allowed to administer marijuana in the state of New York.

Oregon.

Oregon allows the distribution of medical marijuana for Alzheimer’s disease, cachexia,

cancer, chronic pain, epilepsy, glaucoma, HIV/AIDS, multiple sclerosis, nausea, PTSD, and

other conditions that are subject to approval. A patient in Oregon is allowed to have a total of

twenty-four ounces of marijuana in their possession at a time. The state has approved of state

licensed dispensaries but currently do not have any dispensaries approved and running. Only

patients with debilitating medical conditions are allowed to have their caregivers administer

marijuana for them. The patient may only have one primary caregiver, and the caregiver must be

twenty-one years or older.


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Rhode Island.

Rhode Island allows for the distribution of medical marijuana for Alzheimer’s disease,

cachexia, cancer, chronic pain, glaucoma, hepatitis C, nausea, seizures, severe and persistent

muscle spasms and other conditions that are subject to approval. A patient that is approved in

Rhode Island for medical marijuana may currently possess up to two and one half ounces on

their person at one time. Currently, Rhode Island does not allow more than three dispensaries in

the entire state at any given time. Caregivers are allowed to administer marijuana if they are

twenty-one years of age and they are allowed to have more than one primary patient at a time but

no more than a total of five patients.

Vermont.

Vermont allows for the distribution of medical marijuana for cachexia, cancer,

HIV/AIDS, multiple sclerosis, seizures, severe pain and severe nausea. These patients are only

allowed to have up to two ounces on themselves at a time. Vermont currently has running

dispensaries, but there are no more than four allowed in the state at a time. Vermont is the only

medical marijuana approved state that allows dispensaries to make home deliveries. Caregivers

are allowed but must be twenty-one years or older and they are only permitted to have one

patient at a time.

Washington.

Washington was the first state in the United States to allow the use of both medical and

recreational marijuana. Distribution for medical marijuana in Washington requires a patient to

have cachexia, cancer, Crohn’s disease, epilepsy, glaucoma, hepatitis C, HIV/AIDS, chronic

pain, muscle spasms and/or spasticity, multiple sclerosis, nausea, seizures and other conditions

that are subject to approval. The state allows a patient to have twenty-four ounces in their


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possession at one time. Washington currently has the highest allowance of legally home-grown

marijuana at a total of thirty-nine plants, with twenty-four that can be usable and fifteen that

must still in progress. There are no state regulated dispensaries in the state, but similar to

California, some cities in Washington regulate their local dispensaries. Caregivers are allowed

to administer medical marijuana as long as they are designated by the patient, eighteen years or

older, and are prohibited from consuming marijuana for personal use.

Medical Marijuana Costs versus Recreational Marijuana Costs

Medical marijuana tends to be more expensive than illegal recreational marijuana. That

being said, medical marijuana is still cheaper than legal recreational marijuana.

Of the twenty-three states that have legalized medical marijuana, only Arizona, California,

Colorado, Connecticut, Maine, Michigan, Montana, New Mexico, Rhode Island and Washington

employ licensed dispensaries to sell medical marijuana. Because the sale and distribution of

marijuana of any kind remains illegal under federal law, these dispensaries operate in a gray area

at best and frequently face threats of forced shutdowns from federal officials (Ross, 2014).

Taxing on Marijuana

Medical marijuana in most states is subject for sales tax. Some don’t believe medical

marijuana should be taxed because of the fact that it isn’t covered by health insurances.

Others believe that because it is a medication that the state should not be able to benefit off of its

residents’ medications (Marijuana Policy Project, 2013).

Prescription drugs are exempt from having a sales tax, but because marijuana is a

Schedule 1 controlled substance, it cannot be prescribed legally under federal or state law (Office

of Diversion Control, 2014). The California board of equalization looked at the sales tax from

medical marijuana sales in 2007. It is estimated that medical marijuana brings in a total of $700


54

million to $1.3 billion a year. Based on the annual sales of medical marijuana in the state of

California in 2007, the total amount of sales tax that the state received was between $58 million

and $105 million (Raghavan, 2013). According to the Colorado Department of Public Health

and Environment, Colorado only allows patients that are on medical marijuana who are classified

as low income to be exempt from the sales tax.

In addition to medical marijuana sales generating tax revenue, in most or all states with

regulated dispensaries, the application and registration fees levied on medical marijuana

businesses cover the costs of regulating them. In twenty states, those who possess medical

marijuana are legally required to purchase and attach state-issued stamps onto his or her

marijuana products. The total cost of the tax is generally determined by the quantity of marijuana

products possessed. Unlike typical criminal laws that prohibit the possession and sale of

controlled substances, drug tax stamp laws primarily assess financial penalties on the defendant

for noncompliance (NORML, 2014).

Eleven school districts in Colorado that had applied for grants will receive nearly one

million dollars in funding from marijuana tax revenues. These grants will go towards hiring

school nurses, social workers, and psychologists to help prevent and treat substance abuse among

students. Other areas that the tax revenue will be put towards in Colorado include substance

abuse programs, school construction, and training and equipment for law enforcement agencies

to deal with marijuana-specific problems. This includes people driving under the influence of

marijuana (NORML, 2014).

Federally Approving Medical Marijuana

The United States would benefit exponentially if citizens would consider removing

marijuana from the Schedule I substance list to either Schedule II or III. In an article written by


55

Divya Raghavan, the United States of America could make approximately $3,098,866,907 per

year from marijuana tax revenue. This number would help decrease United States’ debt, reduce

the costs of law enforcement officials involved in illegal substances, and decrease the number of

citizens in jail for marijuana related charges.

The twenty-three states that currently approve the usage of medical marijuana have

different distribution laws. By making the use of medical marijuana legal across all fifty states,

the government would be able to regulate the distribution of marijuana in the same manner that

we regulate alcohol and tobacco. A pharmaceutical company could make multiple forms of

medical marijuana in addition to producing multiple strengths. All medications and forms would

be approved through the Food and Drug Administration.

Places of Distribution

Dispensaries.

Each state has different regulations for how their dispensaries are run. Hawaii, Montana,

Oregon, Vermont, and Washington do not allow dispensaries within the state; three of these

states have legalized the use of marijuana for medical and recreational purposes. The majority of

the states do not have strict regulations on dispensaries, if they have regulations at all. Nevada

has multiple dispensaries throughout the state but there are no policies in the law that approve of

these dispensaries. These dispensaries are also not regulated by the state based on the product

they receive, where the shipment comes from and who is purchasing the marijuana (Find Law,

2014).

Pharmacies.

Due to the influx of states that are legalizing marijuana, medically or recreationally, state

legislatures are required to come up with ways to locally regulate the dispensaries that distribute


56

marijuana. One possibility is having local and nationwide pharmacies become legalized medical

marijuana dispensaries. Because there is such an increase in the number of states that are

legalizing medical marijuana, it would be beneficial for a pharmacist to supervise the making of

whichever form of medical marijuana has been prescribed. Ideally, this would then assure a safe

and accurate dose in the prescriptions being received by the consumer. A possible complication

that pharmacies would need to look into is whether or not insurance companies will continue to

provide coverage to the facility, as the distribution of marijuana may be viewed as a liability for

the pharmacy. The pharmacists would need to know whether or not their employers would

provide them with legal protection for the distribution of marijuana for medical purposes. Even

though the state may legally protect the pharmacist, they could still be under federal charges of

prosecution from the distribution of marijuana.

Pharmacies should keep all prescriptions behind the counter, with strict protocol for

monitoring the distribution of the product. Each person who is prescribed medical marijuana by

their physician will be required to register within the state in which they reside and receive an

identification card proving their prescription that was approved by a physician. ProCon.org

states that almost all states require patient registration except for Maryland, Minnesota, New

Hampshire and New York. These four states have not yet opened patient registration because

they are still determining the rules required for the program. The identification card would

contain the client’s name, the dosage of the medical marijuana they can receive, and the

expiration date of their prescription. The medical marijuana registration card must be shown

with proof of personal identification, such as a passport or driver’s license. It would be

mandatory to present this card to any state licensed pharmacy approved to distribute medical

marijuana.


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Pharmacies should require employees to take an in-service on how to measure the exact

doses of tetrahydrocannabinol (THC), calculate these doses to prevent overdoses, and how to

educate the client on the correct way to administer the medical marijuana, the effects the client

may experience, and any signs or symptoms that would indicate a need for medical attention.

There should be consistent, nationwide rules on how to measure the amounts of THC in the

different forms of medical marijuana, to provide assurance that the consumer is receiving the

exact dose they have been prescribed. According to The National Institute of Health, presently,

pharmacists are not able to recommend a source of medical marijuana, provide specific

instructions for the drug’s use, or obtain the drug for a patient’s use.

Instructions or a questionnaire should be provided to consumers before distribution that

include asking if they are experienced users, instructions to avoid taking marijuana on an empty

stomach, and a warning that factors such as body mass index, age, or gender can vary the

effectiveness of the medical marijuana (Baca, 2014).

Forms of Marijuana Ingestion

Marijuana is not a uniform product. It can vary by strain, cultivation technique, the way

it’s processed, and the type of plant it comes from (Pacula & Sevigny, 2014). The different

forms of marijuana ingestion include, but are not limited to: inhalation through smoking,

capsules, vaporization, oral ingestion, oils, suppositories, and liquid form. Marijuana can be

prepared for cooking by pulverizing it into powder called “canna flour.” Marijuana can be

extracted into a fat or oil that can be called “canna butter.” There are possibilities for medicated

cookies, brownies, candies, caramels, chocolates, and rice crispy treats. Edible forms of medical

marijuana are one of the most popular ingestible forms that can be purchased in medical

marijuana shops in Colorado. This is because they are discreet, and if there are laws where you


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can’t smoke marijuana in public, one could still medicate themselves with edible forms (Baca,

2014).

Laboratory Testing

Before official distribution of the product, all marijuana plants being used should be

tested for fungus, mold, bacteria, and any other microbial organisms for safety of any consumers,

especially for those who are immunocompromised. All marijuana products should come with a

cannabinoid profile that includes the content of THC, and the doses and number of doses in each

product (Drug Policy Alliance, 2014). There should also be a nation-wide regulated procedure

for testing the amount of THC in each marijuana product that is accurate.

Packaging

With the edible forms of marijuana, the products come with different forms of packaging

that can look very similar to regular food items that would be appealing to any type of person.

There are forms of packaging that look almost identical to popular candy items, such as a

Butterfinger chocolate bar. There are medical marijuana products that look like popular ice

cream bars, soda drinks, chocolate hazelnut spreads, or toaster pastries. These products could be

easily mistaken for a regular food item, and because of this, could be easily ingested by the

wrong person, including children.

Packaging for medical marijuana still comes in the same standardized forms that you

would see used for illegal marijuana. Consideration for packaging that needs to be regulated as a

state is child proof containers; prescription identification which would state the patient, the

prescribing physicians, the dose, the expiration date, and the state registration identification card

number. Considerations in the instructions for packaging should include proper disposal of

excess residue and proper disposal of empty packaging. Proper disposal of excess residue and


59

empty packaging should be disposed in a sharps container and should be treated similar to that of

a diabetic patient when disposing used needles.

Advertising and Media

Should medical marijuana be advertised? The debate on advertising the use of marijuana

is ongoing. Due to marijuana being considered a Schedule I substance drug under federal law it

would currently be the same as advertising the use of heroin, ecstasy, and lysergic acid

diethylamide (LSD). Schedule I substances are considered to have no use medically in health

care and are at a high risk for abuse.

Most families in the United States would frown upon the advertising of illegal

substances. Using advertising for a drug such as marijuana could increase the “cool factor” in

the child and adolescent age group. By thinking using marijuana is “cool” to do, the younger

population may have an increased susceptibility to unnecessary use and abuse of marijuana.

This can be compared to the advertising of tobacco. Tobacco companies would portray the use

of tobacco as masculine or sexy. This, in turn, increased the rates of tobacco use.

Advertisement of medical marijuana, in our eyes, should not be utilized in the media.

Advertising the use of medical marijuana could increase the rates of drug-seeking behaviors in

patients, when they may not actually need medical marijuana. Even drugs that are currently

legalized are not advertised such as Adderall because it is considered a stimulant.

Possible Alternative Product

Cannabidiol (CBD) is being studied as an alternative to medical marijuana. Unlike THC,

CBD doesn’t create the “high” or “stoned” effect. It is being currently tested for treating

uncontrollable seizures (Nguyen, 2014). The fact that CBD-rich cannabis doesn’t get one high

makes it an appealing treatment option for patients seeking anti-inflammatory, anti-pain, anti-


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anxiety, anti-psychotic, or anti-spasm effects without troubling lethargy, excessive hunger or

dysphoria.

Regulation of Marijuana

The focus of this community assessment project is to explore the health effects, including

risks and benefits, of legalizing medical marijuana in North Dakota. The following sections will

go into more detail about the following (1) regulation of medical marijuana, including laws

regarding legalization and state and federal regulation, (2) the laws pertaining to whether an

individual can cross state lines while in possession of marijuana, (3) what the research says about

the taxation of marijuana and what would be an appropriate tax to place on marijuana sales, (4)

limits of purchase including how much medical marijuana a person is allowed to possess and the

criteria for a prescription, as well as how much Tetrahydrocannabinol (THC) can legally be

allowed in the product, (5) insurance coverage, (6) and laws regarding marijuana and how it

relates to driving under the influence (DUI). These are important topics for a community to

discuss when debating whether to legalize medical marijuana in their state because regulation

and laws must be in place and be appropriate to ensure the safety of the community.

Delving many years back into United States history, one can see that there has been an

ongoing debate about the legalization of medical marijuana usage. There is a fine line that is

drawn between the unwanted consequence of substance abuse and its counterpart, which is

having marijuana available and legal to those that need it to treat medical ailments. The problem

that follows the legalization of medical marijuana is that many times that line gets crossed. The

first state to decide the benefits of legalization outweighed the risks was California, making

medical marijuana usage, with a valid prescription, legal in 1996 (National Conference of State

Legislatures, 2014). As of 2014, with New York being the newest legalized state, there are now


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twenty-three states that have legalized the use of marijuana for medical purposes (National

Conference of State Legislatures, 2014).

Legalization

There are many aspects of legalization that must be addressed when exploring the

health risks and benefits of medical marijuana usage. Some of the main points that will be

discussed in this section of the paper include: whether the United States needs federal laws

governing the usage of marijuana and what organization would be in charge of this, such as the

Food and Drug Administration, as well as what state laws are currently in place in areas that

allow medical marijuana usage legally. To visualize current regulations, the National

Conference of State Legislatures (NCSL) (2014) has compiled two tables that compare laws

between states. The first is Appendix D, Table G1, which shows the following: statutory

language, with a link provided to access the bill, and the year marijuana was legalized in that

state; whether the state requires patients to have ID cards or be registered; whether the state

allows dispensaries whether the state law specifies medical conditions that qualify for a

prescription; whether the state recognizes a medical marijuana prescription from patients

residing in other states; and whether the state allows for retail sales; or recreational use (National

Conference of State Legislatures, 2014).

The second illustration of state laws is table G2, which addresses states that do not have a

comprehensive marijuana law, but have limited laws in place, meaning medical marijuana cannot

be obtained from anyone that has a prescription but is used solely for research purposes at certain

institutions. This table shows all of the same information as table G1 with the addition of: the

definition of products allowed, whether the state allows medical marijuana for legal defense, and

whether it can be dispensed to minors (National Conference of State Legislatures, 2014).


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State and Federal Laws

Marijuana has almost always been in the American culture, and was used in the

marketplace during the early 1900s. How the drug has been viewed and been used has changed

and reshaped many laws over the last century. Marijuana has impacted the lives of farmers

growing marijuana for hemp ropes, sails for ships, and clothing. This plant was later seen as a

potential problem during the Mexican Revolution of 1910 (PBS, 2014). With the influx of

people from Mexico, the recreational use of marijuana also became widespread. During the

Great Depression, people became afraid of this new drug and the potential effects. By 1931, 29

states had outlawed marijuana. In 1937, the federal government passed the Marijuana Tax Act

which banned marijuana, making it a criminal offense to be in possession of the drug. However,

throughout the 1960’s and 70’s marijuana punishments became less harsh, and people became

more accepting of marijuana (PBS, 2014). In the late 1970’s, marijuana consumption reached an

all-time high (Caulkins, Kilmer, MacCoun, Pacula, & Reuter, 2012). During this time, 11 states

decriminalized the use and possession of marijuana, and many states lowered the penalties given

to offenders (PBS, 2014).

Decriminalization is defined as the discontinuation of a criminal offense to have small

amounts of the drug, one ounce or less (PBS, 2014). Many federal and state laws are not the

same when dealing with the issue of marijuana. On the federal level, marijuana is still illegal;

yet, some states are changing or allowing their own rules. This makes for a very complicated

legal system. On the federal level, marijuana is still considered a Schedule 1 substance under the

Controlled Substance Act. The category of a Schedule 1 substance is considered to be addictive

and can cause dependency with no medical purpose, which is why it is a federal crime (National

Conference of State Legislatures, 2014). According to Stone (2014), the “Schedule 1 category


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implies that it has a high potential for abuse, does not have any accepted medical use and lacks

accepted safety under medical supervision” (p. 285). The federal government could be

pressured, in the future, to change marijuana to a Schedule 2 substance which contains drugs

prescribed for a medical purpose (Yardley, 2011). However, the federal government is not likely

to change the scheduled control category in the next few years and there are still laws against

marijuana on the federal level. Marijuana penalties vary depending on the number of offenses,

the amount of marijuana, paraphernalia, and the number of plants. The imprisonment time can

vary from one year, to life in jail, and the fines of the criminal act can be anywhere from $1,000

to $1,000,000 depending on the crime (National Organization for the Reform of Marijuana Laws,

2014). Yet, some states are not enforcing these federal laws because medical marijuana is legal

due to popular vote.

Many states have passed laws which “legalize” marijuana for medical and recreational

purposes. However, this is still illegal on the federal level. State law does not have precedence

over the federal law. Furthermore, it is as if these states are ignoring the federal law. Smith

(2012) stated,

What is clear is that marijuana remains illegal under federal law. In theory an army of

DEA agents could swoop down on every joint-smoker in Washington or pot-grower in Colorado

and haul them off to federal court and thence to federal prison. But that would require either a

huge shift in Justice Department resources or a huge increase in federal marijuana enforcement

funding, or both, and neither seems likely. More likely is selective, exemplary enforcement

aimed at commercial operations, said one former White House anti-drug official (para. 5).

It is clear, federal laws have superiority over state laws; but it does not mean state laws

are null and void (Smith, 2012). States are now making their own laws, and going against the


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federal government. This controversy that exists between the state and federal governments

make the issue of legalizing marijuana more confusing and troublesome.

When states are allowed to make different laws then the federal government, it makes for

a confusing legal system. States are ignoring federal law which prohibits marijuana use, making

their own laws to legalize it for medicinal and recreational use. In fact 35 states/provinces allow

marijuana products with low THC/high CBD- Cannabidol for the purposes of either research or

medical use (National Conference of State Legislature, 2014). These states include: Alabama,

Alaska, Arizona, California, Colorado, Connecticut, Delaware, District of Columbia, Florida,

Hawaii, Illinois, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota,

Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New

York, North Carolina, Oregon, Rhode Island, South Carolina, Tennessee, Utah, Vermont,

Washington and Wisconsin (National Conference of State Legislatures, 2014).

In North Dakota, marijuana is the most common illegal drug used (Office of National

Drug Control Policy, 2011). It is not just North Dakota, but other states are also seeing a high

usage of marijuana. In fact, marijuana is the most widely used illicit drug in the United States

(Cerda, Wall, Keyes, Galea, & Hasin, 2012). Yet, certain states are still legalizing the use of this

drug. There are some benefits to the states if marijuana is legalized. According to Caulkins,

Kilmer, MacCoun, Pacula, and Reuter (2012), there are many reasons for permitting the sale of

marijuana. Some of these reasons include: increasing tax revenues for states,

eliminating/decreasing arrests for marijuana, stopping black market sales of marijuana, allowing

law enforcement resources to be used for other important matters, and limiting access to youth

(Caulkins et al., 2012).


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On the contrary there are doubts if legalizing marijuana on the state level would actually

benefit the state. With the unprecedented legalization, problems have occurred for the states that

have passed such laws. There are more arrests for possession of marijuana than any other

criminal offense (Kleiman, 2011). This puts more pressure on the local law enforcement and

legal system, causing a direct increase in policing needed at the community level. Tax-payer

dollars do not offset the increased cost of law enforcement; therefore, it becomes an overall

burden to the community. Another problem that has come from the legalization of marijuana is

the lack of organization and structure when regulating this drug. Especially because marijuana is

still considered an illicit drug, the role of regulation falls on the state and local levels (McGill,

2014). Another negative effect of legalizing medical marijuana at the state level is the projected

increase in the overall use of marijuana. As stated by Caulkins et al. (2012), consumption of

marijuana could increase anywhere from 5-50%. There is no way to know this exact statistic,

but a rise in marijuana use is strongly projected.

Discrepancies in state and federal law have created numerous issues on how to proceed in

the future. As aforementioned, legalization of medical marijuana was largely pushed through by

popular vote. This indicates the popular opinion regarding the Schedule 1 substance has

changed, or at the very least grown more tolerant, than previous decades. Now, our country sits

at a crossroads regarding the controversial issue of legalization, whether to allow the sale and use

of marijuana (as we have historically done) or to enforce current federal laws to a greater degree.

As more states move towards legalization, it is vital to align the goals of the state and federal

government. More research and laws will be needed, for we are currently divided as a nation

about the legalization of marijuana.


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Crossing State Lines

Marijuana has only been legalized as a recreational drug in a few states, but what impact

does this have on other states across the country? Can individuals who have medical or

recreational marijuana take it across state lines? These are important questions not only for

Colorado, Washington, Alaska, Oregon, and Washington, D.C., but for neighboring states and

other states across the United States of America (Merica, 2014). As a country, we need to be

knowledgeable about this potential problem. The legalization of recreational marijuana in the

states mentioned could lead to marijuana being distributed to the rest of the United States.

The current laws in many states do not allow marijuana. Depending on the current laws

in each state, medical marijuana permits may or may not be accepted in other states; however,

medical marijuana is not permitted to be transported by any means, even if the two states both

allow medical marijuana (HG.org, 2014). Transportation of marijuana across state lines is

against the federal laws and those transporting it could be prosecuted. As stated by LawInfo

(2014), “Transporting marijuana on an airplane, even between cities in a medical marijuana state,

also may lead to federal drug-transportation charges” (para. 2). Each state varies from the next

and different state laws may lead to arrests and other punishments. Travelers may be unaware of

the legal ramifications for transporting the substance across state lines.

It is important to be aware of the laws that are currently enacted. Just because

medical or recreational marijuana is legal in one state does not mean it is legal in another.

Different laws apply to different states, and as stated earlier, under no circumstance is marijuana

allowed to be transferred across state lines. In the future this may change if the federal laws

change, or if marijuana is legalized across America.


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Taxation on Marijuana

As Americans, we pay taxes every day on the items we purchase. Whether it is food, gas,

property taxes, and much more, we are always paying our government taxes for the things we

use. This raises questions about the taxation of marijuana in North Dakota. Based on the current

tax placed on one pack of cigarettes in North Dakota, which is $0.44, one can make the

assumption that North Dakota residents are against raising taxes since this rate is very low.

(ND.gov, n.d.). In other states across the country, taxes are anywhere from two to three dollars

on one pack of cigarettes. Will the taxes in North Dakota for marijuana be just as low as

cigarettes? If marijuana were to become legalized in North Dakota within the next few years, we

must look at the cost to our state, and which legal issues (like taxes) might be associated with it.

As marijuana increasingly becomes legal in states across the country, we are very likely

to see a decline in the price of this drug. Recent wholesale rates range from $500-$1,500 per

pound of commercial grade marijuana, increasing the further away from Mexico you go, and

$2000-$4500 per pound is the current price for high potency marijuana (Caulkins et al., 2012).

Many experts are suggesting the cost of marijuana will significantly be reduced, due to the

legalization of this drug. It is estimated that there would be an 80 – 90% drop in the value of

marijuana; where a few ounces would cost a couple of dollars (Caulkins et al., 2012). This

dramatic cost decrease of marijuana is startling. The possible price drop of marijuana that is

predicted for the future could lead to heavier usage and easier access, which would affect our

whole community.

There are many projected problems and issues associated with the decline in marijuana

cost. As a community, we could balance out the lower price by increasing taxes on marijuana.

Having a higher tax on marijuana would not only help the local government and aid in the


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regulation of this drug, it could also benefit the community. These taxes would produce revenue

for the communities marijuana is being distributed and sold in (Caulkins et al., 2012; Cerda et

al., 2012). There are many questions as to how high or low of a tax should be applied to

marijuana. When establishing a tax for marijuana, it is important to keep in mind that too low of

a tax will not help the community. A small tax will promote more usage, because of the

accessibility and low cost. According to Van Ours (2012), when the price of marijuana is

lowered, the age that individuals are trying marijuana for the first time is also lowered. This

lower cost will also mean a lower profit for the state and local government (Office of National

Drug Control Policy, n.d.). However, too high of a marijuana tax is hazardous to the community

as well. Taxation on marijuana should be low enough to stop the illegal sale of marijuana,

because a high tax on marijuana could encourage individuals to buy marijuana from a black

market at a cheaper rate, yet sufficiently high enough to discourage marijuana use. The

marijuana tax needs to be high enough to be a benefit to the community, yet also low enough to

discourage any illegal behavior.

The marijuana tax, whether it is higher or lower, could also be regulated by the potency

of the drug. Much like alcohol is taxed depending on beverage, so too could marijuana be taxed

(McGill, 2014). Taxes could be dependent on the levels of delta-9-tetrahydrocannabinol (THC)

in the marijuana (Caulkins et al., 2012; Van Ours, 2012). The level of THC in marijuana can

vary greatly, ranging anywhere from 2 - 3% for less expensive product, all the way up to 20 -

30%, which is a very potent marijuana plant (Caulkins et al., 2012). By relying on dispensaries

to accurately report their product’s potency, this leaves the government vulnerable because their

tax dollars are in the hands of the distributors. Additionally, there is little to no regulation

currently on these state dispensaries which may lead to a loose interpretation of the law to benefit


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the dispensaries. Other areas which need regulation are pesticides, contaminants, potency,

packaging, amount, and many other issues that may affect taxation (Caulkins et al., 2012; Stone,

2014). Whether marijuana is based on the potency of the drug or not, taxation needs to coexist

with regulation in order to maintain the integrity of the system.

Without a comprehensive system of both regulation and a standardized form of taxation,

marijuana could pose many of the same problems if it were legalized as it does with it currently

being illegal. By entering the mainstream and gaining acceptance, it is projected to increase in

its usage due to increased availability and lower cost. Communities may be able to benefit

financially if they can regulate and control the substance as they have previously with alcohol

and cigarettes. Although without proper guidelines, the legalization of marijuana could quickly

turn into a negative issue for communities.

Limits of Purchase

In states with legal medical marijuana, there are rules and regulations on the amount of

medical marijuana a physician can prescribe (refer to Appendix B, Table H1). Each of the 23

states and DC have different prescription limits for medical marijuana. Table H1 in Appendix B

presents these limits in the second column. It must be understood that the second column shows

the maximum limit the state allows to be prescribed. Each patient does not necessarily receive

the maximum limit. These limits are shown in ounces, or a “how many day’s supply,” and

whether or not more can be prescribed by the physician on an individual case basis.

In Table H1, the 23 states and DC which permit medical marijuana are listed in

alphabetical order in the first column. The second column shows the amount each state has

deemed legal for an individual to “possess,” when they have the legal right to carry medical

marijuana. The second column shows if the state allows growing of medical marijuana by


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individuals that have a prescription for its use. If the state does not allow personal growing of

medical marijuana at home, they have dispensaries where an individual would go to pick up their

prescription of marijuana, e.g. the state of New York (New York State Medical Marijuana

Program, 2014).

The states have varying amounts of medical marijuana that is allowed to be prescribed by

physicians. Alaska and Montana allow only one ounce per month (Alaska Senate, 1998;

Montana Public Health and Human Services, 2014). In Colorado, District of Colombia, New

Hampshire, New Jersey and Vermont two ounces per month is allowed (Colorado Senate, 2012;

District of Colombia Department of Health, 2010; New Hampshire Department of Health and

Human Services, 2010; State of New Jersey Department of Health, 2014; Vermont Department

of Public Safety-Division of Criminal Justice Services, 2014). Three states have their

prescription limits written as a 30 day supply of marijuana; they are Connecticut, Maryland, and

New York (Connecticut Senate, 2012; Maryland Department of Health and Mental Hygiene,

2014; New York State Medical Marijuana Program, 2014). The amount prescribed varies

between one ounce to 24 ounces a month in Oregon and Washington (Washington State

Legislature, 2011).

Column 3 of Table H1 indicates where individuals are allowed to grow their own

personal supply of medical marijuana. Although the state allows personal cultivation of medical

marijuana, the number of plants, including the number of immature and mature plants, allowed is

indicated, such as the state of Alaska (Alaska Senate, 1998). If no information is found, or the

state does not have their information published, then “limited amount” is written. In states where

growing medical marijuana is not allowed the word “no” is written in the table. In 15 out of 24

states where medical marijuana is legal, patients may grow their own supply. In 9 of the 24 states


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they do not allow personal cultivation of medical marijuana, and dispensaries are available where

patients will pick up their prescriptions.

Criteria for prescription

Marijuana is a schedule 1 controlled substance in the United States and is considered to

be an illegal drug by the U. S. federal government (IIgen et al., 2013). While marijuana is

considered to be illegal by the federal government, individual states possess the legal authority to

declare marijuana to be a legal drug within their state. Twenty-three states and the District of

Colombia (DC) have made “medical marijuana” legal for their residents (Anderson, 2014).

Medical marijuana is a drug prescribed by physicians to an individual with a debilitating medical

condition (IIgen et al., 2013). According to the Medical Board of California (2014), all patient

cases where the physician prescribes medical marijuana should be based on clinical trials, and

when available, medical literature and reports, their experience, or another physician’s

experience. Each individual state provides guidelines on what that state considers a debilitating

medical condition (Anderson, 2014).

According to Anderson (2014), there are eight frequent debilitating medical conditions

medical marijuana is prescribed for. These conditions are: cancer, glaucoma, HIV/AIDs, muscle

spasms, seizures, severe pain, severe nausea, and cachexia or dramatic weight loss or muscle

atrophy. Table H2 presents information on the states with legal medical marijuana, and the

medical conditions it may legally be prescribed for.

In table H2 in Appendix B, the 23 states and District of Colombia (DC) which permit

medical marijuana are listed in alphabetic order in the first columns. The columns of Table H2

indicate the 8 frequent conditions medical marijuana is prescribed for. Table H2 identifies the

states with these medical conditions accepted with the word “yes” in the box. If the box is left


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blank, medical marijuana is not approved for the treatment of this condition. States not listed do

not allow the use of marijuana for medical purposes.

In addition to the eight frequent conditions medical marijuana is prescribed for, many

states also allow medical marijuana usage for other conditions. Crohn’s disease is a condition

that affects a person’s digestive tract, and medical marijuana has been approved in 11 out of 50

states as a treatment option for Crohn’s disease (Mayo Clinic Staff, 2014). Post-traumatic stress

disorder (PTSD) is a condition that causes a person to feel stressed or frightened even though

they are no longer in danger. Seven out of 50 states have legalized the use of medical marijuana

for the treatment of PTSD (National Institute of Mental Health, 2014). Amyotrophic lateral

sclerosis (ALS), also known as Lou Gehrig’s disease is a fatal medical condition which causes

muscle weakness and lack of muscle control. Twelve out of 50 states have approved medical

marijuana for the treatment of this condition (Mayo Clinic Staff, 2014). Multiple Sclerosis (MS)

is a medical condition that causes the neurons from a person’s brain to become damaged,

resulting in delayed or impaired transmission to other parts of a person’s body. Twelve out of 50

states have approved medical marijuana for the treatment of this condition (Multiple Sclerosis

Association of American, 2014). Alzheimer’s disease is a condition that results in memory loss

and symptoms can include agitation. Eight out of 50 states have approved medical marijuana for

the treatment of this condition (Alzheimer’s Association, 2014). Hepatitis C is a contagious liver

disease that differs in severity. It can be an illness that only lasts a few weeks, or a lifelong

infection of the liver (Centers for Disease Control and Prevention, 2014). Patients with chronic

Hepatitis C can have symptoms that include fatigue, insomnia, loss of appetite, muscle and joint

pain, and depression. Thirteen out of 50 states have legalized medical marijuana as a treatment

option for Hepatitis C.


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Insurance

With any prescribed medications, it is beneficial to have coverage by medical insurance

plans. Information on insurance coverage for the use of medical marijuana is limited. Medicaid

does not cover medical marijuana (State of New Jersey, 2014). The Cinahl search engine

provided no results for articles when searching for the terms: medical marijuana and insurance,

marijuana and insurance, marijuana and insurance coverage. The Science Direct search engine

provided no results for articles when searching the terms; medical marijuana and insurance,

marijuana and insurance, marijuana and insurance coverage.

This lack of insurance coverage for medical marijuana may be because marijuana in any

form is considered an illegal drug by the United States federal government. This distinction does

not allow marijuana and its effectiveness as a prescription drug, to be tested by the Food and

Drug Administration (FDA) (White House, 2010). The FDA requires hundreds to thousands of

participants in their studies to assess the risks and benefits of a drug (National Institute on Drug

Abuse, 2014). Without marijuana research and thorough testing, it will not meet the safety and

efficacy standards of a medical drug covered by insurance companies (National Institute on Drug

Abuse, 2014). Most medical insurance plans only cover FDA approved medical drugs.

Testing and DUI

With more states deciding to legalize medical marijuana use, an important factor to look

at is what laws need to be in place regarding driving under the influence of marijuana and how

does law enforcement test for this. This is especially important because in 2009, 25 percent of

all positive drug tests for fatally injured drivers could be attributed to cannabinoids. In addition

cannabinoids also accounted for 43 percent among fatalities involving drivers 24 years of age

and younger (Glascoff, Shrader & Haddock, 2013). These statistics show that marijuana impairs


74

driving ability, sometimes enough to cause fatal motor vehicle accidents. While the term driving

under the influence (DUI) commonly refers to operating a motor vehicle while impaired by

having consumed alcohol, it is not limited to only being impaired from alcohol; it can also

include impairment from drugs (Glascoff et al., 2013). The THC level that represents

comparable impairment to a blood alcohol content of 0.05% would be 7-10 nanograms per

milliliter in blood serum (Pacula, Kilmer, Wagenaar, Chaloupka, & Caulkins, 2014).

Washington and Colorado have both set legal limits for driving impairment to 5 nanograms per

milliliter in blood.

There are multiple field sobriety tests as well as chemical tests to determine alcohol

impairment which makes it fairly easy for law enforcement to deem someone “driving under the

influence,” but it is not as easy to determine impairment from drugs because there is not a quick

breathalyser test for drugs and blood and urine results cannot be determined on the spot

(Glascoff et al., 2013). There is also a diversity of drugs that can cause impairment, and law

enforcement may not be able to rely solely on the physical symptoms of drug use, therefore

many law enforcement agencies rely on standardized field sobriety tests to determine impairment

(Glascoff et al., 2013).

There is conflicting research about marijuana impairment in relation to operating motor

vehicles (Glascoff et al., 2013). Most laboratory tests generally show acute impairment of

memory, attention, and psychomotor control. One study cited by Glascoff and associates (2013)

states that after consuming cannabinoids, drivers might be more cautious and tend to compensate

for perceived impairment, while another study found that marijuana use by drivers is associated

with a significantly increased risk of being involved in motor vehicle crashes. Other studies also

show an increased risk of automobile crashes following the use of marijuana (Glascoff et al.,


75

2013). Some driving impairments, including decreased car handling performance, increased

reaction time, impaired time and distance estimation, inability to maintain headway, lateral

travel, subjective sleepiness, impaired motor coordination, and impaired sustained vigilance can

persist for up to three hours after the use of marijuana (Glascoff et al, 2013). A literature review

of nine studies also showed that drivers who consume marijuana within three hours of driving

are almost twice as likely to cause a motor vehicle collision as those individuals who are not

under any influence of drugs or alcohol.

Impairment to driving ability creates a dangerous situation for the driver and also to

others; therefore any person driving under the influence of marijuana has the potential to cause

damage to the community. Any community that has legalized the use of marijuana needs to

ensure that law enforcement has the tools and skills to identify a person that is under the

influence. This data also strongly indicates the need for a quick roadside tool that can be used by

law enforcement to identify an individual’s current marijuana level.

Interventions

With medical marijuana already being prescribed and used in 23 states and the District of

Columbia one possible intervention is the revision of federal laws to make marijuana a Schedule

2 substance. As a Schedule 2 substance many other laws could change regarding the research,

testing, insurance coverage, medical reasons for prescription, and more. As a Schedule 2

substance, research would be allowed on the health effects of medical marijuana. If the health

effects are proven to benefit the population then others laws may change allowing insurance

companies to cover marijuana for medical purposes. If the federal government approves medical

marijuana, standardized medical diagnoses and dosage should be developed. With research


76

being allowed, a tool could be developed for on the spot testing for marijuana use. This tool

could be used by law enforcement to help ensure the safety of the community.

The intervention of changing marijuana from a Schedule 1 substance to Schedule 2

would help the medical marijuana legalization process. The process might involve a popular

vote to determine if this is what the populace wants. Individual states would not have to go

against the federal government, thus creating a more unified legal code at the state and federal

level regarding the use of medical marijuana.

When developing the policy of changing marijuana from a Schedule 1 substance to a

Schedule 2, nurses would have to collaborate with many different community support groups and

health care facilities to ensure support of medical marijuana laws in North Dakota.

Collaboration would be needed with city and state legislators to standardize marijuana laws

across the state. With North Dakota’s support, state legislators and politicians could bring

awareness to this issue at a federal level. Collaboration would also be needed with law

enforcement to ensure all marijuana regulations are being followed by community members.

Using the intervention of health teaching, teachers in ND schools would need to be educated on

the health benefits of medical marijuana and the signs and symptoms of usage. Through the

usage of television, billboard, and radio advertisements, the public should be informed about the

consequences of illegal recreational use, and the health benefits of medical marijuana for patients

with debilitating illnesses. Provider education would be needed about the signs and symptoms of

marijuana usage and the criteria for prescription. With community support, health teaching,

collaboration, and policy development and enforcement medical marijuana could be legalized as

a prescription drug in the state of North Dakota. With legalization of medical marijuana in the


77

state, further research would be available to support a change of marijuana laws at the federal

level.

Summary and Discussion

In conclusion, the Fall 2014 Nursing 456 Public Health class would support limiting

legalization of marijuana in North Dakota to medical purposes. Through the interventions

discussed in the previous sections it is believed that medical marijuana can be utilized in a safe

and effective manner in the state of North Dakota. A resolution has been drafted using evidence

gathered during the research of this paper and will be submitted to the North Dakota Public

Health Association (See Appendix A). Understandably, complicated legal steps must take place

in order to provide a safe environment for appropriate use, and hopefully the information

gathered during our research and assessment will assist North Dakota stakeholders and decision

makers to come to an informed decision.


78

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Appendix A

Resolution on Implementing Medical Marijuana in the State of North Dakota

WHEREAS the people of North Dakota have the right to choose whether or not to use medicinal

marijuana.

WHEREAS the people of North Dakota have the right to use medicinal marijuana for the relief

of pain and/or nausea.

WHEREAS patients have the right to use medical marijuana as a therapeutic alternative when

other treatment options have failed.

WHEREAS medical marijuana has fewer drug-to drug interactions, less serious adverse

reactions, and is considered less toxic than some current pharmaceutical options.

WHEREAS the people of North Dakota have the right for a prescription of medical marijuana to

treat their medical condition.

WHEREAS laws and regulations regarding driving under the influence of marijuana would be

enforced.

WHEREAS pharmacies through the state of North Dakota would have the legal right to

distribute all medical marijuana.

WHEREAS universities in the state of North Dakota would need to include courses on how to

distribute medical marijuana in their medical, nursing and pharmacy program curriculum.

Pharmacists from out of state would be required to take an additional course on medical

marijuana distribution. In order to dispense medical marijuana a certificate or license would need

to be on display in the pharmacy.

NOW THEREFORE BE IT RESOLVED that the Fall 2014 Nursing 456 Public Health Class

supports the legalization of medical marijuana in the state of North Dakota.


93

Appendix B

6 Common Misconceptions

Using medical marijuana makes a person feel

‘high’ and can’t be used in children

The component THC can be extracted from

the rest of the plant as in Cannabidiol. THC-A

is a tincture which can be used for various

forms of epilepsy on children without causing

the ‘high’ feeling

People will die from using marijuana Between 1997 and 2005, the time for which

data was available, marijuana was not

reported as a primary cause of death

according to the FDA

Medical marijuana can only be used for pain

relief

Marijuana contains over 400 other chemical

constituents, one of which is steroids that

possess anti-inflammatory properties as well

as Vitamin A

Smoking marijuana causes lung cancer Not smoking anything at all might be the

healthier option, but a study conducted in

2006 by the University of California in Los

Angeles implies that there is no association

between marijuana and lung cancer.

Furthermore it suggested that it might have

“some protective effect”

There are too many health risks involved with

marijuana usage

Most of the identified health risks of

marijuana use are related to smoke, not to the

cannabinoids that produce the benefits.

Furthermore marijuana is less toxic than

many of the drugs that physicians prescribe

every day

Retrieved from: http://medicalmarijuana.procon.org/view.resource.php?resourceID=000091


94

Appendix C

Marijuana/Cannabis (Tetrahydrocannabinol,THC)

Marijuana is a greenish mixture of dried shredded flowers, stems, seeds, and leaves of the hemp

plant Cannabis Sativa. This plant contains a mind-altering, psychoactive chemical called delta-9-

tetrahydrocannabinol (THC). Other known components include cannabidiol (CBD), cannabinol

(CBN), tetrahydrocannabivarin (THCV), cannbigerol (CBG), as well as other related

compounds. Hashish consists of resinous secretions of the cannabis plant.

Synonyms: Cannabis, marijuana, pot, reefer, bud, grass, weed, dope, ganja, herb, boom,

gangster, Mary Jane, sinsemilla, shit, joint, hash, has oil, blow, blunt, green, Aunt Mary, skunk,

chronic, cheeba, bomber, bammy, jolly green, flower, dro, hydro, and roach.

Source: Cannabis contains several hundred different chemicals. Some of these chemicals are

called cannabinoids, like cannabinol, cannabidiol, cannabinolidic acids, cannabigerol,

cannabichromene, and forms of THC. Delta-9-tetrahydrocannabinol, a form of THC, is known to

be responsible for the psychoactive effects of the drug.

Drug Class: Cannabis/Marijuana: appetite stimulant, sedative, tranquilizer, antiemetic,

analgesic, anti-inflammatory, anti-convulsant, hypnotic central nervous system agent, muscle

relaxants, or hallucinogen.

Route of Administration: Marijuana is usually smoked as a cigarette, in a pipe, or in a bong.

Marijuana can also be orally ingested.

Side Effects: Fatigue, paranoia, memory problems, depersonalization, mood alterations,

decreased motor coordination, lethargy, slurred speech, dizziness, difficulty problem solving,

distorted perception, and difficulty sustaining attention. Some more serious damaging effects

with long term use can include lung damage, respiratory issues, and cardiovascular effects.

Sensory functions are not greatly impaired, but perceptual functions are considerably affected.

Duration of Effects: Effects from smoking cannabis can be felt within minutes and reach their

peak in about half an hour; smokers can experience the euphoria for up to 2 hours. Behavioral

and physiologic effects usually return to baseline levels within 3-5 hours.

Tolerance, Dependence, and Withdrawal Effect: Tolerance may develop rapidly after only a

few doses but also disappear rapidly. Marijuana can become addicting. The withdrawal effects

are less life threatening than those of other drugs, like opioids. Some common symptoms of

withdrawal may include restlessness, irritability, mild agitation, insomnia, decreased appetite,

diaphoresis, and nausea.

Drug Interactions: CNS depressants increase drowsiness and CNS depression. When taken

concurrently with alcohol, marijuana is more likely to be a traffic safety risk factor than when

consumed alone. Other than that, marijuana has limited drug to drug interactions.

Retrieved from: http://www.nhtsa.gov/people/injury/research/job185drugs/cannabis.htm


95

Appendix D

National Institute on Drug Abuse fact sheet (2014)

National Institute of Drug Abuse (2014). Marijuana. retrieved from

http://www.drugabuse.gov/publications/drugfacts/marijuana on October 8, 2014.

Screening for Drug Use in General Medical Settings: A Resource Guide for Providers

(2014)

www.drugabuse.gov/sites/default/files/resource_guide.pdf


96

Appendix E

BabyBlog: Clearing the Smoke about Marijuana use during Pregnancy

http://www.mothertobabyca.org/high-times-for-marijuana-clearing-the-smoke-

about-marijuana-use-during-pregnancy/

Marijuana & Pregnancy Handout – The Fetal Infant Mortality Review (FIMR)

http://www.acphd.org/media/129914/marijuana_eng.pdf

Organization of Teratology Information Specialists (OTIS) Marijuana & Pregnancy fact

sheet handout

http://www.mothertobaby.org/files/marijuana.pdf


97

Appendix F

Marijuana & the Responsible Parent

Environmental Resource Council (2014). Marijuana and the Responsible Parent.

Retrieved from http://www.envrc.org/parents-marijuana.htm on October 24, 2014.

NIDA for Teens website

http://teens.drugabuse.gov/drug-facts/marijuana


98

Appendix G

Table G1

State Medical Marijuana/Cannabis Program Laws

State

Statutory Language

(year)

Patient

Registry

or ID

cards

Allows

Dispensaries

Specifies

Conditions

Recognizes

Patients from

other states

State Allows for Retail

Sales/Adult Use

Alaska Measure 8 (1998)SB

94 (1999)Statute Title

17, Chapter 37

Yes No Yes

Arizona Proposition 203(2010) Yes Yes Yes Yes

California Proposition

215(1996) SB

420(2003)

Yes Yes No

Colorado Amendment 20(2000) Yes Yes Yes Amendment 64(2012)

Task

Force Implementation

Recommendations(2013)

Analysis of CO

Amendment 64 (2013)

Colorado Marijuana

Sales and Tax Reports

2014 "Edibles"

regulation measure

Connecticut HB 5387 (2012) Yes Yes Yes

Delaware SB 17 (2011) Yes Yes Yes Yes

District of

Columbia

Initiative

59(1998) L18-

0210 (2010)

Yes Yes Yes

Hawaii SB 862 (2000) Yes No Yes

Illinois HB 1 (2013) Eff.

1/1/2014

Proposed rules as of

April, 2014

Yes Yes Yes No

Maine Question 2(1999) LD

611(2002)

Question

5(2009) LD

1811(2010)

LD 1296 (2011)

Yes Yes Yes Yes

Maryland HB 702 (2003) SB

308 (2011) HB

180/SB

Yes Yes Yes

http://www.elections.alaska.gov/doc/oep/1998/98bal8.htm

http://www.legis.state.ak.us/PDF/21/Bills/SB0094F.PDF

http://www.legis.state.ak.us/PDF/21/Bills/SB0094F.PDF

http://touchngo.com/lglcntr/akstats/Statutes/Title17/Chapter37.htm

http://touchngo.com/lglcntr/akstats/Statutes/Title17/Chapter37.htm

http://www.azdhs.gov/prop203/

http://vote96.sos.ca.gov/BP/215text.htm

http://vote96.sos.ca.gov/BP/215text.htm

http://www.leginfo.ca.gov/pub/03-04/bill/sen/sb_0401-0450/sb_420_bill_20031012_chaptered.html

http://www.leginfo.ca.gov/pub/03-04/bill/sen/sb_0401-0450/sb_420_bill_20031012_chaptered.html

http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheadername1=Content-Disposition&blobheadername2=Content-Type&blobheadervalue1=inline%3B+filename%3D%22Colorado+Constitution+Article+XVIII.pdf%22&blobheadervalue2=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251807302173&ssbinary=true

http://www.sos.state.co.us/pubs/elections/Initiatives/titleBoard/filings/2011-2012/30Final.pdf

http://www.colorado.gov/cms/forms/dor-tax/A64TaskForceFinalReport.pdf



http://coloradofutures.colostate.edu/cfc-amendment-64-study/

http://coloradofutures.colostate.edu/cfc-amendment-64-study/

http://www.colorado.gov/cs/Satellite/Revenue-Main/XRM/1251633259746

http://www.colorado.gov/cs/Satellite/Revenue-Main/XRM/1251633259746

http://www.leg.state.co.us/clics/clics2014a/csl.nsf/fsbillcont3/4882145846DC62CE87257C98005D4C5D?Open&file=1366_enr.pdf

http://www.leg.state.co.us/clics/clics2014a/csl.nsf/fsbillcont3/4882145846DC62CE87257C98005D4C5D?Open&file=1366_enr.pdf

http://www.cga.ct.gov/2012/FC/2012HB-05389-R000597-FC.htm

http://legis.delaware.gov/LIS/lis146.nsf/vwLegislation/SB+17/$file/legis.html?open

http://www.washingtonpost.com/wp-srv/local/longterm/library/dcelections/races/dcq59.htm#text

http://www.washingtonpost.com/wp-srv/local/longterm/library/dcelections/races/dcq59.htm#text

http://dcclims1.dccouncil.us/lims/legislation.aspx?LegNo=B18-0622&Description=%22LEGALIZATION+OF+MARIJUANA+FOR+MEDICAL+TREATMENT+AMENDMENT+ACT+OF+2010%22.%0d%0a++&ID=23608

http://dcclims1.dccouncil.us/lims/legislation.aspx?LegNo=B18-0622&Description=%22LEGALIZATION+OF+MARIJUANA+FOR+MEDICAL+TREATMENT+AMENDMENT+ACT+OF+2010%22.%0d%0a++&ID=23608

http://www.capitol.hawaii.gov/hrscurrent/Vol06_Ch0321-0344/HRS0329/HRS_0329-0121.htm

http://www.ilga.gov/legislation/BillStatus.asp?DocNum=1&GAID=12&DocTypeID=HB&SessionID=85&GA=98

http://www2.illinois.gov/gov/mcpp/Pages/update-04182014.aspx

http://www2.illinois.gov/gov/mcpp/Pages/update-04182014.aspx

http://www.mainelegislature.org/legis/statutes/22/title22sec2383-b.html

http://www.mainepatientsrights.org/Petition%20MEDICAL%20MARIJUANA.pdf

http://www.mainepatientsrights.org/Petition%20MEDICAL%20MARIJUANA.pdf

http://www.votesmart.org/election_ballot_measures_detail.php?ballot_id=1383

http://www.votesmart.org/election_ballot_measures_detail.php?ballot_id=1383

http://www.mainelegislature.org/legis/bills/bills_124th/chappdfs/PUBLIC631.pdf

http://www.mainelegislature.org/legis/bills/bills_124th/chappdfs/PUBLIC631.pdf

http://www.mainelegislature.org/legis/bills/bills_125th/chapters/PUBLIC407.asp

http://mlis.state.md.us/pdf-documents/2003rs/bills/hb/hb0702t.pdf

http://mlis.state.md.us/2011rs/bills/sb/sb0308e.pdf

http://mlis.state.md.us/2011rs/bills/sb/sb0308e.pdf

http://mgaleg.maryland.gov/webmga/frmMain.aspx?id=sb0580&stab=01&pid=billpage&tab=subject3&ys=2013RS



99

State

Statutory Language

(year)

Patient

Registry

or ID

cards

Allows

Dispensaries

Specifies

Conditions

Recognizes

Patients from

other states


Sales/Adult Use

580(2013) HB 1101-

Chapter 403 (2013)

SB 923 (signed

4/14/14)

HB 881- similar to

SB 923

Massachusetts Question 3 (2012)

Regulations(2013)

Yes Yes Yes

Michigan Proposal 1 (2008) Yes No Yes Yes

Minnesota SF 2471, Chapter

311 (2014)

Yes Yes,

limited,

liquid

extract

products

only

Yes

Montana Initiative

148(2004) SB

423(2011)

Yes No** Yes No

Nevada Question

9(2000) NRS

453A NAC 453A

Yes No Yes

New

Hampshire

HB 573 (2013) Yes Yes Yes Yes, with a

note from their

home

state, but

they cannot

purchase or

grow their

own in NH.

New Jersey SB 119 (2009)

Program information

Yes Yes Yes

New Mexico SB 523 (2007)

Medical Cannabis

Program

Yes Yes Yes

New York A6357 (2014) Signed

by governor 7/5/14

Yes Ingested

doses may

not contain

more than

10 mg of

THC,

product

may not be

Yes


http://mgaleg.maryland.gov/2013RS/bills/hb/hb1101T.pdf

http://mgaleg.maryland.gov/2013RS/bills/hb/hb1101T.pdf

http://mgaleg.maryland.gov/2013RS/Chapters_noln/CH_403_hb1101t.pdf

http://mgaleg.maryland.gov/2014RS/bills/sb/sb0923T.pdf

http://www.malegislature.gov/Laws/SessionLaws/Acts/2012/Chapter369

http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/medical-marijuana/

http://www.michigan.gov/documents/sos/ED-20_11-08_Props_Poster2_251561_7.pdf

https://www.revisor.mn.gov/laws/?id=311&doctype=Chapter&type=0&year=2014

http://sos.mt.gov/elections/Archives/2010s/2012/Initiatives/IR-124.asp

http://sos.mt.gov/elections/Archives/2010s/2012/Initiatives/IR-124.asp

http://data.opi.mt.gov/bills/2011/billhtml/SB0423.htm

http://data.opi.mt.gov/bills/2011/billhtml/SB0423.htm

http://www.ballotpedia.org/wiki/index.php/Nevada_Question_9_(2000)

http://www.ballotpedia.org/wiki/index.php/Nevada_Question_9_(2000)

http://leg.state.nv.us/NRS/NRS-453A.html

http://leg.state.nv.us/NRS/NRS-453A.html

http://leg.state.nv.us/NAC/NAC-453A.html

http://www.gencourt.state.nh.us/legislation/2013/HB0573.html

http://www.njleg.state.nj.us/2008/Bills/S0500/119_R3.HTM

http://www.state.nj.us/health/medicalmarijuana/

http://www.nmlegis.gov/Sessions/07%20Regular/bills/senate/SB0523.html

http://nmhealth.org/mcp/

http://nmhealth.org/mcp/

http://assembly.state.ny.us/leg/?default_fld=&bn=A06357&term=2013&Summary=Y&Actions=Y


100

State

Statutory Language

(year)

Patient

Registry

or ID

cards

Allows

Dispensaries

Specifies

Conditions

Recognizes

Patients from

other states


Sales/Adult Use

combusted

(smoked).

Oregon Oregon Medical

Marijuana Act(1998)

SB 161 (2007)

Yes No Yes

Rhode Island SB 791 (2007) SB

185 (2009)

Yes Yes Yes Yes

Vermont SB 76 (2004) SB

7 (2007) SB 17(2011)

Yes Yes Yes

Washington Initiative

692(1998) SB

5798 (2010)

SB 5073 (2011)

No No Yes Initiative 502 (2012)

WAC Marijuana rules:

Chapter 314-55 WAC

TABLE 1. STATE MEDICAL MARIJUANA/CANNABIS PROGRAM LAWS

Note. Adapted from “State Medical Marijuana Laws” by the National Conference of State

Legislatures, 2014. Retrieved from http://www.ncsl.org/research/health/state-medical-marijuana-

laws.aspx

Table G2

Limited Access Marijuana Product Laws (low THC/high CBD – Cannabidol)

State

Program Name

and Statutory

Language (year)

Patient

Registry

or ID

cards

Dispensaries or

Source of

Product(s)

Specifies

Conditio

ns

Recogni

zes

Patients

from

other

states

Defintion of

Products

Allowed

Allows

for

Legal

Defense

Allowe

d for

Minor

s

Alabam

a

SB 174 "Carly's

Law"(Act 2014-

277) Allows

University of

Alabama

Birmingham to

conduct

effectiveness res

Only the Univ.

Alabama

Birmingham is

allowed to

dispense

Yes,

debilitati

ng

epileptic

conditio

ns

No Low THC=

below 3% THC

Yes Yes

http://www.oregon.gov/DHS/ph/ommp/docs/ors.pdf

http://www.oregon.gov/DHS/ph/ommp/docs/ors.pdf

http://www.leg.state.or.us/07reg/measures/sb0100.dir/sb0161.en.html

http://webserver.rilin.state.ri.us/BillText/BillText07/SenateText07/S0791aa.pdf



http://www.leg.state.vt.us/docs/legdoc.cfm?URL=/docs/2004/acts/ACT135.HTM

http://www.leg.state.vt.us/docs/legdoc.cfm?URL=/docs/2008/bills/senate/S-007.HTM

http://www.leg.state.vt.us/docs/legdoc.cfm?URL=/docs/2008/bills/senate/S-007.HTM

http://www.leg.state.vt.us/docs/2012/Acts/ACT065.pdf

http://apps.leg.wa.gov/RCW/default.aspx?cite=69.51A&full=true

http://apps.leg.wa.gov/RCW/default.aspx?cite=69.51A&full=true

http://apps.leg.wa.gov/documents/billdocs/2009-10/Pdf/Bills/Session%20Law%202010/5798-S.SL.pdf

http://apps.leg.wa.gov/documents/billdocs/2009-10/Pdf/Bills/Session%20Law%202010/5798-S.SL.pdf

http://www.cqstatetrack.com/texis/redir?id=4d2f0f0d73

http://sos.wa.gov/_assets/elections/initiatives/i502.pdf

http://apps.leg.wa.gov/wac/default.aspx?cite=314-55

http://apps.leg.wa.gov/wac/default.aspx?cite=314-55

http://alisondb.legislature.state.al.us/acas/ViewBillsStatusACASLogin.asp?BillNumber=sb174

http://alisondb.legislature.state.al.us/acas/ViewBillsStatusACASLogin.asp?BillNumber=sb174


101

State

Program Name

and Statutory

Language (year)

Patient

Registry

or ID

cards

Dispensaries or

Source of

Product(s)

Specifies

Conditio

ns

Recogni

zes

Patients

from

other

states

Defintion of

Products

Allowed

Allows

for

Legal

Defense

Allowe

d for

Minor

s

earch using low-

THC products

for treating

seizure disorders

for up to 5 years.

Florida Compassionate

Medical

Cannabis Act of

2014 CS for SB

1030 (2014)

Patient treatment

information and

outcomes will be

collected and used

for intractable

childhood epilepsy

research

Yes Yes, 5 across the

state by region.

Yes,

cancer,

medical

conditio

n or

seizure

disorder

s that

chronic

ally

produce

s

sympto

ms that

can be

alleviate

d by

low-

THC

product

s

No Low THC=

below .8% THC

and above 10%

CBD by weight

Yes,

with

appro

val

from 2

doctor

s

Iowa SF 2360, Medical

Cannabidiol Act of

2014 (Effective

7/1/14)

Yes Doesn't define, Yes,

intracta

ble

epilepsy

No Low THC=

below 3% THC,

no more than

32 oz.

Yes Yes

Kentuc

ky

SB

124 (2014) Clara

Madeline Gilliam

Act

Exempt

cannabidiol from

the definition of

marijuana and

allows it to be

administerd by a

public university

or school of

medicine in

Kentucky for

No Universities in

Kentucky with

medical schools.

No No No

http://www.flsenate.gov/Session/Bill/2014/1030

http://www.flsenate.gov/Session/Bill/2014/1030

http://www.flsenate.gov/Session/Bill/2014/1030/BillText/er/HTML







http://coolice.legis.iowa.gov/linc/85/external/govbills/SF2360.pdf



http://www.lrc.ky.gov/record/14rs/SB124.htm

http://www.lrc.ky.gov/record/14rs/SB124.htm


102

State

Program Name

and Statutory

Language (year)

Patient

Registry

or ID

cards

Dispensaries or

Source of

Product(s)

Specifies

Conditio

ns

Recogni

zes

Patients

from

other

states

Defintion of

Products

Allowed

Allows

for

Legal

Defense

Allowe

d for

Minor

s

clinical trial or

expanded

access program

approved by the

FDA.

Mississi

ppi

HB 1231 "Harper

Grace's Law"

2014

All provided

through National

Center for Natural

Products Research

at the Univ. of

Mississippi and

dispensed by the

Dept. of Pharmacy

Services at the

Univ. of Mississippi

Medical Center

Yes,

debilitati

ng

epileptic

conditio

n or

related

illness

No Processed

cannabis

plant extract, oil

or resin that

contains more

than 15%

cannabidiol, or

a dilution of the

resin that

contains at

least 50

milligrams of

cannabidiol

(CBD) per

milliliter, but not

more than one-

half of one

percent (0.5%)

of

tetrahydrocann

abinol (THC)

Yes, if

an an

authoriz

ed

patient

or

guardia

Yes

Missour

i

HB 2238 (2014) Yes Yes,

creates cannabidiol

oil care centers

and cultivation and

production

facilities.

Yes,

intracta

ble

epilepsy

No Equal or less

than .3% THC

and at least 5%

CBD by weight.

Yes Yes

North

Carolin

a

HB 1220 (2014)

Epilepsy

Alternative

Treatment Act-

Pilot Study

Yes Yes,

intracta

ble

epilepsy

No Less than

three-tenths of

one percent

(0.3%)

tetrahydrocann

abinol (THC) by

weight.

Is composed of

at least ten

percent (10%)

cannabidiol by

weight.

Yes Yes

http://billstatus.ls.state.ms.us/2014/pdf/history/HB/HB1231.xml

http://www.house.mo.gov/billsummary.aspx?bill=HB2238&year=2014&code=R

http://www.ncleg.net/Sessions/2013/Bills/House/PDF/H1220v7.pdf


103

State

Program Name

and Statutory

Language (year)

Patient

Registry

or ID

cards

Dispensaries or

Source of

Product(s)

Specifies

Conditio

ns

Recogni

zes

Patients

from

other

states

Defintion of

Products

Allowed

Allows

for

Legal

Defense

Allowe

d for

Minor

s

Contains no

other

psychoactive

substance.

South

Carolin

a

SB 1035 (2014)

Medical

Cannabis

Therapeutic

Treatment Act-

Julian's Law

Yes Must use CBD

product from an

approved source;

and

(2) approved by

the United States

Food and Drug

Administration to

be used for

treatment of a

condition specified

in an

investigational new

drug application.

(B) The principal

investigator and

any subinvestigator

may receive

cannabidiol directly

from an approved

source or

authorized

distributor for an

approved source

for use in the

expanded access

clinical trials.

Lennox-

Gastaut

Syndro

me,

Dravet

Syndro

me,

also

known

as

severe

myoclon

ic

epilepsy

of

infancy,

or any

other

form of

refractor

y

epilepsy

that is

not

adequat

ely

treated

by

tradition

al

medical

therapie

s.

No At least 98

percent

cannabidiol

(CBD) and not

more than 0.90

percent

tetrahydrocann

abinol (THC) by

volume that has

been extracted

from marijuana

or synthesized

in a laboratory

Yes Yes

Tenness

ee

SB 2531(2014)

Creates a four-

year study of

high CBD/low

THC marijuana

at TN Tech Univ.

Research

ers need

to track

patient

informati

on and

outcomes

Only products

produced by

Tennessee Tech

University.

Yes,

intracta

ble

seisure

conditio

ns.

No Less than .9%

THC as part of

a clinical

research study

http://www.scstatehouse.gov/billsearch.php?billnumbers=1035&session=0&summary=B

http://wapp.capitol.tn.gov/apps/BillInfo/default.aspx?BillNumber=SB2531&GA=108


104

State

Program Name

and Statutory

Language (year)

Patient

Registry

or ID

cards

Dispensaries or

Source of

Product(s)

Specifies

Conditio

ns

Recogni

zes

Patients

from

other

states

Defintion of

Products

Allowed

Allows

for

Legal

Defense

Allowe

d for

Minor

s

Utah HB 105 (2014)

Hemp Extract

Registration Act

Yes Allows higher

education

institution to grow

or cultivate

industrial hemp

Yes,

intracta

ble

epilepsy

that

hasn't

respond

ed to

three or

more

treatme

nt

options

suggest

ed by

neurolo

gist

No Less than .3%

THC by weight

and at least

15% CBD by

weight and

contains no

other

psychoactive

substances

Yes Yes

Wiscons

in

AB 726 (2013 Act

267)

No No in-state

production/manufa

cturing mechanism

provided.

Seizure

disorder

s

"Cannabidiol in

a form without a

psychoactive

effect."

No Yes

TABLE 2. LIMITED ACCESS MARIJUANA PRODUCT LAWS (LOW THC/HIGH CBD- CANNABIDIOL)

Note. Adapted from “State Medical Marijuana Laws” by the National Conference of State

Legislatures, 2014. Retrieved from http://www.ncsl.org/research/health/state-medical-marijuana-

laws.aspx

http://le.utah.gov/~2014/bills/static/hb0105.html

http://docs.legis.wisconsin.gov/2013/related/acts/267

http://docs.legis.wisconsin.gov/2013/related/acts/267


105

Appendix H

Table H1

Personal Possession Limits for Medical Marijuana

Personal Possession Limits for Medical Marijuana

States with

Legal Medical

Marijuana Personal Possession limit

Allowed to grow personal supply, if

yes how many plants allowed at

same time

Alaska 1 ounces usable 6 plants (3 mature, 3 immature)

Arizona 2.5 ounces usable 12 plants

California 8 ounces usable or more if recommended by physician 12 plants (6 mature, 6 immature )

Colorado 2 ounces usable 6 plants (3 mature, 3 immature)

Connecticut 30 day supply No

DC 2 ounces dried, DC Mayor’s ruling may increase limit

to 4 ounces No

Delaware 6 ounces usable No

Hawaii 3 ounces usable 7 plants (3 mature, 4 immature )

Illinois 2.5 ounces per 14 day period No

Maine 2.5 ounces 6 plants

Maryland 30 day supply No

Massachusetts 60 day supply up to 10 ounces yes, limited amounts

Michigan 2.5 ounces 12 plants

Minnesota Limits to be determined. Only non-smoking

preparations allowed No

Montana 1 ounce 4 plants (4 mature, 12 seedlings)

Nevada 2.5 ounces 12 plants

New Hampshire 2 ounces No

New Jersey 2 ounces per month No

New Mexico 6 ounces ( more if approved by their Dr.) 16 plants ( 4 mature, 12 immature)

New York 30 day supply from pharmacists; only oils, pills and/

or extracts prepared from the plant may be obtained No

Oregon 24 ounces usable 6 plants (6 mature, 18 seedlings)

Rhode Island 2.5 ounces of cultivated marijuana 12 plants

Vermont 2 ounces usable 9 plants (2 mature and 7 immature)

Washington 24 ounces usable 15 plants


106

Note. Adapted from “The State of Alaska: Application for Medical Marijuana Registry” by the

Department of Health and Social Services, 2014. Retrieved from http://dhss.alaska.gov/dph/

VitalStats/Documents/PDFs/MedicalMarijuana.pdf

“Proposition 203” by the Arizona Senate, 2011. Retrieved from

http://www.azsos.gov/election/2010/info/pubpamphlet/english/prop203.htm

“SB 420, the Compassionate use act of 1996” by the California Senate, 2003. Retrieved from

http://www.leginfo.ca.gov/pub/03-04/bill/sen/sb_0401-0450/sb_420_bill_2003

1012_chaptered.html

“Debilitating Conditions for Medical Marijuana Use” by the Colorado Department of Health and

Environment, 2013. Retrieved from https://www.colorado.gov/pacific/sites/default/files

/CHEIS_MMJ_Debilitating-Medical-Conditions.pdf

“HB 5389, the Palliative use of marijuana” by the Connecticut Senate, 2012. Retrieved from

http://www.cga.ct.gov/2012/ACT/PA/2012PA-00055-R00HB-05389-PA.htm

“The Legalization of marijuana for medical treatment initiative of 1999” by the District of

Colombia, Amendment Act 201, 2010. Retrieved from http://doh.dc.gov/sites/default/files/dc/

sites/doh/ publication/attachments/Legal-Marijuana-Med-Treat-Amend-Act-2010_0.pdf

“Medical marijuana program” by the State of Delaware. (2014). Retrieved from:

http://dhss.delaware.gov/ dph/hsp/medmarhome.html#qp7

“Hawaii medical use of marijuana” by the State of Hawaii, Department of Public Safety

Narcotics Enforcement Division, 2012. Retrieved from http://dps.hawaii.gov/wp-

content/uploads/2012/09/Physian-Information-Med-Marijuana-rev113011.pdf

“House Bill 1” by the Illinois Senate, 2013. Retrieved from

http://www.ilga.gov/legislation/98/HB /09800HB0001ham001.htm


107

“Medical Marijuana” by the State of Maine, Bureau of Corporations, Elections & Commissions,

2014. Retrieved from http://www.maine.gov/sos/cec/elec/medicalmarijuanaact.html

“Bill 923” by the Maryland Senate, 2014. Retrieved from http://mgaleg.maryland.gov/2014RS/

bills/sb/sb0923e.pdf

“Medical Use of Marijuana in Massachusetts” by the Commonwealth of Massachusetts,

Department of Public Health, 2012. Retrieved from http://www.mass.gov/eohhs/docs/

dph/quality/drugcontrol/medical-marijuana/medical-marijuana-faq.pdf

“Frequently Asked Question for the Michigan Medical Marihuana Registry Programs” by the

Lara Department of Licensing and Regulations, 2014. Retrieved from

http://www.michigan.gov/documents/lara/lara_MMP_FAQ_6-28-13_426011_7.pdf

“Chapter 311” by the Office of the Revisor of Statutes, 2014 Minnesota Session Laws, 2014.

Retrieved from https://www.revisor.mn.gov/laws/?id=311&year=2014&type=0

“Montana Medical Marijuana Program Local Protections” by the Montana Public Health and

Human Services, 2014. Retrieved from http://leg.mt.gov/bills/mca/50/46/50-46-319.htm

“Medical Marijuana Establishment Application Press Packet” by the Nevada Division of Public

and Behavioral Health, 2014. Retrieved from http://www.health.nv.gov/MedicalMarijuana

/MMEPressPacketFinal.pdf

“New Hampshire Statues Section 126-x, the Use of Cannabis for Therapeutic Purposes” by the

New Hampshire Department of Health and Human Services, 2010. Retrieved from

http://www.gencourt.state.nh.us/rsa/html/X/126-X/126-X-8.htm

“Frequently Asked Questions” by the State of New Jersey Department of Health, 2014.

Retrieved from http://www.state.nj.us/health/medicalmarijuana/pat_faqs.shtml#22


108

“Law Enforcement Information Sheet” by the New Mexico Department of Health, 2014.

Retrieved from http://nmhealth.org/publication/view/regulation/126/

“About the Medical Marijuana Program” by the New York State Medical Marijuana Program,

2014. Retrieved from http://www.health.ny.gov/regulations/medical_marijuana/

“The Oregon Medical Marijuana Program” by the Oregon Public Health Authority, 2014.

Retrieved from http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/

MedicalMarijuanaProgram/Documents/ommpHandbook.pdf

“Protections for the Medical Use of Marijuana” by the State of Rhode Island Department of

Health, 2014. Retrieved from http://webserver.rilin.state.ri.us/Statutes/TITLE21/21-28.6/21-

28.6-4.HTM

“Marijuana Registry Frequently Asked Questions” by Vermont Department of Public Safety-

Division of Criminal Justice Services, 2014. Retrieved from http://vcic.vermont.gov/


“Medical Cannabis” by the Washington State Legislature, 2011. Retrieved from



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Table H2

8 Conditions Medical Marijuana is Most Frequently Prescribed for

8 Conditions Medical Marijuana Is Most Frequently Prescribed For

States with

Legal Medical

Marijuana

Cancer Glaucoma HIV/AIDs

Persistent

Muscle

spasms

Seizures Severe

Pain

Severe

Nausea

Cachexia,

Muscle

Atrophy,

or

Dramatic

Weight

Loss

Alaska yes yes yes yes yes yes yes yes

Arizona yes yes yes yes yes yes yes yes

California yes yes yes yes yes yes yes yes

Colorado yes yes yes yes yes yes yes yes

Connecticut yes yes yes yes yes

DC yes yes yes yes yes yes

Delaware yes yes yes yes yes yes yes

Hawaii yes yes yes yes yes yes

Illinois yes yes yes

Maine yes yes yes yes yes yes

Maryland yes yes yes yes

Massachusetts yes yes yes

Michigan yes yes yes yes yes yes yes

Minnesota yes yes yes yes yes yes

Montana yes yes yes yes

Nevada yes yes yes yes yes yes

New

Hampshire yes yes yes yes yes yes yes yes

New Jersey yes yes yes yes yes

New Mexico yes yes yes yes yes

New York yes yes yes yes yes yes

Oregon yes yes yes yes yes

Rhode Island yes yes yes yes yes yes yes yes

Vermont yes yes yes yes yes yes

Washington yes yes yes yes yes yes yes yes


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Note. Adapted from “The State of Alaska: Application for Medical Marijuana Registry” by the

Department of Health and Social Services, 2014. Retrieved from http://dhss.alaska.gov/dph/

VitalStats/Documents/PDFs/MedicalMarijuana.pdf

“Proposition 203” by the Arizona Senate, 2011. Retrieved from

http://www.azsos.gov/election/2010/info/pubpamphlet/english/prop203.htm

“Medical Marijuana Program Frequently Asked Questions” by the California Department of

Public Health, 2014. Retrieved from

http://www.cdph.ca.gov/programs/MMP/Pages/MMPFAQ.aspx#1

“Debilitating Conditions for Medical Marijuana” Use by the Colorado Department of Health and

Environment, 2013. Retrieved from

https://www.colorado.gov/pacific/sites/default/files/CHEIS_MMJ_Debilitating-Medical-

Conditions.pdf

“Qualification Requirements” by the State of Connecticut, Department of Consumer Protection ,

2013. Retrieved from http://www.ct.gov/dcp/cwp/view.asp?a=42

87&q=509628&dcpNav=|55376|&dcpNav_GID=2109

“Qualifying Conditions” by the District of Colombia, Department of Health , 2014. Retrieved

from http://doh.dc.gov/sites/default/files/dc/sites/doh/publication/attachments/140529%20

Qualifying%20conditions%20emergency%20and%20proposed.pdf

“Title 16, the Delaware Medical Marijuana Act” by the Delaware Senate , 2011. Retrieved from:

http://delcode.delaware.gov/title16/c049a/index.shtml

“Is the Grass Always Greener” By L. Ching, and J. Brannon, 2014. Retrieved from

http://www.publicpolicycenter.hawaii.edu/projects-programs/_hcr48/_general/lrb-report-grass-

greener.pdf


111

“Illinois Medical Cannabis Pilot Program” by the Illinois Department of Public Health, 2014.

Retrieved from http://www2.illinois.gov/gov/mcpp/Documents/DPH%20FAQ%20080814.pdf

“Medical Marijuana” by the State of Maine. Bureau of Corporations, Elections & Commissions,

2014. Retrieved from http://www.maine.gov/sos/cec/elec/medicalmarijuanaact.html

“Certifying Physicians” by the Maryland Department of Health and Mental Hygiene, 2014.

Retrieved from http://dhmh.maryland.gov/docs/Certifying%20physicians%20Draft%20

Regulations%20approved%20for%20release%20for%20informal%20Comments%207.22.14.pdf

“Medical Use of Marijuana in Massachusetts” by the Commonwealth of Massachusetts,

Department of Public Health, 2012. Retrieved from http://www.mass.gov/eohhs/docs/

dph/quality/drugcontrol/medical-marijuana/medical-marijuana-faq.pdf

“Frequently Asked Question for the Michigan Medical Marihuana Registry Programs” by the

Lara Department of Licensing and Regulations, 2014. Retrieved from

http://www.michigan.gov/documents/lara/lara_MMP_FAQ_6-28-13_426011_7.pdf

“Medical Cannabis” by the Minnesota Department of Health, 2014. Retrieved from

http://www.health.state.mn.us/topics/cannabis/

“Montana Medical Marijuana Program Definitions” by the Montana Public Health and Human

Services, 2014. Retrieved from http://leg.mt.gov/bills/mca/50/46/50-46-302.htm

“Medical Marijuana Establishment FAQs” by the Nevada Division of Public and Behavioral

Health, 2014. Retrieved from http://health.nv.gov/MedicalMarijuana/MME_FAQs.pdf

“New Hampshire Statues Section 126-X Definitions” by the New Hampshire Department of

Health and Human Services, 2010. Retrieved from http://www.gencourt.state.nh.us/

rsa/html/X/126-X/126-X-1.htm


112

“Do I Qualify?” by the State of New Jersey Department of Health, 2014. Retrieved from

http://www.state.nj.us/health/medicalmarijuana/qual.shtml

“Frequently Asked Questions” by the New Mexico Department of Health, 2014. Retrieved from

http://nmhealth.org/publication/view/help/131/

“About the Medical Marijuana Program” by the New York State Medical Marijuana Program,

2014. Retrieved from http://www.health.ny.gov/regulations/medical_marijuana/

“The Oregon Medical Marijuana Program” by the Oregon Public Health Authority, 2014.

Retrieved from http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/

MedicalMarijuanaProgram/Documents/ommpHandbook.pdf

“Medical Marijuana” by the State of Rhode Island Department of Health, 2014. Retrieved from

http://www.health.ri.gov/healthcare/medicalmarijuana/index.php

“Marijuana Registry Frequently Asked Questions” by Vermont Department of Public Safety-

Division of Criminal Justice Services, 2014. Retrieved from http://vcic.vermont.gov/


“Medical Cannabis” by the Washington State Legislature, 2011. Retrieved from



113