Growing Pains Part 1
Seeds of controversy: It took nine years for Colorado’s medical marijuana industry to take off after Amendment 20. Some worry it’s now out of control.
Colorado Senate Bill 109 highlights
Senate Bill 109 was created to regulate the medical side of Colorado’s medical marijuana industry.
■ Physicians and patients are required to have a bona fide relationship.
■ Physicians are required to have a valid, unrestricted license to practice medicine in Colorado and a valid, unrestricted U.S. Department of Justice Federal Drug Enforcement Administration controlled substances registration.
■ Physicians are precluded from accepting or soliciting money from caregivers or centers, providing discounts to patients who agree to use a particular caregiver or center, examining patients at centers or having an economic interest in a business that sells medical marijuana.
■ The Colorado Department of Health and Environment is permitted to create rules for the medical marijuana program, including consideration of adding debilitating medical conditions to the state constitution and allowing patients to claim indigence.
■ The medical marijuana cash fund, generated by application fees, can be used only to operate the medical marijuana program and shouldn’t be transferred to any other state fund.
■ The Colorado Board of Medical Examiners may review and investigate physicians it has a reasonable cause to believe violated the medical marijuana program.
Source: Colorado Revised Statutes
Steamboat Springs Kara Rosen is among the more than 100,000 Colorado residents who have become legal users of marijuana since 2009.
The 32-year-old Hayden resident and cancer survivor has used medical marijuana every day for about a year. It’s the only remedy she’s found to treat pain, digestion problems, nausea, loss of appetite and insomnia.
“I had lung cancer,” said Rosen, who owns Airtech Heating & Sheet Metal with her husband, Shelby. “I had it surgically removed. I have to deal with the pain just like other people deal with pain. I just do it in a different way. And it’s not a bad way.”
Medical marijuana became legal in Colorado, for patients with certain conditions and a doctor’s recommendation, after nearly 54 percent of voters approved Amendment 20 in 2000.
Nearly a decade later, Rosen is happy she had that option when confronting her post-cancer pain.
But Rosen’s story isn’t typical. The vast majority of Coloradans who use medical marijuana do so to treat severe pain, not the effects of cancer, glaucoma, HIV/AIDS and the other preapproved conditions.
For every Rosen, there are many more like Kip Strean.
Although Strean said he uses medical marijuana to relieve chronic back and shoulder pain, as well as insomnia, the 59-year-old also said he’s been smoking marijuana for about 40 years.
Strean, a musician who has lived in Steamboat Springs since 2000, was a child of the 1960s. He said marijuana is part of his culture. After a spring 2009 visit to Amsterdam, known in part for its legalization of marijuana, he applied for a state-issued medical marijuana registry card.
“I decided to get the card because I was tired of feeling like I was doing anything illegal anymore,” he said. “I mean, come on, the acceptance of it today is so much different than it was in the ’60s.”
In the nine years after it was added to the state constitution, medical marijuana mostly flew under the radar in Colorado. But a sequence of events starting in 2009 triggered what has become an emerging industry, changing the business and social landscape in Colorado while creating a model for the rest of the country.
Some lawmakers, law enforcement officers, state officials and medical professionals said a surge is taking place in the industry, which was largely unregulated and rife with abuse before legislation took effect July 1.
The biggest problem, they say, is approved medical marijuana users defrauding the system to smoke pot recreationally.
“Anybody who doesn’t think there’s abuse going on has to be pretty naïve. We don’t have 108,000 people with debilitating medical conditions,” Colorado Attorney General John Suthers said in August, referring to an earlier estimate of the number of approved medical marijuana cardholders.
Some Routt County dispensary owners acknowledge the willingness of some to take advantage of the system.
“I would say over 50 percent of cardholders use recreationally — a lot for pain management or as a stress reducer,” said Chris Ward, whose Milner medical marijuana center has a Hawaiian theme to reflect his upbringing on the island of Kauai.
A ‘perfect storm’
Colorado is one of 14 states with legislation making the use of medical marijuana legal. California came first in 1996. Earlier this year, Washington, D.C., approved it.
After Colorado voters approved Amendment 20, the state’s constitution was amended to allow the use of medical marijuana for eight debilitating conditions: cancer, glaucoma, HIV/AIDS, cachexia (physical wasting away though weight loss and muscle atrophy), severe pain, severe nausea, seizures and persistent muscle spasms.
Several events last year created what Ned Calonge, the state’s chief medical officer, called a “perfect storm” for medical marijuana in Colorado.
First, U.S. Attorney General Eric Holder said in March 2009 that federal raids of medical marijuana dispensaries would stop. Then, the Colorado Board of Health chose not to impose a limit on the number of patients a medical marijuana provider, called a caregiver, could have. And finally, the U.S. Justice Department sent a memo to prosecutors in October 2009 instructing them to not use federal resources against people in compliance with state medical marijuana laws.
The industry quickly took off. There were 4,720 Colorado cardholders by the end of 2008. As of Aug. 31, that number had swelled to an estimated 113,000, according to the Colorado Department of Public Health and Environment. The agency is charged with overseeing the state’s Medical Marijuana Registry. The estimate is based on the volume of applications the registry receives.
Coinciding with the exploding number of approved marijuana users, state officials once estimated that 1,100 medical marijuana centers operated in the state. A stretch of South Broadway Street in Denver, for example, is referred to as “The Green Mile” or “Broadsterdam” for the many medical marijuana centers there, some next door to or across the street from each other.
“We never imagined that the surge would be so high or would be sustained for so many months,” Calonge said in a telephone interview. “All these elements came together and gave birth to this industry.”
Routt County, with a population of 23,500, has five medical marijuana centers — a sixth in Yampa has closed. Steamboat, with more than 12,000 residents, is home to three of them. The number of pharmacies in the county outnumbers medical marijuana centers by one.
In a Colorado Department of Public Health and Environment office building in Denver, U.S. Postal Service boxes sit stacked on shelves in the new mailroom of the Office of Vital Statistics Medical Marijuana Registry.
Ron Hyman, the Colorado registrar and director of the Medical Marijuana Registry office in Denver, estimated in August that more than 30,000 medical marijuana card applications sat unopened in those boxes. Another batch of applications — an additional 30,000 or more — had just been sent for data entry to Integrated Document Solutions in Pueblo, part of Colorado’s Department of Personnel and Administration.
Hyman said those applications were opened and each $90 application fee was deposited. But because the applications haven’t been processed, medical marijuana registry cards haven’t been issued.
“I believe today we are mailing out cards for applications we received in early January,” he said Aug. 20.
The lack of cards doesn’t prevent users from being able to possess and smoke marijuana or use marijuana products. Patients use copies of the notarized application, physician authorization, photo identification and registered mail receipt as their temporary medical marijuana cards. The permanent cards — pieces of white paper outlined in red that resemble a sales tax license — take as long as nine months to process. Cardholders must renew their licenses every year.
The Office of Vital Statistics receives about 1,000 pieces of medical-marijuana-related mail daily, of which about 500 applications are approved, about 250 are incomplete and returned and about 250 are information changes for people already on the registry. Hyman said the volume of mail overwhelmed the office’s mailroom. So the Medical Marijuana Registry got its own.
The office also processes birth and death certificates and marriage licenses. Hyman estimated that “well over 80 percent” of his job was dedicated solely to the Medical Marijuana Registry during the past year.
Thousands of other pieces of unopened mail from patients on the registry wanting to update information won’t be processed until after Hyman’s staff catches up on the application backlog. He’s been given the go-ahead to triple his staff, to 33 employees, after a supplemental budget request he made in June was approved.
“In 2008, the entire year, I had 5,000 patients,” Hyman said. “Now I get that in a week. One person could easily handle the registry on their own from start to finish” in 2008.
A chronic debate
Dr. Brian Harrington, a physician with Yampa Valley Medical Associates in Steamboat, says the abuse and misuse of medical marijuana undermines the legitimacy and reasons for it.
Because of the medical marijuana registry backlog, only 41,039 patients — 292 in Routt County — are listed as being approved for medical marijuana as of Dec. 31, 2009, in the statistics section of the registry website. Of those patients, 92 percent cite severe pain for at least one qualifying debilitating condition. Patients can list more than one.
Muscle spasms, cited on 29 percent of applications, are the second most frequently reported condition. Cancer accounts for 2 percent, and glaucoma and HIV/AIDS were cited on 1 percent of applications.
Harrington said he has never recommended the use of medical marijuana but has discussed it with patients because he recognizes that it could have medical value for the right person. He also said the severe pain condition has opened the door for recreational users.
“Heroin takes care of pain,” he said while sitting in an exam room at his office. “Just to say marijuana takes care of pain is not a good argument.”
Brian Vicente, executive director of Sensible Colorado, an advocate for the state’s medical marijuana patients, disagrees that a majority of patients are citing severe pain simply as an excuse to use marijuana recreationally.
“There’s a lot of people in an active state like Colorado that suffer from chronic pain related to biking injuries, skiing injuries,” he said in August at his Denver office. “If they and their doctor feel it’s better to use marijuana than hydrocodone or OxyContin as a better treatment regimen, I think we have to respect that.”
Registered nurse Shannon Winegarner, the director of hospice and palliative care for the Northwest Colorado Visiting Nurse Association, said her organization supports the use of medical marijuana for its end-of-life patients because it is a legal medication defined by the state constitution.
“In my experience working with terminally ill patients, I have definitely seen people using marijuana to effectively manage symptoms that were not managed by other treatments,” she said about patients suffering from nausea, anxiety and weight loss.
“Our primary goal in hospice is to manage comfort — quality of life versus quantity of life. We don’t discriminate on the choice of medications.”
Hyman, who runs the Medical Marijuana Registry, doesn’t think all patients approved for medical marijuana have legitimate medical needs. But in the decade he’s run the program — and especially during the past year — Hyman said he’s spoken with many patients who have said medical marijuana has had a tremendous impact on their lives.
“For these individuals, it’s imperative we maintain the integrity of the program and reduce abuses,” he said. “If the public loses confidence, it hurts the integrity of the program. I think it’s imperative we have this avenue available for patients who need it.”
That so many have been approved to use medical marijuana indicates the industry is growing, Attorney General Suthers said, but he added that there’s not much integrity to the process of determining debilitating medical conditions.
“About 75 percent of the patients are males,” he said. “The average age (currently 40) is dropping precipitously. I would predict to you in a couple years the average age of a patient will be 24, 25, something like that.”
Charish Adams, 30, tried medical marijuana after injuring her back in May while trying to move furniture at her Hayden home. The medications doctors prescribed were ineffective. It’s not that they didn’t work; Adams couldn’t keep them down.
She was diagnosed in 2009 with gastroesophageal reflux disease, or chronic acid reflux disease, after vomiting nearly every morning for 10 years. Adams, the mother of a 10-year-old boy, joked that during that time, she constantly thought she was pregnant.
Knowing she couldn’t take pills — she couldn’t even keep Advil down — Adams first visited a chiropractor and acupuncturist to relieve her back pain.
Nothing worked, she said. Having used marijuana in the past, Adams thought she would give it a try. In June, she went to Mary’s, a medical marijuana center in Oak Creek.
Through her visits to Mary’s, she discovered tinctures — an alcohol- or glycerin-based liquid extract typically made from dried marijuana — and started taking an eyedropper full about once a week for her acid reflux. She hasn’t vomited since June.
“What it does is it stops the acid, it settles my stomach and doesn’t allow it to come back up,” Adams said. “I’d recommend it to anybody with nausea problems, headaches, usually anything that goes with being sick.”
Medicine vs. drug
Harrington, the Steamboat physician, struggles with the idea of marijuana as medicine. It’s listed as a Schedule 1 controlled substance by the federal government.
Under the Controlled Substances Act, marijuana is categorized with drugs including heroin and LSD. The Act states that Schedule 1 controlled substances have a high potential for abuse and have no “currently accepted medical use” in treatments in the United States.
Harrington said there’s a conflict between the medicinal value of marijuana and its health risks if it’s smoked, which the U.S. Food and Drug Administration has never approved as a medical delivery method.
He says marijuana is habit-forming, has been linked to respiratory problems if smoked and can cause a decline in cognitive function and increase anxiety.
“I do think the health benefits of marijuana are well-overplayed,” he said.
But Harrington acknowledged that ingesting marijuana, if used as a medicine, makes more sense than smoking it. He mentioned Marinol, an FDA-approved pill form of synthetic delta-9-tetrahydrocannabinol, or THC, thought to be the active ingredient in marijuana.
After surgery for her lung cancer, Kara Rosen experienced pain from the muscles doctors sliced through and ribs they fractured to get to her lung. The medications her doctors prescribed contributed to or exacerbated her digestion problems, nausea, loss of appetite and insomnia.
She got a recommendation from a Denver doctor and was approved for a medical marijuana card. She found that medical marijuana was the only thing that worked for her pain and other post-cancer ailments. But she rarely smokes it. Instead, she drinks teas or eats cookies infused with marijuana.
Infused products, a burgeoning portion of the state’s medical marijuana industry, are becoming more common and popular among patients, center owners said.
At 61, Jacob Wise, who owns Mary’s in Oak Creek, calls himself an old hippie. He is a civil engineer by trade, lost millions as a real estate developer when the industry went south and has counseled cocaine addicts as a minister certified in three religions. Owning a medical marijuana center was another venture.
When he opened his business, Wise said, he thought the industry was a scam, a way for recreational users to smoke legally. But the 42-year recreational and medical marijuana user said he’s seen improvement in his patients.
Wise is pushing tinctures, which he makes, for patients like Charish Adams. He also treats seven cancer patients with them.
“I’m going after the tincture business because I see it more as a medical application,” he said. “The other business is bigger right now, but eventually tinctures will be more popular. Tinctures don’t give the euphoric feeling. People smoke pot for the rose glass syndrome — ‘I feel good. Everything’s purty.’”
Regulating the medicine
Calonge, the state’s chief medical officer, said the rapid growth of medical marijuana in Colorado led to fraudulent, substandard care from doctors who charged fees to sign medical marijuana recommendations for patients they saw via webcam or met at a medical marijuana center.
He called those evaluations and that care “recreational use masquerading as a medical program.”
In the spring, Colorado lawmakers began discussing two pieces of legislation aimed at governing the industry for the first time. Senate Bill 109 was created to regulate the medical side of the industry and, among other provisions, precludes doctors from having any financial relationships with medical marijuana centers.
House Bill 1284 was created to regulate the business side of the medical marijuana industry. Among its many provisions, it forces medical marijuana center owners to undergo criminal background checks and forbids their ownership if they’ve been convicted of a drug-related felony.
Colorado Gov. Bill Ritter signed both pieces of legislation into law in June. They took effect July 1.
Calonge said Senate Bill 109 was intended to reduce some of the fraudulent actions by doctors that had become commonplace.
“I believe if we’re going to call it medical marijuana, we have to hold it to the same standards as all medical care,” he said.
“We believe (Senate Bill 109) is the first step to really put it back in the medical realm from the recreational-use realm and, we believe, more in line with what people voted when they voted for Amendment 20.”
House Bill 1284 has been called a significant piece of legislation that could become a model for the rest of the country.
Vicente, executive director of Sensible Colorado, who is not a medical marijuana cardholder (“I don’t have a qualifying condition,” he said.) called House Bill 1284 a landmark piece of legislation. He said it was a major step forward in legitimizing centers as safe access facilities for medical marijuana. But Vicente said the legislation has issues that he hopes to work through with legislators this session.
Despite the concerns, he said Colorado’s medical marijuana has become a legitimate business in the past year.
“We do have a constitutional amendment and a state law in the Colorado Revised Statutes that regulate this industry,” Vicente said. “I think it is legitimate, and I think it’s going to continue being one of the few growing areas of our economy, at least for the immediate future.”
Part 2 Green rush: Medical marijuana has become the basis for lucrative businesses, and entrepreneurs are not the only ones who could cash in.
Part 3 Blazing the trail: Municipalities across the state have been forced to weigh in on the marijuana debate. The months ahead will shape the industry.