This is the accessible text file for GAO report number GAO-03-189 
entitled 'Marijuana: Early Experiences with Four States' Laws That 
Allow Use for Medical Purposes' which was released on November 29, 
2002.



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Report to the Chairman, Subcommittee on Criminal Justice, Drug Policy 

and Human Resources, Committee on Government Reform, 

U.S. House of Representatives:



November 2002:



Marijuana:



Early Experiences with Four States Laws That Allow Use for Medical 

Purposes:



GAO-03-189:



Contents:



Letter:



Results in Brief:



Background:



Implementation in Oregon, Alaska, Hawaii, and California:



Few Registrants, Most with Severe Pain or Muscle Spasms:



Few Physicians Make Marijuana Recommendations; Some Guidance Available:



Difficult to Measure the Impact of State Medical Marijuana Laws on Law 

Enforcement Activities:



Agency Comments and Our Evaluation:



Appendix I: Objectives, Scope, and Methodology:



Objectives:



Scope and Methodology: State Selection and Data:



Scope and Methodology: Law Enforcement Opinions:



Appendix II: The Supreme Courts Decision in United States v. Oakland 

Cannabis Buyers Cooperative:



Appendix III: Medical Marijuana Registries in Oregon, Alaska, 

Hawaii, and Select California Counties:



Oregon:



Alaska:



Hawaii:



California:



Appendix IV: Descriptions of Allowable Conditions under State Medical 

Marijuana Laws:



Appendix V: Comments from the Department of Justice:



Appendix VI: GAO Contacts and Staff Acknowledgments:



GAO Contacts:



Staff Acknowledgments:



Tables:



Table 1: Registry Requirements and Verification Procedures in Oregon, 

Alaska and Hawaii, as of July 2002:



Table 2: Definition and Provisions Regarding Caregivers in Oregon, 

Alaska and Hawaii:



Table 3: Allowable Conditions for Medical Marijuana Use in Four States:



Table 4: Permissible Amounts of Medical Marijuana and Plant Maturity in 

Oregon, Alaska, and Hawaii:



Table 5: Safety and Public Use Restrictions in Oregon, Alaska, Hawaii 

and California:



Table 6: Medical Marijuana Registrants in Oregon, Hawaii, and Alaska, 

by Projected 2002 State Population:



Table 7: Registrants in Four California Counties by County Population:



Table 8: Registrant Age in Alaska, Hawaii and Oregon:



Table 9: Registrant Conditions in Oregon and Hawaii:



Table 10: Number of Marijuana Recommendations Made by Oregon 

Physicians, as of February 2002:



Table 11: Doctor Guidance Provided by Selected State Medical 

Organizations:



Figures:



Figure 1: Example of Oregons Medical Marijuana Registry Card:



Figure 2: Example of San Franciscos Medical Marijuana Registry Cards:



Figure 3: Example of Alaskas Medical Marijuana Certification Card:



Figure 4: Example of Hawaiis Medical Marijuana Registry Card:



Abbreviations:



CSA: Controlled Substances Act of 1970:



DEA: Drug Enforcement Administration:



FBI: Federal Bureau of Investigation:



HHS:Department of Health and Human Services:



UCR: Uniform Crime Reports:



November 1, 2002:



The Honorable Mark Souder

Chairman, Subcommittee on Criminal Justice, 

 Drug Policy and Human Resources

Committee on Government Reform

House of Representatives:



Dear Mr. Chairman:



A number of states have adopted laws that allow medical use of 

marijuana. Federal law, however, does not recognize any accepted 

medical use for marijuana and individuals remain subject to federal 

prosecution for marijuana possession. Debate continues over the medical 

effectiveness of marijuana, and over government policies surrounding 

medical use. A bill introduced in the House of Representatives in July 

2001 would modify the federal classification of marijuana and allow 

doctors, in states with medical marijuana laws, to recommend or 

prescribe marijuana.[Footnote 1] As the debate continues, so has 

interest in how state medical marijuana programs are operating, and in 

the issues faced by federal and state law enforcement officials in 

enforcing criminal marijuana provisions.[Footnote 2]



This report responds to your request that we examine the implementation 

of medical marijuana laws in selected states. We did not examine the 

effectiveness of states or local jurisdictions efforts to administer 

their programs and did not judge the validity of their approaches for 

implementing states laws. As agreed with your staff, we selected 

Oregon, Alaska, Hawaii, and California because they had medical 

marijuana laws in effect for at least 6 months and, according to our 

preliminary work, some data was available on patient and physician 

participation.[Footnote 3] For these states, we are reporting on (1) 

their approach to implementing their medical marijuana laws and how 

these approaches compare, and the results of any state audits or 

reviews; (2) the number, age, gender, and medical conditions of 

patients that have had doctors recommend marijuana for medical use in 

each state; (3) how many doctors are known to have recommended 

marijuana in each state, and what guidance is available for making 

these recommendations; and (4) the perceptions of federal and state law 

enforcement officials, and whether data are available to show how the 

enforcement of state marijuana laws has been affected by the 

introduction of these states medical marijuana laws.



In conducting our work, we examined applicable federal and state laws 

and regulations and spoke with responsible program officials in Oregon, 

Alaska, Hawaii, and California. In the four states, we obtained and 

analyzed available information on program implementation, program 

audits, and program participation by patients and doctors. We also met 

with various federal, state, and local law enforcement officials--

including officials with the Drug Enforcement Administration (DEA) and 

U.S. Attorneys offices in Washington, D.C., and the four selected 

states--to discuss data on arrests and prosecutions and views on the 

impact of the states medical marijuana laws on their law enforcement 

efforts.



Results from our review of these states cannot be generalized to other 

states with state medical marijuana laws, nor are they generalizable 

across the states selected for review. Similarly, in California, the 

information from the local jurisdictions we reviewed cannot be 

generalized to all local jurisdictions in California. We conducted our 

review between September 2001 and June 2002 in accordance with 

generally accepted government auditing standards. (Appendix I describes 

our scope and methodology in greater detail.):



Results in Brief:



State laws in Oregon, Alaska, Hawaii, and California allow medical use 

of marijuana under specified conditions. All four states require a 

patient to have a physicians recommendation to be eligible for medical 

marijuana use. Alaska, Hawaii, and Oregon have established state-run 

registries for patients and caregivers to document their eligibility to 

engage in medical marijuana use; these states require physician 

documentation of a persons debilitating condition to register. Laws in 

these three states also establish maximum allowable amounts of 

marijuana for medical purposes. Californias law does not establish a 

state-run registry or establish maximum allowable amounts of marijuana. 

Some local California jurisdictions have developed their own guidelines 

and voluntary registries. Oregon has changed some verification 

practices and administrative procedures as a result of a review of 

their medical marijuana program.



Relatively few people had registered to use marijuana for medical 

purposes in Oregon, Hawaii, and Alaska. As of Spring 2002, about 

2,450 people, or about 0.05 percent of the total population of the 

three states combined, had registered as medical marijuana users. 

Statewide figures for California are unknown. In Oregon, Alaska, and 

Hawaii, over 

70 percent of registrants were over 40 years of age or older, and in 

Hawaii and Oregon, the two states where gender information is 

collected, about 70 percent of registrants were men. Data from Hawaii 

and Oregon also showed that about 75 percent and more than 80 percent 

respectively, of the physician recommendations were for severe pain and 

conditions associated with muscle spasms, such as multiple sclerosis. 

Statewide figures on gender and medical conditions were not available 

for Alaska or California.



Hawaii and Oregon were the only two states that had data on the number 

of physicians recommending marijuana. As of February 2002, less than 

one percent of the approximately 5,700 physicians in Hawaii and three 

percent of Oregons physicians out of about 12,900 had recommended 

marijuana to their patients. Oregon also was the only state that 

maintained data on the number of times individual physicians 

recommended marijuana--as of February 2002, about 62 percent of the 

Oregon physicians recommending marijuana made one recommendation. 

Professional medical associations in all four states provided some 

guidance to physicians. The associations caution physicians about the 

legal issues facing them, or give advice on practices to follow and 

avoid. Most state medical board officials said they would only become 

involved with physicians recommending marijuana in cases where a 

complaint was filed against a physician for violating state medical 

practice standards. Californias medical board provides informal 

guidelines on making marijuana recommendations to their patients.



Data were not readily available to measure how marijuana-related law 

enforcement has been affected by the introduction of medical marijuana 

laws. To assess the relationship between trends in marijuana-related 

law enforcement activities and the passage of medical marijuana laws 

would require a statistical analysis over time that included measures 

of law enforcement activities, such as arrests, as well as data on 

other factors that are not easily measured, such as changes in 

perceptions about marijuana and shifts in law enforcement priorities. 

Officials from over half of the 37 selected federal, state, and local 

law enforcement organizations we interviewed in the four states said 

that the introduction of medical marijuana laws had not greatly 

affected their law enforcement activities. These officials indicated 

that they had not encountered situations involving a medical marijuana 

defense or they had other drug priorities. However, officials with some 

of the organizations told us that the laws in their states had made it 

more difficult to prosecute marijuana cases where medical use might be 

claimed; there was confusion over how to handle seized marijuana; and 

that, in their view, the laws had softened public attitudes toward 

marijuana.



In commenting on a draft of this report, the Department of Justice 

(DOJ) said that we fully described the current status of the programs 

in the states reviewed. However, DOJ stated that we failed to 

adequately address some of the serious difficulties associated with 

such programs. Specifically, DOJ commented that the report did not 

adequately address issues related to the (1) inherent conflict between 

state laws permitting the use of marijuana and federal laws that do 

not; (2) potential for facilitating illegal trafficking; (3) impact of 

such laws on cooperation among federal, state, and local law 

enforcement; and (4) lack of data on the medicinal value of marijuana. 

DOJ further stated that our use of the phrase medical marijuana 

implicitly accepts a premise that is contrary to existing federal law.



We disagree. We believe the report adequately addresses the issues 

within the scope of our review. With respect to DOJs first issue, our 

report describes how laws in the selected states and federal law treat 

the use of marijuana--the opening paragraph of our report specifically 

states that federal law does not recognize any accepted medical use of 

marijuana and individuals remain subject to federal prosecution for 

marijuana possession regardless of state medical marijuana laws. With 

regard to the second and third issues raised by DOJ concerning the 

potential for facilitating illegal trafficking and the impact on 

cooperation between federal, state, and local law enforcement 

officials, respectively, we interviewed federal, state, and local law 

enforcement officials about their perceptions concerning the impact of 

state medical marijuana laws on their activities and our report conveys 

the views and opinions of those officials. However, based on comments 

from law enforcement officials on a draft section of this report, we 

modified our report to discuss some of the issues law enforcement faces 

when dealing with medical marijuana laws and seized marijuana. 

Concerning the fourth issue--the lack of data on marijuanas medical 

value--our report discusses that a continuing debate exists over the 

medical value of marijuana, but an analysis of the scientific aspects 

of this debate was beyond the scope of our review.



Finally, we disagree with DOJs comment that our use of the phrase 

medical marijuana accepts a premise contrary to federal law. The 

introduction to our report specifically states that, throughout the 

report, we use the phrase medical marijuana to describe marijuana use 

that qualifies for a medical use exception under state law. Our 

detailed response to DOJs comments is provided on pages 35 to 38 and 

we have reprinted a copy of DOJs comments in appendix V.



Background:



The cannabis plant, commonly known as marijuana, is the most widely 

used illicit drug in the United States. According to recent national 

survey figures, over 75 percent of the 14 million illicit drug users 12 

years or older are estimated to have used marijuana alone or with other 

drugs in the month prior to the survey.[Footnote 4] Marijuana can be 

consumed in food or drinks, but most commonly dried portions of the 

leaves and flowers are smoked. Marijuana is widely used and the only 

major drug of abuse grown within the United States borders, according 

to the Drug Enforcement Administration.



Marijuana is a controlled substance under federal law and is classified 

in the most restrictive of categories of drugs by the federal 

government. The federal Controlled Substances Act of 1970 

(CSA)[Footnote 5] places all federally controlled substances into one 

of five schedules, depending on the drugs likelihood for abuse or 

dependence, and whether the drug has an accepted medical use.[Footnote 

6] Marijuana is classified under Schedule I,[Footnote 7] the 

classification reserved for drugs that have been found by the federal 

government to have a high abuse potential, a lack of accepted safety 

under medical supervision, and no currently accepted medical 

use.[Footnote 8] In contrast, the other schedules are for drugs of 

varying addictive properties, but found by the federal government to 

have a currently accepted medical use.[Footnote 9] The CSA does not 

allow Schedule I drugs to be dispensed upon a prescription, unlike 

drugs in the other schedules.[Footnote 10] In particular, the CSA 

provides federal sanctions for possession, manufacture, distribution or 

dispensing of Schedule I substances, including marijuana, except in the 

context of a government-approved research project.[Footnote 11]



The potential medical value of marijuana has been a continuing debate. 

For example, beginning in 1978, the federal government allowed the 

first patient to use marijuana as medicine under the Single Patient 

Investigational New Drug procedure, which allows treatment for 

individual patients using drugs that have not been approved by the Food 

and Drug Administration. An additional 12 patients were approved under 

the procedure between 1978 and 1992. When the volume of applicants 

tripled, the Secretary of the Department of Health and Human Services 

(HHS) decided not to supply marijuana to any more patients. According 

to Kuromiya v. United States, HHS concluded that the use of the single 

patient Investigational New Drug procedure would not yield useful data 

to resolve the remaining safety and effectiveness issues.[Footnote 12]



In 1999, an Institute of Medicine study[Footnote 13] commissioned by 

the White House Office of National Drug Control Policy recognized both 

a potential therapeutic value and potential harmful effects, 

particularly the harmful effects from smoked marijuana. The study 

called for more research on the physiological and psychological effects 

of marijuana and on better delivery systems. A 2001 report by the 

American Medical Associations Council on Scientific Affairs also 

summarized the medical and scientific research in this area, similarly 

calling for more research.[Footnote 14]



In May 1999, HHS released procedures allowing researchers not funded by 

the National Institute of Health to obtain research-grade marijuana for 

approved clinical studies. Sixteen proposals have been submitted for 

research under these procedures, and seven of the proposals had been 

approved as of May 2002.



Some states have passed laws that create a medical use exception to 

otherwise applicable state marijuana sanctions. California was the 

first state to pass such a law in 1996 when California voters passed a 

ballot initiative, Proposition 215 (The Compassionate Use Act of 1996) 

that removed certain state criminal penalties for the medical use of 

marijuana.[Footnote 15] Since then, voters in Oregon, Alaska, Colorado, 

Maine, Washington and Nevada have passed medical marijuana initiatives, 

and Hawaii has enacted a medical marijuana measure through its 

legislature. While state criminal penalties do not apply to medical 

marijuana users defined by the states statute, federal penalties 

remain, as determined by the Supreme Court in United States v. Oakland 

Cannabis Buyers Cooperative.[Footnote 16] (Appendix II provides more 

information on the Supreme Courts decision.):



In California, Alaska, and Oregon, where voters passed medical 

marijuana laws through ballot initiatives, each state provided an 

official ballot pamphlet, which included the text of the proposed law 

and arguments from proponents and opponents. Opponents of the 

initiatives referred to federal marijuana prohibitions, legal marijuana 

alternatives, and evidence of the dangers of smoked marijuana. 

Proponents referred to supportive studies and positive statements from 

medical personnel. In Hawaii, where the state legislature enacted the 

medical marijuana measure, law enforcement officials, advocacy groups, 

and medical professionals made similar arguments for or against the 

proposed law during the legislative process.



Implementation in Oregon, Alaska, Hawaii, and California:



Oregon, Alaska, Hawaii, and California laws allow medical use of 

marijuana under certain conditions.[Footnote 17] All four states 

require a patient to have a physicians recommendation to be eligible 

for medical marijuana. Consistent with their laws, Oregon, Alaska, and 

Hawaii also have designated a state agency to administer patient 

registries--which document a patients eligibility to use medical 

marijuana based on the written certification of a licensed physician--

and issue cards to identify certified registrants. Also, laws in 

Oregon, Alaska, and Hawaii establish limits on the amounts of marijuana 

a patient is allowed to possess for medical purposes. California does 

not provide for state implementation of its law. In particular, 

California has not delegated authority to a state agency or established 

a statewide patient registry. In addition, California law does not 

prescribe a specific amount of marijuana that can be possessed for 

medical purposes. In the absence of specific statutory language, some 

local California jurisdictions have established their own registries, 

physician certification requirements, and guidelines for allowable 

marijuana amounts for medical purposes. Only Oregon has reviewed its 

medical marijuana program, and as a result of that review, has changed 

some of its procedures and practices, including verifying all doctor 

recommendations.



States and Some Local California Jurisdictions Maintain Medical 

Marijuana Registries:



To document their eligibility to engage in medical marijuana use, 

applicants in Oregon, Alaska, and Hawaii must register with state 

agencies charged with implementing provisions of the medical marijuana 

laws in those states (hereinafter referred to as registry states). In 

Oregon, the Department of Human Services is responsible, and in Alaska, 

the Department of Health and Social Services. In Hawaii, the Narcotics 

Enforcement Division within the Department of Public Safety is 

responsible for the states medical marijuana registry. Applicants 

meeting state requirements are entered into a registry maintained by 

each state. In California, a number of counties have established 

voluntary registries to certify eligibility under the state s medical 

marijuana law.[Footnote 18]



The three registry states, Oregon, Alaska and Hawaii, have similar 

registry requirements. Potential registrants must supply written 

documentation by a physician licensed in that state certifying that the 

person suffers from a debilitating medical condition (as defined by the 

state statute) and in the physicians opinion would benefit from the 

use of marijuana. They also must provide information on the name, 

address, and birth date of the applicant (and of their caregiver, where 

one is specified) along with identification to verify the personal 

information. In each state, registry agencies must verify the 

information in the application based on procedures set in that states 

statutes or regulations before issuing the applicant a medical 

marijuana identification card. All three states allow law enforcement 

officers to rely upon registry applications in lieu of registry cards 

to determine whether a medical use exception applies. Figure 1 provides 

an example of the registry card issued by Oregon. (Appendix III 

provides examples of registry cards from Alaska and Hawaii.):



Figure 1: Example of Oregons Medical Marijuana Registry Card:



[See PDF for image]



Source: Oregon Department of Human Services.



[End of figure]



Hawaiis Department of Public Safety requires that doctors submit the 

completed registry application to the state agency, and if approved, 

the medical use certification is returned to the doctor for issuance to 

their patient. By contrast, registry agencies in Oregon and Alaska 

require that the registry card applicant submit the physician statement 

as part of the application, and issue the card directly to the patient. 

Alaska allows registry cards to be revoked if the registrant commits an 

offense involving a controlled substance of any type, whereas Oregon 

and Hawaii allow registry cards to be revoked only for marijuana-

related offenses, such as sale. Table 1 summarizes registry 

requirements and verification procedures of the responsible agencies in 

each registry state as of July 2002.



Table 1: Registry Requirements and Verification Procedures in Oregon, 

Alaska and Hawaii, as of July 2002:



Registry requirements: Completed application form; [Empty]; Oregon: 

x[A] (submitted by applicant); Alaska: x (submitted by applicant); 

Hawaii: x (submitted by physician).



Registry requirements: Written physician documentation; [Empty]; 

Oregon: x [B]; Alaska: x [C]; Hawaii: x [D].



Registry requirements: Applicant name, address and date of birth. Must 

include a copy of a current photographic identification card, such as 

license, or ID card number; [Empty]; Oregon: x; Alaska: x; Hawaii: x.



Registry requirements: Primary caregiver name, address and date of 

birth. Must include a copy of a current photographic identification 

card, such as license, or ID card number; [Empty]; Oregon: x; Alaska: 

x; Hawaii: x.



Registry requirements: Sworn caregiver statement on department form 

regarding lack of felony drug conviction, not on probation or parole, 

and over 21; [Empty]; Oregon: [Empty]; Alaska: x; Hawaii: [Empty].



Registry requirements: Address of site where marijuana will be 

produced; [Empty]; Oregon: x; Alaska: [Empty]; Hawaii: x.



Registry requirements: Annual renewal for registry card; [Empty]; 

Oregon: x; Alaska: x; Hawaii: x.



Registry requirements: Minors: parents declaration form and agreement 

to serve as minors caregiver; [Empty]; Oregon: x (must be notarized); 

Alaska: x; Hawaii: x.



Registry requirements: Registration fee; [Empty]; Oregon: $150; Alaska: 

$25 first time; $20 renewal; Hawaii: $25.



Registry requirements: Registry Verification Procedures; [Empty]; 

Oregon: [Empty]; Alaska: [Empty]; Hawaii: [Empty].



Registry requirements: Doctor has a valid license in state; [Empty]; 

Oregon: x; Alaska: x; Hawaii: x.



Registry requirements: Verification call or letter sent to doctor re: 

recommendation; [Empty]; Oregon: x; Alaska: x[E]; Hawaii: x.



Registry requirements: Patient contacted to validate application 

information; [Empty]; Oregon: x; Alaska: x[E]; Hawaii: x.



Registry requirements: Caregiver contacted to validate application 

information; [Empty]; Oregon: x[E]; Alaska: x[E]; Hawaii: x[E].



Registry requirements: Registry checked to assure caregiver only serves 

one patient; [Empty]; Oregon: [Empty]; Alaska: x; Hawaii: [Empty].



[A] A legible written statement with all the form information included 

will be accepted.



[B] Attending physician completes a state declaration form that the 

person has been diagnosed with a debilitating medical condition and 

that the medical use of marijuana may mitigate the symptoms or effects 

of the patients condition, or applicant provides medical records of 

debilitating condition signed by physician that contains all 

information required on physician form.



[C] Signed physician statement that the patient was examined within 

bona fide relationship and is diagnosed with a debilitating medical 

condition, other medications were considered and that patient might 

benefit from marijuana.



[D] Signed statement that in the physicians opinion, the qualifying 

patient has a debilitating medical condition and the potential benefits 

of the medical use of marijuana would likely outweigh the health risks 

for the qualifying patient, OR medical records with same information.



[E] Agency officials verify when they believe it is appropriate.



Source: Oregon, Alaska, and Hawaii medical marijuana state statutes, 

administrative rules and program officials.



[End of table]



Californias statute does not establish a state registry or require 

that a person or caregiver be registered to qualify for a medical use 

exception. Californias law requires that medical use has been 

recommended by a physician who has determined that the persons health 

would benefit from the use of marijuana for certain symptoms or 

conditions. The exception applies based upon the written or oral 

recommendation or approval of a physician. After the medical marijuana 

law was passed, the California Attorney General assembled a task force 

to discuss implementation issues in light of the ambiguities and 

significant omissions in the language of the initiative. The task 

force recommended a statewide registry be created and administered by 

the Department of Health Services, among other things, to clarify 

Californias law.[Footnote 19] However, a bill incorporating many of 

the ideas agreed upon by the task force was not enacted by the 

California legislature.[Footnote 20]



Some California communities have created voluntary local registries to 

provide medical marijuana users with registry cards to document that 

the cardholder has met certain medical use requirements. Figure 2 

provides examples of patient and caregiver registry cards issued by San 

Franciscos Department of Public Health. (See the following section for 

a discussion of caregivers.):



Figure 2: Example of San Franciscos Medical Marijuana Registry Cards:



[See PDF for image]



Source: San Francisco Department of Public Health.



[End of figure]



According to a September 2000 letter by the California Attorney 

General, medical marijuana policies have been created in some counties. 

Local registries have been created in Humboldt, Mendocino, San 

Francisco, and Sonoma counties. A medical marijuana registry in the 

city of Arcata, located in Humboldt County, was discontinued, however, 

the Arcata police department accepts registry cards from Humboldt 

County. A more recent list of medical marijuana registries operated by 

a county or city was not available, an official with the Attorney 

Generals office said, because there is no requirement for counties or 

cities to report on provisions they adopt regarding medical use of 

marijuana. At least two counties have since approved development of 

county medical marijuana registries, in San Diego in November 2001, and 

in Del Norte, in April 2002. Several cannabis buyers clubs, or 

cannabis cooperatives may have also established voluntary registries of 

their members.



(Appendix III provides additional discussion on state registry 

procedures in Oregon, Alaska, and Hawaii, procedures in selected 

California county registries, and examples of registry cards.):



Medical Marijuana Patient Primary Caregivers:



Laws in Oregon, Alaska, Hawaii, and California allow medical marijuana 

users to designate a primary caregiver. To qualify as a caregiver in 

the registry states, persons must be part of the state registry and be 

issued medical marijuana cards. Registered caregivers may assist 

registrants in their medical use of marijuana without violating state 

criminal laws for possession or cultivation of marijuana, within the 

allowed medical use amounts. Alaska allows registrants to designate a 

primary and alternate caregiver. Both must submit a sworn statement 

that they are at least 

21 years old, have not been convicted of a felony drug offense, and are 

not currently on probation or parole. In Hawaii and Alaska, caregivers 

can serve only one patient at a time. Alaska, however, allows 

exceptions for patients related to the caregiver by blood or marriage, 

or with agency approval, such as circumstances where a patient resides 

in a licensed hospice program. Oregon does not specify a limit to the 

number of patients one caregiver may serve. Table 2 provides 

information on definitions and caregiver provisions in Oregon, Alaska, 

and Hawaii.



Table 2: Definition and Provisions Regarding Caregivers in Oregon, 

Alaska and Hawaii:



Definition of Caregiver; Oregon: Designated primary caregiver means 

an individual eighteen years of age or older who has significant 

responsibility for managing the well-being of a person who has been 

diagnosed with a debilitating medical condition and who is designated 

as such on that persons application for a registry identification card 

or in other written notification to the division. Designated primary 

caregiver does not include the persons attending physician.; Alaska: 

Primary caregiver means a person listed as a primary caregiver (in 

the state medical use registry) and in physical possession of a 

caregiver registry identification card: primary caregiver also 

includes an alternate caregiver when the alternate caregiver is in 

physical possession of the caregiver registry identification card. 

Alternate caregiver means a person who is listed as an alternate 

caregiver (in the state medical use registry).; Hawaii: Primary 

caregiver means a person, other than the qualifying patient and the 

qualifying patients physician, who is eighteen years of age or older, 

and who has agreed to undertake responsibility for managing the well-

being of the qualifying patient with respect to the medical use of 

marijuana..



Limit to number of caregivers per patient; Oregon: 1; Alaska: 2 (a 

primary and an alternate); Hawaii: 1.



Limit to number of patients per caregiver; Oregon: Not specified; 

Alaska: 1; (exceptions may be granted by state agency); Hawaii: 1.



Criminal record restriction on serving as caregiver; Oregon: Not 

specified; Alaska: Yes; Hawaii: Not specified.



Source: Oregon, Alaska, and Hawaii medical marijuana statutes and 

administrative rules.



[End of table]



Californias statute also allows qualified medical marijuana users to 

designate a primary caregiver. The statue defines primary caregiver 

to mean the individual designated by the person exempted under this 

section who has consistently assumed responsibility for the housing, 

health or safety of that person. There is no requirement that the 

patient-caregiver relationship be registered or otherwise documented, 

nor is there a specified limit to the number of patients that can 

designate a particular caregiver.



Physician Recommendation Requirements:



In all four states, patients must obtain a physicians diagnosis that 

he or she suffers from a medical condition eligible for marijuana use 

under that states statute, and a physician recommendation for the use 

of marijuana. California does not have a requirement that the diagnosis 

or recommendation be documented, as the other states do. In the 

registry states, patients must supply written documentation of their 

physicians medical determination and marijuana recommendation in their 

registry applications. This documentation must conform with program 

requirements, reflecting that the physician made his or her 

recommendation in the context of a bona fide physician-patient 

relationship.



Californias law does not require patients to submit documentation of a 

physicians determination or recommendation to any state entity, nor 

does it specify particular examination requirements. According to 

Californias law, marijuana may be used for medical purposes where 

that medical use is deemed appropriate and has been recommended by a 

physician who has determined that the persons health would benefit 

from the use of marijuana in treating certain medical conditions; such 

recommendations may be oral or written.



The physician certification form adopted by Hawaiis Department of 

Public Safety calls for doctors recommending marijuana to a patient to 

certify that I have primary responsibility for the care and treatment 

of the named patient and based on my professional opinion and having 

completed a medical examination and/or full assessment of my patients 

medical history and current medical condition in the course of a bona 

fide physician-patient relationship have issued this written 

certificate. Similarly in Alaska, the recommending physician signs a 

statement that they personally examined the patient on a specific date, 

and that the examination took place in the context of a bona fide 

physician-patient relationship.



Under Oregons medical marijuana law, the patients attending physician 

must supply physician documentation. Oregons administrative rules 

defining attending physician were amended in March 2002 to more fully 

describe the conditions for meeting the definition. To qualify, the 

physician must have established a physician-patient relationship with 

the patient and must diagnose the patient with a debilitating condition 

in the context of that relationship.[Footnote 21] Agency officials 

stated that they changed the definition of an attending physician in 

light of information that one doctor responsible for many medical 

marijuana recommendations had not followed standard physician-patient 

practices, such as keeping written patient records. (See physician 

section.) Under its regulations, the Department of Human Services will 

contact each physician making a medical marijuana recommendation to 

assure that the physician is an attending physician and, with patient 

approval, the department may review the physicians patient file in 

connection with this inquiry.



Qualifying State Conditions for Use of Medical Marijuana:



The laws in all four states we reviewed identify medical 

conditions[Footnote 22] for which marijuana may be used for medical 

purposes. Table 3 displays the allowed medical conditions for which 

marijuana may be used in each state. (See appendix IV for descriptions 

from general medical sources of the allowable conditions identified by 

the state laws.):



Table 3: Allowable Conditions for Medical Marijuana Use in Four States:



Conditions[A]: Cancer; Oregon: x; Alaska: x; Hawaii: x; California: x.



Conditions[A]: Glaucoma; Oregon: x; Alaska: x; Hawaii: x; California: 

x.



Conditions[A]: HIV positive status; Oregon: x; Alaska: x; Hawaii: x; 

California: [Empty].



Conditions[A]: AIDS; Oregon: x; Alaska: x; Hawaii: x; California: x.



Conditions[A]: Cachexia; Oregon: x; Alaska: x; Hawaii: x; California: 

[Empty].



Conditions[A]: Wasting syndrome; Oregon: [Empty]; Alaska: [Empty]; 

Hawaii: x; California: [Empty].



Conditions[A]: Anorexia; Oregon: [Empty]; Alaska: [Empty]; Hawaii: 

[Empty]; California: x.



Conditions[A]: Epilepsy and other seizure disorders; Oregon: x; Alaska: 

x; Hawaii: x; California: [Empty].



Conditions[A]: Multiple sclerosis and other disorders characterized by 

persistent muscle spasticity; Oregon: x; Alaska: x; Hawaii: x; 

California: x.



Conditions[A]: Crohns disease; Oregon: [Empty]; Alaska: [Empty]; 

Hawaii: x; California: [Empty].



Conditions[A]: Alzheimers disease; Oregon: x; Alaska: [Empty]; Hawaii: 

[Empty]; California: [Empty].



Conditions[A]: Arthritis; Oregon: [Empty]; Alaska: [Empty]; Hawaii: 

[Empty]; California: x.



Conditions[A]: Migraine; Oregon: [Empty]; Alaska: [Empty]; Hawaii: 

[Empty]; California: x.



Conditions[A]: Severe pain; Oregon: x; Alaska: x; Hawaii: x; 

California: [Empty].



Conditions[A]: Chronic pain; Oregon: [Empty]; Alaska: [Empty]; Hawaii: 

[Empty]; California: x.



Conditions[A]: Severe nausea; Oregon: x; Alaska: x; Hawaii: x; 

California: [Empty].



Conditions[A]: Any other illness for which marijuana provides 

relief[B]; Oregon: [Empty]; Alaska: [Empty]; Hawaii: [Empty]; 

California: x.



[A] Oregons, Alaskas, and Hawaiis medical marijuana statutes use the 

term debilitating medical condition to encompass the conditions 

eligible for medical marijuana use. Californias statute does not use 

this term, but simply lists the eligible conditions.



[B] Californias statute does not define any other illness for which 

marijuana provides relief.:



Source: California, Oregon, Alaska and Hawaii medical marijuana 

statutes and Oregon administrative rules.



[End of table]



Allowable Amounts of Marijuana for Medical Use:



Statutes in Oregon, Alaska, and Hawaii define the maximum amount of 

marijuana and the number of plants that an individual registrant and 

their caregiver may possess under medical marijuana laws, while 

Californias statute does not provide such definitions. Oregon and 

Hawaii regulations also provide definitions of marijuana plant 

maturity. Table 4 provides the definitions of quantity and maturity for 

each registry state.



Table 4: Permissible Amounts of Medical Marijuana and Plant Maturity in 

Oregon, Alaska, and Hawaii:



Allowable amount; Oregon: A patient and a designated primary caregiver 

may not individually or collectively possess more than three mature 

plants, four immature marijuana plants, and one ounce of usable 

marijuana per each mature plant, if present at a location at which 

marijuana is produced, including any residence associated with that 

location.; If not at a location where marijuana is produced, including 

any residence associated with that location, the allowable amount is 

one ounce of usable marijuana.[A]; Alaska: A patient, primary caregiver 

or alternate caregiver may not possess in the aggregate more than one 

ounce of marijuana in usable form; and six marijuana plants, with no 

more than three mature and flowering plants producing usable marijuana 

at any one time.; Hawaii: Adequate Supply means an amount of 

marijuana jointly possessed between the qualifying patient and the 

primary caregiver that is not more than is reasonably necessary to 

assure the uninterrupted availability of marijuana for the express 

purpose of alleviating the symptoms or effects of a qualifying 

patients debilitating medical condition; provided that the adequate 

supply jointly possessed by the qualifying patient and the primary 

caregiver not exceed three mature marijuana plants, four immature 

marijuana plants, and one ounce of usable marijuana per each mature 

plant..



Plant maturity; Oregon: Mature plant means the following: A marijuana 

plant shall be considered mature when male or female flower buds are 

readily observed on the plant by unaided visual examination. Until this 

sexual differentiation has taken place, a marijuana plant will be 

considered immature.; Alaska: Not specified; Hawaii: Immature 

marijuana plant means a marijuana plant, whether male or female, that 

has not yet flowered and which does not yet have buds that are readily 

observed by unaided visual examination. Mature plant means a 

marijuana plant, whether male or female, that has flowered and which 

has buds that are readily observed by unaided visual examination..



[A] Registered patients and caregivers in Oregon who exceed the acts 

quantity restrictions are not immune from prosecution, but may 

establish an affirmative defense in a marijuana prosecution that the 

greater amount is medically necessary to mitigate the symptoms or 

effects of the patients debilitating medical condition. Ore. Rev. 

Stat. 475.306(2).



Source: Oregon, Alaska, and Hawaii medical marijuana statutes and 

administrative rules.



[End of table]



Californias statute does not specify an amount of marijuana allowable 

under medical use provisions; however, some local jurisdictions have 

established their own guidelines. The statutes criminal exemption is 

for personal medical purposes but does not define an amount 

appropriate for personal medical purposes. The California Attorney 

Generals medical marijuana task force debated establishing an 

allowable amount but could not come to a consensus on this issue, 

proposing that the Department of Health Services determine an 

appropriate amount. Participants did agree that the amount of marijuana 

a patient may possess might well depend on the type and severity of 

illness. They concluded that an appropriate amount of marijuana was 

ultimately a medical issue, better analyzed and decided by medical 

professionals. In the absence of state specified amounts, a number of 

the states 58 counties and some cities have informally established 

maximum allowable amounts of marijuana for medical purposes. According 

to the September 2000 summary by the California Attorney Generals 

office, the amount of marijuana an individual patient and their 

caregiver were allowed to have varied, with a two-plant limit in one 

area, and a 48 plant (indoors, with mature flowers) limit in another 

area. In May 2002, Del Norte County raised their limit from 

6 plants to 99 plants per individual patient.



Safety and Public Use Restrictions:



California, Oregon, Alaska, and Hawaii prohibit medical marijuana use 

in specific situations relating to safety or public use. Patients or 

caregivers who violate these prohibitions are subject to state 

marijuana sanctions and, in the registry states, may also forfeit their 

registry cards.[Footnote 23] Table 5 reflects the various states 

safety or public use restrictions.



Table 5: Safety and Public Use Restrictions in Oregon, Alaska, Hawaii 

and California:



Safety restrictions; Oregon: Oregons medical marijuana statute 

prohibits driving under the influence of marijuana.; Alaska: Alaskas 

medical marijuana statute prohibits medical use of marijuana that 

endangers the health or well-being of any person.; Hawaii: Hawaiis 

medical marijuana statute prohibits medical use of marijuana that 

endangers the health or well-being of another person.; California: 

Californias medical marijuana statute provides that, Nothing in this 

section shall be construed to supersede legislation prohibiting persons 

from engaging in conduct that endangers others, nor to condone the 

diversion of marijuana for nonmedical purposes..



Public use restrictions; Oregon: Oregons medical marijuana statute 

prohibits patients and caregivers from engaging in the medical use of 

marijuana in public places as defined in Ore. Rev. Stat. 161.015,[A] or 

in public view or in a correctional facility as defined in Ore. Rev. 

Stat. 162.135(2) or youth correction facility as defined in Ore. Rev. 

Stat 162.135(6).; Alaska: Alaskas medical marijuana law prohibits the 

medical use of marijuana in plain view of, or in a place open to, the 

general public. The law also states that medical marijuana use need not 

be accommodated in any place of employment; in any correctional 

facility, medical facility, or facility monitored by the Alaska 

Department of Administration; on or within 500 feet of school grounds; 

at or within 500 feet of a recreation or youth center; or on a school 

bus.; Hawaii: Hawaiis medical marijuana statute prohibits the medical 

use of marijuana in a school bus, public bus, or any moving vehicle; in 

the workplace of ones employment; on any school grounds; at any public 

park, public beach, public recreation center, recreation or youth 

center; or other place open to the public.; California: (not 

specified).



[A] As defined in Ore. Rev. Stat. 161.015, a public place means a place 

to which the general public has access including, but not limited to, 

hallways, lobbies and other parts of apartment houses and hotels not 

constituting rooms or apartments designed for actual residence, and 

highways, streets, schools, places of amusement, parks, playgrounds and 

premises used in connection with public passenger transportation.



Source: California, Oregon, Alaska and Hawaii state statutes.



[End of table]



Management Review Results in Oregon Program Changes:



Oregon was the only state of the four we reviewed to have conducted a 

management review of their states medical marijuana program.[Footnote 

24] The Oregon Department of Human Services conducted the review after 

concerns arose that a doctors signature for marijuana recommendations 

had been forged. The review team reported a number of program areas 

needing improvement, and proposed a corrective plan of action. Most of 

the actions had been completed, as of May 2002. Lack of verification of 

physician signature was a key problem identified by the team. All 

physician signatures are now verified. A number of other team findings 

had to do with program management and staffing. The Program Manager was 

replaced, additional staff was added, and their roles were clarified, 

according to officials. Another area of recommendation was the 

processing of applications and database management, such as how to 

handle incomplete applications, handling of voided applications, edit 

checks for data entry, and reducing the application backlog. As of May 

2002, some action items were still open, such as computer flags for 

problem patient numbers or database checks on patients and caregivers 

at the same address.



Few Registrants, Most with Severe Pain or Muscle Spasms:



A relatively small number of people are registered as medical marijuana 

users in Oregon, Hawaii, and Alaska. In those states, most registrants 

were over 40 years old. Severe pain and muscle spasms (spasticity) were 

the most common medical conditions for which marijuana was recommended 

in the states where data was gathered.



Small Number of Medical Marijuana Registrants:



Relatively few people are registered as medical marijuana users in 

Alaska, Hawaii and Oregon. In these states, registry data showed that 

the number of participants registered was below 0.05 percent or less of 

the total population of each respective state. Data doesnt exist to 

identify the total population of people with medical conditions that 

might qualify for marijuana use because not all the conditions 

specified in the states laws are diseases for which population data is 

available. For example, a debilitating condition of severe pain may 

be a symptom for a number of specific medical conditions, such as a 

back injury, however not all patients with back injury suffer severe 

pain. Table 6 shows the number of patients registered in Oregon, 

Hawaii, and Alaska, at the time of our review as compared to the total 

population from the U.S. Census Bureau population projections for 2002.



Table 6: Medical Marijuana Registrants in Oregon, Hawaii, and Alaska, 

by Projected 2002 State Population:



State: Oregon; State population: 3,488,000; Number of registrants: 

1,691; Percent of registrants by state population: 0.05.



State: Hawaii; State population: 1,289,000; Number of registrants: 573; 

Percent of registrants by state population: 0.04.



State: Alaska; State population: 672,000; Number of registrants: 190; 

Percent of registrants by state population: 0.03.



State: Totals; State population: 5,449,000; Number of registrants: 

2,454; Percent of registrants by state population: 0.05.



Note: Oregon data as of February 2002, Alaska and Hawaii data as of 

April 2002.



Source: Oregon, Hawaii, and Alaska state medical marijuana registries 

and U.S. Bureau of the Census population projections for 2002.



[End of table]



There is no statewide data on participants in California because the 

medical marijuana law does not provide for a state registry. We 

obtained information from four county registries in San Francisco, 

Humboldt, Mendocino and Sonoma counties.[Footnote 25] In each of these 

registries, participation was 0.5 percent or less than the respective 

countys population. However, because the local registries are 

voluntary it is unknown how many people in those jurisdictions have 

received medical recommendations from their doctors for marijuana but 

have not registered.



Table 7 shows the number of patients registered in four California 

counties and as a percent of the population for those counties, since 

each registry was established.



Table 7: Registrants in Four California Counties by County Population:



Registrant source: San Francisco Department of Public Health; County 

population: 793,729; Number of registrants: 3551; Percent of 

registrants by county population: 0.44.



Registrant source: Sonoma County Medical Association; County 

population: 468,754; Number of registrants: 435; Percent of registrants 

by county population: 0.09.



Registrant source: Humboldt County Department of Public Health; County 

population: 127,754; Number of registrants: 182; Percent of registrants 

by county population: 0.14.



Registrant source: Mendocino County; County population: 87,273; Number 

of registrants: 430; Percent of registrants by county population: 0.49.



Note: San Francisco and Sonoma county data as of July 2002, Humboldt 

county data as of January 2002, and Mendocino county data as of April 

2002. :



Sources: California State Association of Counties (as of January 2002), 

and California medical marijuana county registries.



[End of table]



Medical Marijuana Registrant Demographics:



Most medical marijuana registrants in Hawaii and Oregon--the states 

where both gender and age data were available--were males over 40 years 

old. Hawaii and Oregon were the only states that provided gender 

information; in both cases approximately 70 percent of registrants were 

men. In Alaska, Hawaii, and Oregon state records showed that over 

70 percent of all registrants in each state were 40 years of age or 

older. Only in one state was there a person under the age of 18 

registered as a medical marijuana user. Table 8 shows the distribution 

of registrants by age in the registry states.



Table 8: Registrant Age in Alaska, Hawaii and Oregon:



(Percent in each age category).



Age: Under 18; Alaska: 1 (1%); Hawaii: 0; Oregon: 0.



Age: 19-29; Alaska: 10 (5%); Hawaii: 16 (3%); Oregon: 145 (9%).



Age: 30-39; Alaska: 42 (22%); Hawaii: 70 (12%); Oregon: 247 (15%).



Age: 40-49; Alaska: 84 (44%); Hawaii: 197 (34%); Oregon: 613 (36%).



Age: 50-59; Alaska: 42 (22%); Hawaii: 216 (38%); Oregon: 550 (33%).



Age: Over 60; Alaska: 11 (6%); Hawaii: 74 (13%); Oregon: 136 (8%).



Total; Alaska: 190; Hawaii: 573; Oregon: 1691.



Note: Oregon data as of February 2002, Alaska and Hawaii data as of 

April 2002.



Source: Medical Marijuana registries in Alaska, Hawaii and Oregon. 



[End of table]



In California, none of the local jurisdictions we met with kept 

information on participants gender, and only Sonoma County Medical 

Association provided information on their registrants age. The age of 

medical association registrants was similar to participants in the 

state registries, only slightly younger. Over 60 percent of 

participants that have had their records reviewed by medical 

associations were 40 years or older.



Medical Marijuana Registrant Conditions:



Most medical marijuana recommendations in states where data are 

collected have been made for applicants with severe pain or muscle 

spasticity as their medical condition. Conditions allowed by the 

states medical marijuana laws ranged from illnesses such as cancer and 

AIDS, to symptoms, such as severe pain. Information is not collected on 

the conditions for which marijuana has been recommended in Alaska or 

California. However, data from Hawaiis registry showed that the 

majority of recommendations have been made for the condition of severe 

pain or the condition of muscle spasticity. Likewise, data from 

Oregons registry showed that, 84 percent of recommendations were for 

the condition of severe pain or for muscle spasticity. Table 9 shows 

the number and percentage of patients registered by types of conditions 

in Oregon and Hawaii.



Table 9: Registrant Conditions in Oregon and Hawaii:



Cancer; Oregon: Number of recommendations per condition: 43; Oregon: 

Percent with condition: 3; [Empty]; Hawaii: Number of recommendations 

per condition: 9; Hawaii: Percent with condition: 2.



Glaucoma; Oregon: Number of recommendations per condition: 31; Oregon: 

Percent with condition: 2; [Empty]; Hawaii: Number of recommendations 

per condition: 10; Hawaii: Percent with condition: 2.



HIV positive status or AIDS; Oregon: Number of recommendations per 

condition: 47; Oregon: Percent with condition: 3; [Empty]; Hawaii: 

Number of recommendations per condition: 66; Hawaii: Percent with 

condition: 12.



Cachexia; Oregon: Number of recommendations per condition: 18; Oregon: 

Percent with condition: 1; [Empty]; Hawaii: Number of recommendations 

per condition: -; Hawaii: Percent with condition: -.



Cachexia or wasting syndrome; Oregon: Number of recommendations per 

condition: -; Oregon: Percent with condition: -; [Empty]; Hawaii: 

Number of recommendations per condition: 9; Hawaii: Percent with 

condition: 2.



Epilepsy and other seizure disorders; Oregon: Number of recommendations 

per condition: 43; Oregon: Percent with condition: 3; [Empty]; Hawaii: 

Number of recommendations per condition: 5; Hawaii: Percent with 

condition: 1.



Multiple Sclerosis and other disorders characterized by persistent 

muscle spasms, or spasticity; Oregon: Number of recommendations per 

condition: 459; Oregon: Percent with condition: 28; [Empty]; Hawaii: 

Number of recommendations per condition: 240; Hawaii: Percent with 

condition: 43.



Alzheimers disease; Oregon: Number of recommendations per condition: 

1; Oregon: Percent with condition: Under 1; [Empty]; Hawaii: Number of 

recommendations per condition: -; Hawaii: Percent with condition: -.



Severe pain; Oregon: Number of recommendations per condition: 915; 

Oregon: Percent with condition: 56; [Empty]; Hawaii: Number of 

recommendations per condition: 172; Hawaii: Percent with condition: 31.



Severe nausea; Oregon: Number of recommendations per condition: 83; 

Oregon: Percent with condition: 5; [Empty]; Hawaii: Number of 

recommendations per condition: 12; Hawaii: Percent with condition: 2.



Severe nausea/severe pain; Oregon: Number of recommendations per 

condition: -; Oregon: Percent with condition: -; [Empty]; Hawaii: 

Number of recommendations per condition: 31; Hawaii: Percent with 

condition: 6.



Total; Oregon: Number of recommendations per condition: 1640[A]; 

Oregon: Percent with condition: [Empty]; [Empty]; Hawaii: Number of 

recommendations per condition: 554[B]; Hawaii: Percent with condition: 

[Empty].



[End of table]



Note: Oregon data as of February 2002, Hawaii data as of March 2002.



[A] Information on 51 cases not available.



[B] The number of registrants for Hawaii differs in tables 8 and 9 due 

to differences in the reporting dates.



Source: Oregon and Hawaii medical marijuana registries.



On the basis of records from the Oregon registry, we reviewed the 

information provided by doctors for additional insight into the 

conditions for which registrants use marijuana. The Oregon registry 

keeps track of secondary conditions in cases where the recommending 

doctor specified more than one condition. We examined the pool of 

secondary conditions associated with severe pain[Footnote 26] and 

muscle spasms,[Footnote 27] the two largest condition categories. About 

40 percent of those with severe pain reported muscle spasms, migraines, 

arthritis, or nausea as a secondary medical condition. The most common 

secondary conditions reported by those with spasms were pain, multiple 

sclerosis, and fibromyalgia,[Footnote 28] accounting for 

37 percent of the secondary conditions for spasms. A variety of other 

secondary conditions were identified in the Oregon data, such as acid 

reflux, asthma, chronic fatigue syndrome, hepatitis C, and lupus.



Few Physicians Make Marijuana Recommendations; Some Guidance Available:



In the two states, Hawaii and Oregon, where data on physicians is 

maintained, few physicians have made medical marijuana recommendations. 

Of the pool of recommending physicians in Oregon, most physicians made 

only one to two recommendations. Over half of the medical organizations 

we contacted provide written guidance for physicians considering 

recommending marijuana.



Low Physician Participation:



Only a small percentage of physicians in Hawaii and Oregon were 

identified by state registries as having made recommendations for their 

patients to use marijuana as medicine. These two states maintain 

information on recommending physicians in their registry records. No 

information was available on physician participation in California and 

Alaska. In Hawaii, at the time of our review, there were 5,673 

physicians licensed by the states medical board. Of that number, 44 

(0.78 percent) physicians had recommended marijuana to at least one of 

their patients since the legislation was passed in June 2000. In 

Oregon, at the time of our review, 435 (3 percent) of the 12,926 

licensed physicians in the state had participated in the medical 

marijuana program since May 1999.



Both Hawaii and Oregons medical marijuana registration programs are 

relatively new, which may account for the low level of participation by 

physicians in both states. Oregons program has operated for a year 

longer than Hawaiis, however physician participation overall is low in 

both states. A Hawaii medical association official told us that he 

believes physicians consider a number of factors when deciding whether 

to recommend marijuana as medicine, such as the legal implications of 

recommending marijuana, lack of conclusive research results on the 

drugs medical efficacy, and a doctors own philosophical stance on the 

use of marijuana as medicine.



The lower federal courts are divided in terms of whether doctors can 

make medical marijuana recommendations without facing federal 

enforcement action, including the revocation of doctors DEA 

registrations that allow them to write prescriptions for federally 

controlled substances. In one case, the district court for the Northern 

District of California held that the federal government could not 

revoke doctors registrations, stating that the de-registration policy 

raised grave constitutional doubts concerning doctors exercise of 

free speech rights in making medical marijuana 

recommendations.[Footnote 29] In the other case considering this issue, 

the district court for the District of Columbia ruled that the federal 

government could revoke doctors registrations, stating that [e]ven 

though state law may allow for the prescription or recommendation of 

medicinal marijuana within its borders, to do so is still a violation 

of federal law under the CSA, and there are no First Amendment 

protections for speech that is used as an integral part of conduct in 

violation of a valid criminal statute.[Footnote 30]



Oregon is the only state we reviewed which has registry records that 

identify recommendations by doctor. Few Oregon physicians made 

recommendations to use medical marijuana to more than two patients. 

According to registry data, 82 percent of the participating physicians 

made one or two recommendations, and 18 percent made three or more 

recommendations. Table 10 shows a breakdown of the frequency by which 

physicians made marijuana recommendations.



Table 10: Number of Marijuana Recommendations Made by Oregon 

Physicians, as of February 2002:



Number of recommendations: 1; Number of physicians making 

recommendations: 269; Percentage of recommending physicians: 61.8.



Number of recommendations: 2; Number of physicians making 

recommendations: 87; Percentage of recommending physicians: 20.0.



Number of recommendations: 3; Number of physicians making 

recommendations: 33; Percentage of recommending physicians: 7.6.



Number of recommendations: 4; Number of physicians making 

recommendations: 22; Percentage of recommending physicians: 5.1.



Number of recommendations: 5; Number of physicians making 

recommendations: 8; Percentage of recommending physicians: 1.8.



Number of recommendations: 6; Number of physicians making 

recommendations: 2; Percentage of recommending physicians: 0.5.



Number of recommendations: 7; Number of physicians making 

recommendations: 2; Percentage of recommending physicians: 0.5.



Number of recommendations: 9; Number of physicians making 

recommendations: 2; Percentage of recommending physicians: 0.5.



Number of recommendations: 10; Number of physicians making 

recommendations: 1; Percentage of recommending physicians: 0.2.



Number of recommendations: 11; Number of physicians making 

recommendations: 1; Percentage of recommending physicians: 0.2.



Number of recommendations: 12; Number of physicians making 

recommendations: 1; Percentage of recommending physicians: 0.2.



Number of recommendations: 13; Number of physicians making 

recommendations: 2; Percentage of recommending physicians: 0.5.



Number of recommendations: 14; Number of physicians making 

recommendations: 1; Percentage of recommending physicians: 0.2.



Number of recommendations: 18; Number of physicians making 

recommendations: 1; Percentage of recommending physicians: 0.2.



Number of recommendations: 23; Number of physicians making 

recommendations: 1; Percentage of recommending physicians: 0.2.



Number of recommendations: 38; Number of physicians making 

recommendations: 1; Percentage of recommending physicians: 0.2.



Number of recommendations: 823; Number of physicians making 

recommendations: 1; Percentage of recommending physicians: 0.2.



Source: Oregon Department of Human Services.



[End of table]



State or law enforcement officials in Oregon, California, and Hawaii 

indicated that they were each aware of a particular physician in their 

state that had recommended marijuana to many patients.[Footnote 31] In 

Alaska, a state official knew of no physician that had made many 

recommendations. In Oregon and California the state medical boards have 

had formal complaints filed against these physicians for alleged 

violations of the states Medical Practices Acts, which establish 

physician standards for medical care. The complaints charge the 

physicians with unprofessional conduct violations such as failure to 

conduct a medical examination, failure to maintain adequate and 

accurate records, and failure to confer with other medical care 

providers. In Oregon, the physician recommending marijuana to over 800 

patients was disciplined.[Footnote 32] The California case was still 

pending. At the time of our review, there was no medical practice 

complaint filed against the Hawaiian doctor known to have made many 

marijuana recommendations.



Physician Guidance for Making Medical Marijuana Recommendations:



In all four states, professional medical associations provide some 

guidance for physicians in regards to recommending marijuana to 

patients. State medical boards, in general, have limited involvement in 

providing this type of guidance. Table 11 indicates the type of 

guidance available from these medical organizations in each state.



Table 11: Doctor Guidance Provided by Selected State Medical 

Organizations:



State Medical Organizations: Oregon State Board of Medical Examiners; 

Guidance provided: No; Description: [Empty].



State Medical Organizations: Oregon Medical Association; Guidance 

provided: Yes; Description: The association has a document informing 

members of the legal issues facing doctors and advising them on doctor-

patient discussions and documentation concerning the use of marijuana 

for medicine, and actions to avoid..



State Medical Organizations: Alaska State Medical Board; Guidance 

provided: No; Description: [Empty].



State Medical Organizations: Alaska Medical Association; Guidance 

provided: Yes; Description: Those inquiring about recommending 

marijuana are directed to seek legal counsel..



State Medical Organizations: Hawaii State Board of Medical Examiners; 

Guidance provided: No; Description: [Empty].



State Medical Organizations: Hawaii Medical Association; Guidance 

provided: Yes; Description: Those inquiring about recommending 

marijuana are informed of the associations official position against 

medical marijuana and advised of the legal implications involved..



State Medical Organizations: Medical State Board of California; 

Guidance provided: Yes; Description: The board has a document that 

describes the standards physicians recommending marijuana should apply 

to their practice and advises them on how to best protect themselves..



State Medical Organizations: California Medical Association; Guidance 

provided: Yes; Description: The association provides a document 

covering the legal issues facing doctors, doctor-patient discussions 

and documentation concerning the use of marijuana for medicine, actions 

to avoid, and other topics under the law that may be of concern to 

physicians..



Note: Guidance provided as of the time of our review.



Source: State Medical Boards and Medical Associations in Oregon, 

Alaska, Hawaii, and Oregon.



[End of table]



The guidance to physicians considering recommending marijuana to a 

patient in Oregon, for example, includes avoiding engaging in any 

discussions with a patient on how to obtain marijuana, and to avoid 

providing a patient with any written documentation other than that in 

the patients medical records. The medical association also advises 

physicians to clearly document in a patients medical records 

conversations that take place between the physician and patient about 

the use of marijuana as medicine. Oregons medical association notes 

that until the federal government advises whether it considers a 

physicians medical marijuana recommendation in a patient chart to 

violate federal law, no physician is fully protected from federal 

enforcement action.



Most of the state medical board officials we contacted stated that the 

medical boards do not provide guidance for physicians on recommending 

marijuana to patients. The medical boards do become involved with 

physicians making marijuana recommendations if a complaint for 

violating state medical practices is filed against them. Once a 

complaint is filed, the boards investigate a physicians practice. Any 

subsequent action occurs if the allegations against a doctor included 

violations of the statutes regulating physician conduct.



California medical boards informal guidance states that physicians 

recommending marijuana to their patients should apply the accepted 

standards of medical responsibility such as the physical examination of 

the patient, development of a treatment plan, and discussion of side 

effects. In addition, the board warns physicians that their best legal 

protection is by documenting how they arrived at their decision to 

recommend marijuana as well as any actions taken for the patient.



Difficult to Measure the Impact of State Medical Marijuana Laws on Law 

Enforcement Activities:



Data are not readily available to show whether the introduction of 

medical marijuana laws have affected marijuana-related law enforcement 

activities. Assessing such a relationship would require a statistical 

analysis over time that included measures of law enforcement 

activities, such as arrests, as well as other measures that may 

influence law enforcement activities. It may be difficult to identify 

the relevant measures because crime is a sociological phenomena 

influenced by a variety of factors.[Footnote 33] Local law enforcement 

officials we spoke with about trends in marijuana law enforcement noted 

several factors, other than medical marijuana laws, important in 

assessing trends. These factors included changes in general perceptions 

about marijuana, shifts in funding for various law enforcement 

activities, shifts in local law enforcement priorities from one drug to 

another, or changes in emphasis from drugs to other areas, such as 

terrorism. Demographics might also be a factor.



The limited availability of data on marijuana-related law enforcement 

activity illustrates some of the difficulties in doing a statistically 

valid trend analysis. To fully assess the relationship between the 

passage of states medical marijuana laws and law enforcement, one 

would need data on marijuana related arrests or prosecutions over some 

period of time, and preferably an extended period of time. Although 

state-by-state data on marijuana-related arrests is available from the 

FBI Uniform Crime Reports (UCR), at the time of our review, only data 

up to the year 2000 was available. Yearly data would be insufficient 

for analytic purposes since the passage of the medical marijuana 

initiatives or law in three of the states--Oregon (November 1998), 

Alaska (November 1998), and Hawaii (June 2000)--is too recent to permit 

a rigorous appraisal of trends in arrests and changes in them.[Footnote 

34] Furthermore, although Californias law took effect during 1996 

providing a longer period of data, it is also important to note that 

the FBI cautions about UCR data comparisons between time periods 

because of variations in year-to-year reporting by agencies.[Footnote 

35]



Similar data limitations would occur using marijuana prosecutions as a 

measure of trends in law enforcement activity. Data on marijuana 

prosecutions are not collected or aggregated at the federal level by 

state. At the state level, for the four states we reviewed, the format 

for collecting the data, or time period covered also had limitations. 

For example in California, the state maintains disposition data that 

includes prosecutions, but reflects only the most serious offenses, so 

that marijuana possession that was classified as a misdemeanor would 

not be captured if the defendant was also charged with possession of 

other drugs, or was involved with theft or other non-misdemeanor 

crimes. Further, the data is grouped by the year of final disposition, 

not when the offense occurred. Hawaii does not have statewide 

prosecution data. At the time of our review, prosecution data from 

Oregons statewide Law Enforcement Data System was only available for 

1999 and 2000.



Perceptions of Officials with Selected Law Enforcement Organizations 

Regarding the Impact of Medical Marijuana Laws:



We interviewed officials from 37 selected federal, state, and local law 

enforcement organizations in the four states to obtain their views on 

the effect, if any, state medical marijuana laws had on their law 

enforcement activities. Officials representing 21 of the organizations 

we contacted indicated that medical marijuana laws had had little 

impact on their law enforcement activities for a variety of reasons, 

including very few or no encounters involving medical marijuana 

registry cards or claims of a medical marijuana defense. For example:



* The police department on one Hawaiian island had never been presented 

a medical marijuana registry card, and only 15 registrants lived on the 

island.



* In Alaska, a top official for the State Troopers Drug Unit had never 

encountered a medical marijuana registry card in support of claimed 

medical use.



* In Oregon, one district attorney reported having less than 10 cases 

since the law was passed where the defendant presented a medical 

marijuana defense.[Footnote 36]



* In Los Angeles County, an official in the District Attorneys office 

stated that only three medical marijuana cases have been filed in the 

last two years in the Central Branch office, two of the cases involving 

the same person.



Some of the federal law enforcement officials we interviewed indicated 

that the introduction of medical marijuana laws has had little impact 

on their operations. Senior Department of Justice officials said that 

the Departments overall policy is to enforce all laws regarding 

controlled substances, however they do have limited resources. Further, 

the federal process of using a case-by-case review of potential 

marijuana prosecutions has not changed as a consequence of the states 

medical marijuana laws. These officials said that U.S. Attorneys have 

their own criteria or guidelines for which cases to prosecute that are 

based on the Departments overall strategies and objectives.



Law enforcement officials in the selected states also told us that, 

given the range of drug issues, other illicit drug concerns, such as 

rampant methamphetamine abuse or large-scale marijuana production are 

higher priorities than concerns about abuse of medical marijuana. In at 

least one instance, this emphasis was said to reflect community 

concerns--in Hawaii, one prosecuting attorney estimated that one-third 

to one-half of the murders and most hostage situations in the county 

involved methamphetamines. He said businesses ask why law enforcement 

is bothering with marijuana when they have methamphetamines to deal 

with.



Although many of the officials with other organizations we contacted 

did not clearly indicate whether medical marijuana laws had, or had 

not, had major impact on their activities, officials with two 

organizations said that medical marijuana laws had become a problem 

from their perspective. Specifically, an official with the Oregon State 

Police Drug Enforcement Section said that during 2000 and 2001, there 

were 14 cases in which the suspects had substantial quantities of 

processed or growing marijuana and were arrested for distribution of 

marijuana for profit, yet were able to obtain medical marijuana 

registry cards after their arrests. Because the same two defense 

attorneys represented all the suspects, the police official expressed 

his view that the suspects might have been referred to the same doctor, 

causing the official to speculate about the validity of the 

recommendations. In Northern California--an area where substantial 

amounts of marijuana are grown[Footnote 37]--officials with the 

Humboldt County Drug Task Force[Footnote 38] told us that they have 

encountered growers claiming to be caregivers for multiple medical 

marijuana patients. With a limit of 10 plants per person established by 

the Humboldt County District Attorney, growers can have hundreds of 

plants officials said, and no documentation to support their medical 

use claims is required.[Footnote 39]



Over one-third of officials from the 37 law enforcement organizations 

told us that they believe that the introduction of medical marijuana 

laws have, or could make it, more difficult to pursue or prosecute some 

marijuana cases. In California, some local law enforcement officials 

said that their states medical marijuana law makes them question 

whether it is worth pursuing some criminal marijuana cases because of 

concerns about whether they can effectively prosecute (e.g., with no 

statutory limit on the number of marijuana plants allowed for medical 

use, the amount consistent with a patients personal medical purposes 

is open to interpretation). In Oregon, Hawaii, and Alaska where 

specific plant limits have been established, some law enforcement 

officials and district attorneys said that they were less likely to 

pursue marijuana cases that could be argued as falling under medical 

use provisions. For example, one Oregon District Attorney stated that 

because they have limited resources the District Attorneys might not 

prosecute a case where someone is sick, has an amount of marijuana 

within the medical use limit, and would probably be approved for a card 

if they did apply. Officers in Hawaii reported reluctance of a judge to 

issue a search warrant until detectives were certain that cultivated 

marijuana was not being grown for medical use, or that the growth was 

over the 25-plant limit qualifying for felony charges.



Less concrete, but of concern to law enforcement officials were the 

more subtle consequences attributed to the passage of state medical 

marijuana laws. Officials in over one-fourth of the 37 law enforcement 

organizations we interviewed indicated they believe there has been a 

general softening in public attitude toward marijuana, or public 

perception that marijuana is no longer illegal. For example, state 

troopers in Alaska said that they believe that the law has desensitized 

the public to the issue of marijuana, reflected in fewer calls to 

report illegal marijuana activities than they once received. Hawaiian 

officers stated that it is their view that Hawaiis law may send the 

wrong message because people may believe that the drug is safe or 

legal.



Several law enforcement officials in California and Oregon cited the 

inconsistency between federal and state law as a significant problem, 

particularly regarding how seized marijuana is handled. According to a 

California Attorney General official, state and local law enforcement 

officials are frequently faced with this issue if the court or 

prosecutor concludes that marijuana seized during an arrest was legally 

possessed under California law, and law enforcement is ordered to 

return the marijuana. To return it puts officials in violation of 

federal law for dispensing a Schedule I narcotic, according to the 

California State Sheriffs Association, and in direct violation of the 

court order if they dont return it. The same issue has arisen in 

Portland, Oregon, officials said, when the Portland police seized 2.5 

grams of marijuana from an individual. After the state dismissed 

charges, the court ordered the return of the marijuana to the 

individual, who was a registered medical marijuana user. The city of 

Portland appealed the court order on grounds that its police officers 

could not return the seized marijuana without violating federal law, 

but the Oregon court of appeals rejected this argument in Oregon v. 

Kama.[Footnote 40] Oregon officials said that DEA then obtained a 

federal court order to seize the marijuana from the Portland police 

department. The Department of Justice stated in comments on a draft of 

this report that they believe conflicts between federal and non-federal 

law enforcement over the handling of seized marijuana has been and will 

continue to be a problem.



Law enforcement officials in all four states identified areas of their 

medical marijuana laws that can hamper their marijuana enforcement 

activities because the law could be clearer or provide better control. 

In California, key issues were lack of a definable amount of marijuana 

for medical use, and no systematic way to identify who qualifies for 

the exemption. In Oregon, officers were concerned about individuals 

registering as medical marijuana users after they have been arrested, 

and timely law enforcement access to the registry information. 

Officials with about one-fourth of the law enforcement organizations in 

Hawaii, California and Oregon shared the concern about the degree of 

latitude given to physicians in qualifying patients for medical use.



Agency Comments and Our Evaluation:



We provided a copy of a draft of this report to the Department of 

Justice for review and comment. In a September 27, 2002 letter, DOJs 

Acting United States Assistant Attorney General for Administration 

commented on the draft. DOJs comments are summarized below and 

presented in their entirety in appendix V.



In its comments, DOJ noted that the report fully described the current 

status of the programs in the states reviewed. However, DOJ stated that 

the report failed to adequately address some of the serious 

difficulties associated with such programs. Specifically, according to 

DOJ, the report does not adequately address, through any considered 

analysis, issues related to the (1) inherent conflict between state 

laws permitting the use of marijuana and federal laws that do not; (2) 

potential for facilitating illegal trafficking; (3) impact of such laws 

on cooperation among federal, state, and local law enforcement; and (4) 

lack of data on the medicinal value of marijuana. DOJ further stated 

that our use of the phrase medical marijuana implicitly accepts a 

premise that is contrary to existing federal law.



In regard to the first issue--state laws that permit the use of 

marijuana and federal laws that do not--DOJ pointed out that the most 

fundamental problem with the report is that it failed to emphasize that 

there is no federally recognized medicinal use of marijuana and thus 

possession or use of this substance is a federal crime. We disagree, 

and believe that we have clearly described federal law on the use of 

marijuana. On page 1 of our report, we specifically state that federal 

law does not recognize any accepted medical use for marijuana and 

individuals remain subject to federal prosecution for marijuana 

possession regardless of state medical marijuana laws.



In other comments about state and federal laws, DOJ also pointed out 

that our report failed to mention that state medical marijuana laws 

undermine (1) the closed system of distribution for controlled 

substances under the Controlled Substances Act and (2) the federal 

governments obligations under international drug control treaties 

which, according to DOJ, prohibit the cultivation of marijuana except 

by persons licensed by, and under the direct supervision of, the 

federal government. As discussed in our report, the legal framework for 

our work was the Supreme Courts opinion in United States v. Oakland 

Cannabis Buyers Cooperative, 532 U.S. 483 (2001) which held that the 

federal government can enforce marijuana prohibitions without regard to 

a medical necessity defense, even in states with medical marijuana 

laws. During our review, we saw no reason to expand our analysis beyond 

that set forth in the Supreme Courts decision. This is especially true 

since the scope of our work was to examine how the selected states were 

implementing their medical marijuana laws--not the issues raised in DOJ 

comments.



Regarding the second issue concerning the potential for illegal 

trafficking, DOJ commented that our report did not mention that state 

medical marijuana laws are routinely being abused to facilitate 

traditional illegal trafficking. DOJ also highlighted the lack of 

guidance provided by the California state government to implement its 

medical marijuana law as contributing to the problem in California. Our 

report discusses the views of law enforcement officials representing 37 

organizations in the four states--including federal officials--

regarding the impact of state medical marijuana laws on their law 

enforcement efforts. Our report presented the views they conveyed to 

us. Thus, in those instances where law enforcement officials, including 

representatives of DEA and U.S. Attorneys offices, discussed what they 

considered instances of abuse or potential abuse, we discussed it in 

our report. During our review, none of the federal officials we spoke 

with provided information to support a statement that abuse of medical 

marijuana laws was routinely occurring in any of the states, including 

California. DOJ further asserted that we should include information on 

the underlying criminal arena, on homicides related to marijuana 

cultivation, and on illegal marijuana production and diversion. These 

issues were beyond the scope of our work.



In regard to its third comment pertaining to cooperation among federal, 

state, and local law enforcement officials, DOJ stated that our report 

did not reflect DEAs experience--a worsening of relations between 

federal, state, and local law enforcement. DOJs comments provided 

specific examples of incidents involving conflicts between DEA and non-

federal law enforcement officials, but these examples were not provided 

to us during our fieldwork. In comments on a summary of law enforcement 

opinions, some of the non-federal law enforcement officials we 

interviewed also stated we should discuss the conflict between state 

medical marijuana laws and federal laws as it related to seized 

marijuana.[Footnote 41] We modified our draft to include a discussion 

of these concerns, and have likewise included DOJs comment. It is also 

important to note, however, that contrary to DOJs suggestion, our 

report included a discussion about the concerns of the law enforcement 

officials regarding a softening of the public perception about 

marijuana. Finally, DOJs point that Oregons medical marijuana law 

negatively impacts federal seized asset sharing was an issue outside 

the scope of our review.



In regard to the fourth issue--lack of data on the medicinal value of 

marijuana--DOJ stated that our discussion of the debate over the 

medical value of marijuana is inadequate and does not present an 

accurate picture. We believe our report adequately discusses that a 

continuing debate exists. The overall objective of our review was to 

examine the implementation of state medical marijuana laws, and an 

analysis of the scientific aspects of the medical marijuana debate was 

beyond the scope of our work. We do, however, footnote various studies 

so that readers can access additional information on the studies if 

they desire.



Finally, we disagree with DOJs comment that our use of the term 

medical marijuana accepts a premise contrary to federal law, given that 

we specifically defined the term in relation to state, not federal, 

law. As mentioned earlier, our report specifically states that federal 

law does not recognize any accepted medical use for marijuana and 

individuals remain subject to federal prosecution for marijuana 

possession regardless of state medical marijuana laws. Furthermore, the 

introduction to the report clearly points out that, throughout the 

report, we use the phrase medical marijuana to describe marijuana use 

that qualifies for a medical use exception under state law.



DOJ also provided technical comments, which we have included in this 

report, where appropriate. In addition, as mentioned earlier, some of 

the representatives of state law enforcement organizations provided 

comments on the section of the report dealing with their perceptions, 

and we have made changes to the report, where appropriate.



As agreed with your office, unless you publicly announce the contents 

of this report earlier, we plan no further distribution until 30 days 

from the report date. At that time, we will send copies of this report 

to the Ranking Minority Member, Subcommittee on Criminal Justice, Drug 

Policy and Human Resources, and the Chairman and Ranking Minority 

Member, House Committee on Government Reform; the Chairman and Ranking 

Minority Member of the House Judiciary Committee; the Chairman and 

Ranking Minority Member of the Senate Judiciary Committee; the Attorney 

General; and the Director, Office of Management and Budget. We will 

also make copies available to others on request. In addition, the 

report will be available at no charge on the GAO Web site at http://

www.gao.gov.



If you or your staff have any questions on this report, please contact 

me or John Mortin on (202) 512 -8777. Key contributors are acknowledged 

in appendix V.



Sincerely yours,



Signed by Paul Jones:



Paul Jones

Director, Justice Issues:



[End of section]



Appendix I: Objectives, Scope, and Methodology:



Objectives:



Our overall objectives were to provide fact-based information on how 

selected states implement laws that create a medical use exception to 

specified state marijuana prohibitions, and to document the impact of 

those laws on law enforcement efforts. Specifically, for selected 

states, our objectives were to provide information on (1) their 

approach to implementing their medical marijuana laws and how they 

compare, and the results of any state audits or reviews, (2) the number 

of patients that have had doctors recommend marijuana for medical use 

in each state, for what medical conditions, and by age and gender 

characteristics, (3) how many doctors are known to have recommended 

marijuana in each, and what guidance is available for making these 

recommendations, and 

(4) perceptions of federal and state law enforcement officials, and 

whether data are available to show how law enforcement activities have 

been affected by the exceptions provided by these states medical 

marijuana laws.



We conducted our review between September 2001 and June 2002 in 

accordance with generally accepted government auditing standards.



Scope and Methodology: State Selection and Data:



Eight states have enacted medical marijuana statutes.[Footnote 42] We 

selected four of those states based on the length of time the laws had 

been in place, the availability of data, and congressional interest. 

Two of the eight states, Nevada and Colorado, were not selected because 

their laws had not been in place for at least 6 months when our review 

began. Another two states, Maine and Washington, were not selected 

because they do not have state registries to obtain information on 

program registrants. Alaska, Oregon and Hawaii do have state registries 

and had laws in place for at least 

6 months. Californias law was enacted in 1996; however, the state does 

not have a participant registry. We included it because some local 

registry information was available, and the requestor specifically 

requested information on California and Oregon. Our sample consists of 

these four states: California, Oregon, Alaska, and Hawaii.



We conducted on-site data collection and interviews with senior 

officials at state registries in Oregon and Hawaii, county offices in 

selected California counties, and the senior official in Alaska by 

phone and email. We examined applicable federal and state laws and 

regulations and obtained and analyzed available information on program 

implementation, program audits, and program participation by patients 

and doctors.



Data Reliability:



State and California county officials voluntarily supplied data on 

medical marijuana program registrants and some provided data on 

physician participation. Officials did not provide names to protect 

participants confidentiality. We reviewed the data for reasonableness 

and followed up with appropriate individuals about any questions 

concerning the data. Given the confidentiality of the information, we 

could not check the data back to source documents. We also interviewed 

knowledgeable state and county officials to learn how the data was 

collected and processed, and to gain a full understanding of the data. 

We determined the data was reliable enough for the limited purposes of 

this report. However, the data only reflects those that have registered 

with state and county programs. No estimate is available on the number 

of medical marijuana users that have not registered with a program. 

Additionally, data from the three state registries are not 

representative of participation in other states for which we did not 

collect data. Similarly, data from select California counties only 

reflect each county, not other counties where we did not conduct audit 

work.



Scope and Methodology: Law Enforcement Opinions:



We used a nonprobability sample to select law enforcement 

representatives to provide examples of the policies, procedures, 

experiences, and opinions of law enforcement regarding state medical 

marijuana laws. Our selection of these law enforcement representatives 

was not designed to enable us to project their responses to others, in 

this case, other law enforcement officials. Feedback was requested from 

officials at law enforcement organizations we visited, and incorporated 

where appropriate.



We discussed state medical marijuana laws with federal, state and local 

law enforcement officials in the states of California, Hawaii, Oregon 

and Alaska. On-site interviews were conducted in all but 

Alaska.[Footnote 43] Federal officials in each state included 

representatives from the office of the U.S. Attorney and the Drug 

Enforcement Administration (DEA). The specific U.S. Attorney and DEA 

office and officials we met with were selected by the Department of 

Justice as the most knowledgeable on the subject. For a statewide 

perspective, we interviewed representatives from the Attorney Generals 

office and at least one statewide association in California and Oregon 

representing law enforcement officials. This included representatives 

from the following:



Oregon Attorney General

Oregon Association of Chiefs of Police

California Attorney General

California District Attorney Association

California State Sheriffs Association

Hawaii Attorney General

Hawaii Department of Public Safety

Alaska Attorney General

Alaska State Troopers:



For a local law enforcement perspective, we interviewed district 

attorney and local police department officials. Selection was 

judgmental and based on a number of factors, including: suggestions by 

federal or state officials, jurisdictions where trips were planned to 

interview state medical marijuana registry program officials or state 

officials, or large portions of the state population were covered by 

the department. Local law enforcement representatives included the 

following:



Marion County Oregon District Attorney

Portland Oregon District Attorney

Portland Oregon Bureau of Police 

Oregon State Police

Oregon Association of Chiefs of Police (Dallas Oregon Police Chief 

participated)

Clackamus County Oregon Sheriffs Office

Los Angeles California District Attorney

Los Angeles California Police Department

San Bernardino California Police Department

Orange California Police Department

Eureka California Police Department/ Humboldt (state) Drug Task Force

Arcata California Police Department

San Francisco California Police Department

Hawaii County Hawaii Prosecuting Attorney

Honolulu County Hawaii Prosecuting Attorney

Hawaii County Hawaii Police Department

Honolulu Hawaii Police Department

Maui Hawaii Police Department

Anchorage Alaska District Attorney

Anchorage Alaska Police Department

Juneau Alaska Police Department:



We requested comments from DOJ on a draft of this report in August 

2002. The comments are discussed near the end of the letter and are 

reprinted as appendix V. DOJ also provided technical comments on the 

draft of this report and we incorporated DOJs comments where 

appropriate. In addition, we requested comments from the law 

enforcement officials we interviewed pertaining to the section of this 

report dealing with their perceptions and included their comments where 

appropriate. Finally, we verified the information we obtained on the 

implementation of state medical marijuana laws with the officials we 

contacted during our review.



[End of section]



Appendix II: The Supreme Courts Decision in United States v. Oakland 

Cannabis Buyers Cooperative:



Under the federal Controlled Substances Act of 1970 (CSA), marijuana is 

classified as a Schedule I controlled substance, a classification 

reserved for drugs found by the federal government to have no currently 

accepted medical use. 21 U.S.C. 812(c), Schedule I (c)(10).



Consistent with this classification system, the CSA does not allow 

Schedule I drugs to be dispensed upon a prescription, unlike drugs in 

the less restrictive drug schedules. Id. 829. In particular, the CSA 

prohibits all possession, manufacture, distribution or dispensing of 

Schedule I substances, including marijuana, except in the context of a 

government-approved research project. Id. 823(f), 841(a)(1), 844.



Some states have passed laws that create a medical use exception to 

otherwise applicable state marijuana sanctions. California was the 

first state to pass such a law, when, in 1996, California voters passed 

a ballot initiative, Proposition 215, which removed certain state 

criminal penalties for the medical use of marijuana.



In the wake of Proposition 215, various cannabis clubs formed in 

California to provide marijuana to patients whose physicians had 

recommended such treatment. In 1998, the United States sued to enjoin 

one of these clubs, the Oakland Cannabis Buyers Cooperative, from 

cultivating and distributing marijuana. The United States argued that, 

whether or not the Cooperatives actions were legal under California 

law, they violated the CSA. Following lower court proceedings, the U.S. 

Supreme Court granted the governments petition for a writ of 

certiorari to review whether the CSA permitted the distribution of 

marijuana to patients who could establish medical necessity. United 

States v. Oakland Cannabis Buyers Cooperative, 532 U.S. 483 (2001).



Although the tension between Californias Proposition 215 and the broad 

federal prohibition on marijuana was the backdrop for the Oakland 

Cannabis case, the legal issue addressed by the Supreme Court did not 

involve the constitutionality of either the federal or state statute. 

Rather, the Court confined its analysis to an interpretation of the CSA 

and whether there was a medical necessity defense to the Acts 

marijuana prohibitions. The Court held that there was not. While 

observing that the CSA did not expressly abolish the defense, the Court 

stated that the statutory scheme left no doubt that the defense was 

unavailable for marijuana. Because marijuana appeared in Schedule I, it 

reflected a determination that marijuana had no currently accepted 

medical use for purposes of the CSA. The Court concluded that a medical 

necessity defense could not apply under the CSA to a drug determined to 

have no medical use.



The Oakland Cannabis case upheld the federal governments power to 

enforce federal marijuana prohibitions without regard to a claim of 

medical necessity. Thus, while California (and other states) exempt 

certain medical marijuana users and their designated caregivers from 

state sanctions, these individuals remain subject to federal sanctions 

for marijuana use.



[End of section]



Appendix III: Medical Marijuana Registries in Oregon, Alaska, Hawaii, 

and Select California Counties:



How states implemented registry requirements in the three registry 

states, such as which agency administers the registry or the number of 

staff to manage it, varied in some ways and were similar in other ways. 

Similarly, the county-based registries in California had some 

differences and commonalities.



Oregon:



In Oregon, the Department of Human Services is designated to maintain 

the state medical marijuana registry. A staff of six is responsible for 

reviewing and verifying incoming applications and renewals, including 

following up on those that are incomplete, and input and update of the 

database. Recommending physicians are sent, and must respond to a 

verification letter for the application to be approved. By statute in 

Oregon, an applicant can be denied a card for only two reasons--

submitting incomplete or false information. According to the State 

Public Health Officer, the scope of the Department of Human Services 

responsibility is to see to that there is a written determination of 

the patients condition by a legitimate doctor, and includes an 

attending physician recommendation that the patient might benefit from 

using marijuana. He stated that the staff does not question a doctors 

recommendation for medical marijuana use. The law is clear, he said. It 

is up to the physician to decide what is best.



The Oregon Department of Human Services also considers the addition of 

new conditions to the list of those acceptable for medical use of 

marijuana, as authorized by Oregons medical marijuana statute. At the 

time of our review, only one of the eight petitions that had been 

reviewed by the Department had been approved--agitation due to 

Alzheimers disease. Most of the petitioned conditions have had a 

psychological basis, the State Public Health Officer said.



Alaska:



Alaskas statute designates the Department of Health and Social 

Services to manage the state medical marijuana registry. The full time 

equivalent of one half-time person is responsible for registry duties, 

including checking applications for accuracy and completeness and 

entering the information into the registry. The physicians license is 

checked for approval to practice in Alaska, and if a caregiver is 

designated the registry is checked to assure they are only listed as a 

caregiver for one person unless otherwise approved by the Department. 

Patients, physicians and caregivers are also contacted to verify 

information as appropriate. If all Alaska statutory requirements are 

met, a medical marijuana registry identification card is issued (see 

fig. 4). Registry cards are denied in Alaska if the application is not 

complete, the patient is not otherwise qualified to be registered, or 

if the information in the application is found to be false.



Figure 3: Example of Alaskas Medical Marijuana Certification Card:



[see PDF for image]



Source: Alaska Department of Health and Social Services.



[End of figure]



Alaskas statute allows the Department to add debilitating medical 

conditions to the approved list for use of marijuana. A procedure for 

requesting new conditions is outlined in state regulations. To date, 

there have been no requests to consider new conditions and none have 

been added.



Hawaii:



The medical marijuana law passed by the Hawaiian legislature designates 

the state Department of Public Safety to administer the Hawaiian 

medical marijuana registry. One person within Public Safetys Narcotics 

Enforcement Division staffs the registry. This person is responsible 

for reviewing and approving applications and renewals as complete, 

inputting applicant information into the database, and responding to 

any law enforcement inquiries. Verification procedures in Hawaii are 

similar to those followed in other states. See figure 4 for an example 

of Hawaiis registry card.



Figure 4: Example of Hawaiis Medical Marijuana Registry Card:



[See PDF for image]

 

Source: State of Hawaii Department of Public Safety.



[End of figure]



California:



Registration application requirements and procedures for the voluntary 

California registries we reviewed were unique to each county, but 

shared some procedures with the programs established in the registry 

states.



In Humboldt County, the patient must submit an application and 

physician recommendation to the county Department of Health and Human 

Services, with a $40.00 fee. Applicants are interviewed, photographed, 

and their county residency documents are checked during an in-person 

interview. To protect the confidentiality of doctors, after the 

physician recommendation has been verified, the physician portion of 

the application is detached and shredded. Applications are denied if 

the patient is not a county resident, the physician is not licensed in 

California, or there is not a therapeutic relationship between the 

patient and physician.



The San Francisco Medical Cannabis ID Card Program applications are 

made available through the citys Department of Public Health, where 

the registry is maintained, and also from clinics, doctors offices and 

medical cannabis organizations that have requested them. Applicants 

must bring a physicians statement form, or form documenting that an 

oral recommendation was received, medical records release form, proof 

of identification and residence in San Francisco and the fee. For an 

applicant the fee is $25.00, plus $25.00 for each primary caregiver, up 

to a maximum of three caregivers. Registry cards are valid for up to 2 

years, based on a physicians recommendation. After verifying the 

application documents to its satisfaction, the Department returns the 

entire application package to the applicant, and issues cards to the 

applicant and caregivers. The department does not copy the materials, 

or keep the name of registrants. Information kept on file is limited to 

the serial number of the cards issued, the serial number of the 

identification card submitted, the date the registry card was issued, 

and when it expires.



The Mendocino County Public Heath Department and the Sheriffs office 

jointly run the County Pre-identification Program for county residents. 

The Health Department accepts the applicants Medical Marijuana 

Authorization forms, which includes patient and caregiver information, 

and a section for the physician to complete. The physician section 

requires checking yes or no to a recommendation, and the expiration 

length for the recommendation in months, years or for the patients 

lifetime. No condition information is requested. After verifying the 

physician recommendation, that section is destroyed, and the approved 

authorization sheet is sent to the Sheriffs office. The Sheriffs 

office interviews registrants and caregivers, requiring that they sign 

a declaration as to the caregivers role in patient care. Program 

identification cards with photographs of patients and caregivers are 

issued by the Sheriffs office.



In Sonoma County, the Sonoma County Medical Association, in conjunction 

with the Sonoma County District Attorney, developed a voluntary process 

for the medical association to provide peer review of individuals 

medical records and physician recommendations for medical use of 

marijuana. Based on the review, the patients physician is sent a 

determination regarding whether the patients case met criteria 

established regarding the patient-physician relationship, whether 

marijuana was approved of, and whether the condition is within the 

California state code allowing medical marijuana use. Upon receiving 

the determination from their doctor, patients decide whether to 

voluntarily submit the results to the District Attorney for 

distribution to the appropriate police department or to the sheriffs 

office. According to the medical association director, some patients 

will go through the process but prefer to keep the letter themselves 

rather than have their name in a law enforcement database.



[End of section]



Appendix IV: Descriptions of Allowable Conditions under State Medical 

Marijuana Laws:



Medical marijuana laws in California, Oregon, Hawaii and Alaska 

identify medical conditions or symptoms eligible for medical marijuana 

use, but do not specifically define the conditions or symptoms. The 

following descriptions are based on definitions in the Merriam Webster 

Medical Dictionary and selected other sources.



Alzheimers Disease: Alzheimers is a brain disease that usually starts 

in late middle or old age. It is characterized as a memory loss for 

recent events spreading to memories for more distant events and 

progressing over the course of five to ten years to a profound 

intellectual decline characterized by impaired thought and speech and 

finally complete helplessness.



Anorexia: Anorexia is a lack, or severe loss of appetite, especially 

when prolonged. Many patients develop anorexia as a secondary condition 

to other diseases.



AIDS: Acquired Immune Deficiency Syndrome is a severe disorder caused 

by the human immunodeficiency virus, resulting in a defect in the cells 

responsible for immune response that is manifested by increased 

susceptibility to infections and to certain rare cancers.



Arthritis: Arthritis refers to the inflammation of joints, usually 

accompanied by pain, swelling, and stiffness.



Cachexia: Cachexia is a general physical wasting and malnutrition 

usually associated with chronic disease, such as AIDS or cancer.



Cancer: Cancer is an abnormal growth that tends to grow uncontrolled 

and spread to other areas of the body. It can involve any tissue of the 

body and can have many different forms in each body area. Cancer is a 

group of more than 100 different diseases. Most cancers are named for 

the type of cell or the organ in which they begin.



Crohns Disease: Crohns disease is a serious inflammatory disease of 

the gastrointestinal tract, it predominates in parts of the small and 

large intestine causing diarrhea, abdominal pain, nausea, fever, and at 

times loss of appetite and subsequent weight loss.



Epilepsy: Epilepsy is a disorder marked by disturbed electrical rhythms 

of the central nervous system and typically manifested by convulsive 

attacks, usually with clouding of consciousness.



Glaucoma: Glaucoma is a disease of the eye marked by increased pressure 

within the eyeball that can result in damage to the part of the eye 

referred to as the blind spot and if untreated leads to gradual loss of 

vision.



HIV: Human Immunodeficiency Virus is a virus that reduces the number of 

the cells in the immune system that helps the body fight infection and 

certain rare cancers, and causes acquired immune deficiency syndrome 

(AIDS).



Migraine: A migraine is a severe recurring headache, usually affecting 

only one side of the head, characterized by sharp pain and often 

accompanied by nausea, vomiting, and visual disturbances.



Multiple Sclerosis: Multiple Sclerosis is a disease of the central 

nervous system marked by patches of hardened tissue in the brain or the 

spinal cord causing muscular weakness, loss of coordination, speech and 

visual disturbances, and associated with partial or complete paralysis 

and jerking muscle tremor.



Nausea: Nausea refers to a stomach distress with distaste for food and 

an urge to vomit. Severe Nausea refers to nausea of a great degree.



Pain: Pain refers to an unpleasant sensation that can range from mild, 

localized discomfort to agony. Pain has both physical and emotional 

components. The physical part of pain results from nerve stimulation. 

Pain may be contained to a discrete area, as in an injury, or it can be 

more diffuse, as in disorders that are characterized as causing pain, 

stiffness, and tenderness of the muscles, tendons, and joints. Severe 

pain refers to pain causing great discomfort or distress. Chronic pain 

is often described as pain that lasts six months or more and marked by 

slowly progressing seriousness.



Spasticity: Spasticity is a condition in which certain muscles are 

continuously contracted. This contraction causes stiffness or tightness 

of the muscles and may interfere with gait, movement, and speech. 

Symptoms may include increased muscle tone, a series of rapid muscle 

contractions, exaggerated deep tendon reflexes, muscle spasms, 

involuntary crossing of the legs, and fixed joints. The degree of 

spasticity varies from mild muscle stiffness to severe, painful, and 

uncontrollable muscle spasms.



Wasting Syndrome: A condition characterized by loss of ten percent of 

normal weight without obvious cause. The weight loss is largely the 

result of depletion of the protein in lean body mass and represents a 

metabolic derangement frequent during AIDS.



[End of section]



Appendix V: Comments from the Department of Justice:



U.S. Department of Justice:



Washington, D.C 20530:



Mr. Paul Jones 

Director 

Justice Issues 

U.S. General Accounting Office 

441 G Street, NW Washington, DC 20548:



Dear Mr. Jones:



On August 26, 2002, the General Accounting Office (GAO) provided the 

Department of Justice (DOJ) copies of its draft report entitled 

MEDICAL MARIJUANA: Early Experiences With Four States Laws. While we 

note that the report fully describes the current status of the programs 

in the states reviewed, we are concerned that it fails to adequately 

address some of the serious difficulties associated with such programs. 

The DOJ believes the report does not adequately address, through any 

considered analysis, issues related to the 1) inherent conflict between 

state laws permitting the use of marijuana and federal laws that do 

not; 2) potential for facilitating illegal trafficking; 3) impact of 

such Laws on cooperation among federal, state, and local law 

enforcement; and 4) lack of data on the medicinal value of marijuana. 

Further, the GAOs continued use of the term medical marijuana 

implicitly accepts the fact that there is a 1) proven medicinal value 

to marijuana and 2) legitimate exception to federal law for this use. 

Neither of these premises are true. Finally, we note that the GAO fails 

to consider what the existence of state medical marijuana laws 

communicates. We believe such laws send society the wrong message.



Conflict Between Laws:



The most fundamental problem with the draft GAO report is that it fails 

to emphasize the fact that there is no federally recognized medicinal 

use of marijuana and thus possession or use of this substance is a 

federal crime. Further, the GAO fails to even mention that state laws 

purporting to approve marijuana for medical use undermine the closed 

system of distribution for controlled substances established by the 

Controlled Substances Act (CSA). The time-proven safeguards that have 

made the medical drug supply in the United States the safest in the 

world are lacking. State medical marijuana legislation does not and 

could not require the cultivators and distributors of marijuana to 

comply with the federal requirement that all manufacturers and 

distributors of Schedule I controlled Substances be registered with the 

Drug Enforcement Administration (DEA). The registration process and 

record-keeping requirements established by federal law and administered 

by DEA are critical components of DEAs effort to restrict abuse of

 marijuana and other controlled substances. In this regard, there is 

no analysis nor comparison of state controls of marijuana subject to 

state medical marijuana laws with federal and state controls of other

prescribed medicines covered by the CSA. The regulation of the 
production 

and distribution of prescribed medicines is a critical component in 

preventing the diversion of controlled substances that are properly 

prescribed for medical use. A comparison of DEAs controls of other 

legitimately prescribed controlled substances would highlight the lack 
of 

proper oversight of marijuana as a medicine.:



The registration process is also an important aspect of the United 

States Governments implementation of international drug control 

treaties. These treaties obligate the federal government to prohibit 

the cultivation of marijuana except by persons licensed by, and under 

the direct supervision of, the federal government. The treaties also 

obligate the federal government to control the distribution of 

marijuana. This is required even if the federal government determines 

that marijuana has an accepted medical use. Any state legislation 

purporting to authorize medical use of marijuana is inconsistent with 

the CSA as none of these state laws require the cultivation of 

marijuana that is federally licensed and supervised by the federal 

government. These state laws undermine the ability of the federal 

government to meet its obligations under international law. The GAO 

Draft Report makes no mention of this critical issue.



Abuse of State Laws to facilitate Illegal Drug Trafficking:



The GAO Draft Report does not mention that state medical marijuana 

laws are routinely being abused to facilitate traditional illegal 

marijuana trafficking and use. Information acquired by DEA during 

its investigations of cannabis clubs would provide specific examples 

of this abuse. The report focuses exclusively on so-called medical 

use of marijuana and omits any mention of the abuse of state medical 

marijuana laws. The report fails to reflect the underlying criminal 

arena in which marijuana is produced and consumed and the significant 

profitability that drives the marijuana market. Because of that factor, 

there is a blurred line between medical and illegal commercial markets. 

Further, some U.S. Attorneys Offices have indicated that in their 

district violent crimes associated with marijuana cultivation (such as 

homicides) create significant law enforcement and social issues. 

Without addressing the illegal production and diversion of marijuana, 

the GAO Draft Report provides an incomplete analysis of the impact of 

the medical marijuana laws on the enforcement of drug control laws.



The passage of Proposition 215 in California and similar legislation in 

other states has created unfortunate circumstances for state and local 

law enforcement officers. The state initiatives also have provided 

legal loopholes for drug dealers and marijuana cultivators to avoid 

arrest and prosecution. This is due in part to California state 

governments lack of guidance as to the implementation of the law and 

their seeming unwillingness to enforce state drug laws against 

traffickers who claim to be involved with marijuana under the state 

medical marijuana law. Further, those counties that have taken a 

public position on proposition 215 have contributed to the dilemma now 

being experienced by state and local law enforcement. The vague 

guidelines established throughout the counties in California sends a 

message to many that anyone who has a recommendation from a doctor is 

permitted to grow and possess certain (varying) amounts of marijuana.



Impact on Law Enforcement Operations and Cooperation:



The GAO Draft Report states that [s]ome of the federal law enforcement 

officials we interviewed indicated that the introduction of state 

medical marijuana laws has had little impact on their operations. 

This statement does not accurately reflect DEAs experience in 

addressing state medical marijuana laws. One of the major effects of 

the states legislation is the worsening of relations between federal, 

state, and local law enforcement.



As a result of these circumstances the most significant issue that now 

appears to be occurring is the recognizable rift that the laws have 

created between state and local law enforcement and federal drug 

agents, who are mandated to enforce the federal law. There have been 

and undoubtedly will continue to be instances that occur in the 

affected states where local officers working joint investigations with 

DEA have been ordered or instructed not to seize contraband plants and/

or marijuana by their district attorney or states attorney office. In 

some cases, DEA has been required to obtain Federal warrants to seize 

marijuana being held by local police agencies to prevent the return of 

the marijuana to persons pursuant to State court orders. This conflict 

has lead to several heated incidences on the West Coast.



For example, in one recent case, where federal agents were cooperating 

with local officers to serve a state search warrant at a residence, the 

District Attorney of Butte County, California, advised a Butte County 

detective to arrest a DEA Special Agent if the agent confiscated six 

marijuana plants that were found during the operation. The District 

Attorney asserted that under Californias medical marijuana law the 

plants were lawfully possessed; however, such possession violates 

federal law. The plants were seized and submitted to the DEA laboratory 

for destruction without incident only after negotiations between the 

U.S. Attorney, the District Attorney, and DEA representatives to 

resolve the issue. In another instance, the Oakland Police Department 

referred to the DEA a shooting incident involving the theft of a pound 

of marijuana because the city of Oakland prohibits its officers from 

pursuing any investigation of marijuana that may be claimed to be 

subject to the state medical marijuana law. In this instance the 

victim of the robbery was a marijuana recipient under the state 

medical marijuana law who was attempting to sell the marijuana he had 

to his robbers. Such conflicts over individual mandates have required 

frequent intervention by DEAs Office of Chief Counsel and the DOJ due 

to the clear lack of a coordinated drug law enforcement policy.



Because state and local law enforcement cannot work on certain 

marijuana cases under these laws, federal seized asset sharing has been 

negatively impacted. In the state of Oregon, the state legislation 

prevents the federal government from sharing seized assets directly 

with state/local law enforcement entities in cases involving asset 

seizure without criminal prosecution initiated following marijuana grow 

seizures.



It is much more difficult for federal and state officials to prosecute 

marijuana cases where medicinal use can be claimed. There is growing 

local sentiment that because of these laws, federal law enforcement 

resources should not be devoted to marijuana prosecutions. This 

sentiment also manifests itself injury trials where prosecutors have 

jury nullification concerns (as a result of softened public attitudes 

towards marijuana).



In these states, the perception that marijuana is accepted by the 

public has significantly impacted law enforcement. According to Oregon 

State Police authorities, outlaw motorcycle gang members are now 

applying for marijuana caregiver status, believing that this will 

officially authorize their marijuana grow operations. Marijuana grow 

operations have always presented problems to law enforcement, and 

marijuana potentially subject to state medical marijuana laws only 

serve to further confuse the general public on this drug. Public 

perception on this issue appears to be further softened as a result of 

strong marketing strategies by pro-legalization/medicinal use 

advocates. Groups supporting the legalization of marijuana in Alaska 

are now preparing new proposals to legalize all marijuana. The public 

confusion on this issue can be demonstrated by the fact that the voters 

in these states approved the medical use of marijuana but do not allow 

use in public places (Oregon) or in medical facilities, or nearby 

school grounds, recreation centers or youth centers (Alaska). This 

sends a mixed message to the public as no other medicines are 

restricted in this way.



Marijuana As Medicine:



The GAO Draft Reports discussion of the debate over the medical value 

of marijuana is inadequate and does not present an accurate picture. 

The draft states that [t]he potential medical value of marijuana has 

been a continuing debate. It fails to mention, however, that smoked 

marijuana has never been approved as medicine by the Food and Drug 

Administration (FDA) and has never been proven safe and effective in 

sound scientific studies. Further, at its 2001 Annual Meeting, the 

American Medical Association (AMA)adopted the following as its policy 

on the medicinal use of marijuana:



The AMA calls for further adequate and well-controlled studies of 

marijuana and related cannabinoids in patients who have serious 

conditions for which preclinical, anecdotal, or controlled evidence 

suggests possible efficacy and the application of such results to the 

understanding and treatment of disease; (2) The AMA recommends that 

marijuana be retained in Schedule I of the Controlled Substances Act 

pending the outcome of such studies. (3) The AMA urges the National 

Institutes of Health (NIH) to implement administrative procedures to 

facilitate grant applications and the conduct of well-designed clinical 

research into the medical utility of marijuana.... (4) The AMA believes 

that the NIH should use its resources and influence to support the 

development of a smoke-free inhaled delivery system for marijuana or 

delta-9-tetrahydrocannabinol (THC) to reduce the health hazards 

associated with the combustion and inhalation of marijuana.:



We also believe the GAO Draft Report should at least reference DEA 

final orders concerning petitions to reschedule marijuana published in 

1992 and 2001. These reports contain a comprehensive explanation of the 

scientific and legal bases for keeping marijuana in Schedule 1.



In addition, the GAO Draft Report fails to mention that medical 

marijuana is legally available in the prescription drug Marinol. A 

pharmaceutical product, Marinol is widely available by prescription. It 

comes in the form of a pill and is also being studied by researchers 

for suitability via other delivery methods, such as an inhaler or 

patch, The active ingredient in Marinol is synthetic THC, which has 

been found to relieve the nausea and vomiting associated with 

chemotherapy for cancer patients and to assist with loss of appetite 

with AIDS patients. Unlike smoked marijuana-which contains more than 

400 different chemicals, including most of the hazardous chemicals 

found in tobacco smoke-Marinol has been studied and approved by the 

medical community and the FDA. Information about Marinol is necessary 

to understand the debate over medical use of marijuana.



There is no mention in the report on the prescription of Marinol in 

these states, or more specifically the doctors identified in the study, 

as compared to doctors not prescribing marijuana under state medical 

marijuana laws versus their prescriptions authored for Marinol, if 

any. Although the information concerning the prescription of Marinol 

may not yet be available, it would be available through a longer term 

study by DEA Office of Diversion Control. It would be informative to 

determine if Marinol is sold in any quantity to pharmacies in these 

states by distributors for the manufacturer, both before and after 

state medical marijuana legislation was passed.



As noted by the above comments, we believe that the report falls short 

by not adequately addressing these significant issues. I urge you will 

consider our concerns in preparing the final GAO report on this 

important subject. If you have any questions regarding the Departments 

comments, you may contact Vickie L. Sloan, Director, Audit Liaison 

Office, on (202) 514-0469.



Sincerely,



Signed by Robert F. Diegelman:



Robert F. Diegelman:

Acting Assistant Attorney General 

for Administration:



[End of section]



Appendix VI: GAO Contacts and Staff Acknowledgments:



GAO Contacts:



Paul Jones (202) 512-8777

John Mortin (202) 512-8777:



Staff Acknowledgments:



Tanya Cruz, Christine Davis, Francisco Enriquez, Evan Gilman, and 

Monica Kelly made key contributions to this report.



FOOTNOTES



[1] States Rights to Medical Marijuana Act, H.R. 2592, 107TH Cong. 

(2001). Status as of August 5, 2002: Referred to House Energy and 

Commerce, Subcommittee on Health on July 31, 2001.



[2] Throughout this report, we use the phrase medical marijuana to 

describe marijuana use that qualifies for a medical use exception under 

state law. 



[3] According to United States v. Oakland Cannabis Buyers Cooperative, 

532 U.S. 483, 

502 n.4 (2001), eight states have enacted medical marijuana laws. We 

selected four of those states based on the length of time the laws had 

been in place and the availability of data. Two of the eight states, 

Nevada and Colorado, were not selected because their laws had not been 

in place for at least 6 months when our review began. Also, at the time 

of our review, two other states, Maine and Washington, did not have 

state registries to obtain information on program registrants. Alaska, 

Oregon, and Hawaii have state registries and had laws in place for at 

least 6 months. Californias law was enacted in1996. California does 

not have a participant registry, but based on our preliminary work, 

some local registry information was available. 



[4] U.S. Department of Health and Human Services, Substance Abuse and 

Mental Health Services Administration (SAMHSA), National Household 

Survey on Drug Abuse 2000. Hashish is included by SAMHSA in the 

statistic for marijuana use. 



[5] 21 U.S.C.  801 to 971.



[6] Id.  812(a), (b). 



[7] Id.  812(c), Schedule I (c)(10).



[8] Schedule I includes drugs such as heroin, lysergic acid 

diethylamide (LSD) and other hallucinogenic substances. 21 C.F.R. 

1308.11(c), (d).



[9] Id.  812(b)(2)-(5).



[10] Id.  829. DEA rejected petitions in 1992 and 2001 to reschedule 

marijuana to schedule II. See Notice of Denial of Petition, 66 Fed. 

Reg. 20038 (2001); Marijuana Scheduling Petition; Denial of Petition; 

Remand, 57 Fed. Reg. 10499 (1992) (final order affirming the 1989 

denial after remand); Marijuana Scheduling Petition; Denial of 

Petition, 54 Fed. Reg. 53767 (1989).



[11] Id.  823(f), 841(a)(1), 844.



[12] See 78 F. Supp. 2d 367 (E.D.Pa.1999). In the Kuromiya case, a 

group of approximately 160 plaintiffs raised an equal protection 

challenge to the administration of the Single Patient Investigational 

New Drug program. The plaintiffs contended that they were similarly 

situated to patients currently receiving marijuana under the program 

and that the government acted unconstitutionally in denying them access 

to the same program. The court concluded that the government had a 

rational basis for its decision not to supply marijuana to the 

plaintiffs through this program and granted the governments motion for 

summary judgment.



[13] National Academy of Sciences, Institute of Medicine, Marijuana 

and Medicine: Assessing the Science Base. 1999.



[14] American Medical Association, Council on Scientific Affairs 

Report: Medical Marijuana (A-01), June, 2001. 



[15] The medical use exception in the states we reviewed allows growing 

or possessing marijuana for the purpose of the patients personal 

medical use, and does not extend to other state marijuana prohibitions 

such as distribution outside the patient-caregiver relationship or any 

sale of marijuana.



[16] 532 U.S. 483 (2001). 



[17] The states medical marijuana laws appear at Alaska Stat. Ann. 

11.71.090, 17.37.010 to 17.37.080; Cal. Health & Safety Code Ann. 

11362.5; Haw. Rev. Stat. 329-121 to 329-128; and Ore. Rev. Stat. 

475.300 to 475.346. Alaskas Hawaiis and Oregons administrative 

regulations appear at Alaska Admin. Code, tit. 7, ch. 34; Haw. Admin. 

R., tit. 23, ch. 202; and Ore. Admin. R., ch. 333, div. 8. There are no 

regulations under Californias law.



[18] Under Alaskas and Hawaiis statutes, patients and caregivers must 

strictly comply with the registration requirement in order to receive 

legal protection; unregistered persons may not present a medical use 

defense to a marijuana prosecution in these states. See Alaska Stat. 

Ann. 11.71.090; Haw. Rev. Stat. 329-125. Under Oregons statute, 

unregistered patients who have substantially complied with the act may 

raise such a defense to a marijuana prosecution, while registered 

persons are excepted from criminal charges, so long as they meet the 

acts quantity and use restrictions. See Ore. Rev. Stat. 475.306, 

475.316, 475.319, 475.342. Because Californias law does not establish 

a state-run registry, a medical use defense may be established by any 

individual meeting the acts substantive requirements, that is, 

patients whose doctors have recommended marijuana to treat an allowed 

medical condition and their primary caregivers. See Cal. Health & 

Safety Code Ann. 11362.5; see also People v. Mower, No. S094490, 2002 

Cal. Lexis 4520 (July 18, 2002), in which the California Supreme Court 

interprets Californias medical marijuana act.



[19] Office of the Attorney General, State of California, Department of 

Justice, Medical Marijuana Task Force (July 12, 1999). Other 

recommendations included requiring that the patients personal 

physician make the marijuana recommendation, and allowing cooperative 

marijuana cultivation.



[20] California Senate Bill 187, 2001-2002 Reg. Sess. The bill was 

introduced by California Senator Vasconcellos on February 7, 2001.



[21] As provided in Ore. Admin. R. 333-008-0010, an attending physician 

is a physician who has established a physician/patient relationship 

with the patient, is licensed under ORS chapter 677, and who, with 

respect to a patient diagnosed with a debilitating medical condition: 

(a) Is primarily responsible for the care and treatment of the patient; 

(b) Is primarily responsible for recognized, medical specialty care and 

treatment of the patient; (c) Has been asked to consult and treat the 

patient by the patients primary care physician; or (d) Has reviewed a 

patients medical records at the patients request, has conducted a 

thorough physical examination of the patient, has provided a treatment 

plan and/or follow-up care, and has documented these activities in a 

patient file. 



[22] For simplicity, we use the general term medical condition to 

encompass, diseases, symptoms, and medical conditions. 



[23] Alaskas statute provides a one-year suspension from using or 

obtaining a registry card; Oregons statute provides up to a 6-month 

suspension from using or obtaining a registry card; Hawaiis rules 

provide for revocation of the registry certificate for an indefinite 

time.



[24] Oregons Medical Marijuana Program: A Management Review Oregon 

Department of Human Services, June 11, 2001.



[25] Sonoma County does not maintain a registry of approved medical 

marijuana users, but is included because it does have records of county 

patients whose doctors have recommended marijuana using Sonoma County 

Medical Association peer review process.



[26] Of the 915 registrants that reported severe pain as their primary 

condition, over half reported only one secondary condition, some 

included up to five secondary conditions. The percentages reported here 

include those with only one secondary condition.



[27] Of the 459 registrants that reported spasms as a primary condition 

over 40 percent reported only one secondary condition, some included up 

to four secondary conditions. The percentages reported here include 

those with only one secondary condition.



[28] Fibromyalgia: Chronic pain, stiffness, and tenderness of muscles, 

tendons, and joints without detectable inflammation. Fatigue and sleep 

disorders are common in fibromyalgia patients. 



[29] See Conant v. McCaffrey, No. C-97-00139, 2000 U.S. Dist. LEXIS 

13024 at *19 (N.D. Cal. Sept. 7, 2000) (permanent injunction granted); 

see also Conant v. McCaffrey, 172 F.R.D. 681 (N.D. Cal. 1997) 

(preliminary injunction granted). On October 29, 2002, the Ninth 

Circuit Court of Appeals affirmed, finding that the district court 

convincingly explained how the governments professed enforcement 

policy threatened to interfere with doctors First Amendment rights. 

See Conant v. Walters, No. 00-17222, 2002 U.S. App. LEXIS 22942 at *2 

(9THCir. Oct. 29, 2002)



[30] See Pearson v. McCaffrey, 139 F. Supp. 2d 113, 121 (D.D.C. 2001). 



[31] Program officials in the registry states verify that a physician 

recommendation has been made in accordance with program requirements, 

and that the physician is licensed; they are not authorized to 

determine whether a doctors recommendation is medically appropriate. 



[32] The April 2002 order by the Oregon Board of Medical Examiners 

reprimanded the physician, fined him $5,000, suspended his license for 

90 days, and specified conditions under which any future marijuana 

recommendations would be made, and other disciplinary actions.



[33] According to the FBI introduction to users of Uniform Crime Report 

data.



[34] Programs to implement the laws in Oregon, Alaska and Hawaii were 

developed somewhat later. Alaskas registry was established in June 

1999, Oregons program began operating in May 1999, and Hawaii issued 

its first card in January 2001.



[35] As described in the methodology section of UCRs annual 

publication, Crime in the United States (2000) UCR excludes trend 

statistics if the reporting units have not provided comparable data for 

the periods under consideration, or when it is ascertained that unusual 

fluctuations, such as improved record keeping or annexations are 

involved. Although most law enforcement agencies submit crime reports 

to the UCR program, data are sometimes not received for complete annual 

periods. If data on other factors was available for California to 

analyze the relationship of its medical marijuana law and arrests, one 

would also need to assess the comparability of arrest data from 

different time periods. 



[36] The District Attorney noted that they had won these cases because 

the defendants were not operating within the parameters of the state 

medical marijuana law. 



[37] According to the senior DEA official for the area, three northern 

counties are the source region for much of the domestically produced 

marijuana in the United States, and this production is a major 

contributor to the local economies.



[38] Headed by a Commander from the California Bureau of Narcotics and 

staffed by officers from local law enforcement.



[39] The 10 plant limit can be exceeded if the grower claims to grow 10 

plants for patient A, 10 plants for patient B, and so on. Documentation 

of caregiver status is not required under the states law.



[40] 39 P.3d 866 (Or. Ct. App. 2002); rev. den. 47 P.3d 484 (Or. S. Ct. 

2002). In Kama, the city argued that, because marijuana is a Schedule I 

controlled substance, its police officers would commit the federal 

crime of delivering a controlled substance if they returned seized 

marijuana. The court of appeals disagreed, reasoning that the federal 

Controlled Substances Act, 21 U.S.C. 885(d), confers immunity on state 

or local law enforcement officials lawfully engaged in the enforcement 

of any law or municipal ordinance relating to controlled substances. 

The court concluded that, because the officers were required to return 

the seized marijuana under Oregons medical marijuana act, Or. Rev. 

Stat. 475.323(2), federal law granted them immunity for doing so. 



[41] A summary of law enforcement opinions was sent to those we spoke 

with for their comments.



[42] These eight states were identified in the Supreme Courts decision 

in United States v. Oakland Cannabis Buyers Cooperative, 532 U.S. 483, 

502 n.4 (2001).



[43] As a result of phone discussions with law enforcement officials in 

Alaska, and the low number of registrants in Alaskas medical marijuana 

program, we decided that interviews could be conducted by email and 

phone. 



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