Notes from the Field as Massachusetts Does Medical Marijuana

Editor’s note: Today guest blogger and medical anthropologist Kim Sue offers her observations on how changing marijuana laws have slowly begun to impact the world of the opiate-addicted patients she studies–and the wider society’s assumptions about drugs and the reasons people use them.

I have been closely following the campaign for and roll-out of medical marijuana in Massachusetts as I conduct ongoing ethnographic fieldwork on opiate use and incarceration. Given marijuana’s prominent place in the historical, political, and cultural framings of the War on Drugs, it is critical to consider evolving legal frameworks and cultural attitudes toward the drug.

massachusetts-medical-marijuana-listening-sessions

Last fall, advocates for medical marijuana managed to get it enacted via referendum. The “yes” vote on Question 3 on the Massachusetts ballot enacted a law “eliminating state criminal and civil penalties related to the medical use of marijuana, allowing patients meeting certain conditions to obtain marijuana produced and distributed by new state-regulated centers or, in specific hardship cases, to grow marijuana for their own use.” Anti-drug and law enforcement groups, along with some public officials, opposed such legislation, citing vague wording in the proposal, lax regulation of medical dispensaries in other states, the detrimental effects of marijuana, fears of edible pot products marketed to young people, and the slippery slope to outright legalization.

In a meeting prior to the vote that was organized by the Massachusetts Organization for Addiction Recovery (MOAR), Cory Mashburn, a guest speaker from the Massachusetts Prevention Alliance, predicted that passing the medical marijuana legislation would lead to legalization initiatives such as were on the ballot in Colorado and Washington. “Let’s just cut out the word medical,” Mashburn told attendees at the meeting. “Because you’re not getting a prescription for this, and you’re not going into a pharmacy, and insurance is not covering it.”

Freedom rally poster

State Senator John F. Keenan (D-Quincy), co-chairman of the Joint Committee on Mental Health and Substance Abuse, linked the proposal to prescription opioid abuse. “Considering the epidemic of heavy duty prescription pain killers and the diversion of those pills, despite them being highly regulated,” Keenan said in a statement prior to the election, “it is tough to believe this loosely-worded law wouldn’t also become misused and abused by drug seekers.”

Some of the guys attending the MOAR meeting who were living in a recovery home in Roxbury couldn’t see what all the fuss was about. “We basically abuse legal drugs anyways, like benzos, and other prescription drugs,” one of them said. “So it’s not going to matter about what marijuana is called because we’ll get addicted and abuse it no matter if it’s legal or not.”

The public ended up voting for the measure with 63 percent in favor to 37 percent against. The Massachusetts Department of Public Health (MDPH) was mandated to write the regulations for implementing this proposal within 90 days of the Medical Marijuana Law that officially went into effect January 1. MDPH held three “listening sessions” around the state—one in Worcester, one in Holyoke and one in Boston—to garner the public’s input on implementing the legislation. The MDPH knew that they had to set up at least one non-profit dispensary in each of Massachusetts’ 14 counties, although they didn’t know exactly how they were going to work (and some towns and municipalities were already voting against hosting dispensaries). Specifically, they were interested in the public’s thoughts on what medical conditions should count as “debilitating,” who should be granted permission for “hardship cultivation,” and what exactly constituted the 60-day supply the ballot measure allowed patients to possess.

The “listening session” in Boston was held at the Roxbury Community College. Although the audience that gathered in this majority black neighborhood was overwhelmingly white, it was comprised of a heterogeneous group of people, including those interested in setting up and running dispensaries, patients and their family members who were espousing the benefits of marijuana, as well as community groups concerned with substance abuse prevention and treatment.

Homo cannabis.
Homo cannabis.

One of the most contentious issues concerned what conditions would qualify as “debilitating.” Patients asserted that the decision regarding medical marijuana needed to be left to the doctor and patient to decide individually, not to the state. People cited a wide variety of conditions that were not mentioned in the initiative: neuropathic pain, allodynia, stroke, polymyalgia rheumatica, ulcerative colitis, PTSD from the Iraq War, ALS. One speaker argued that it was “a form of oppression or judgment, having to justify [medical] need.” He continued, “Don’t put yourself in the position of being a moral judge.” A young combat veteran recently returned from Iraq came up to the podium, choked up, and cried. He talked about how useful the marijuana was for his PTSD, for his nightmares. Another man, a combat veteran, listed off a litany of medical conditions “due to my service.” “First of all, I don’t see my maladies there,” he told the MDPH committee, adding that there is “no cure for my anxiety.” And despite agreeing with him that marijuana is effective, “my doctor is prohibited from making that recommendation.”

Also at issue was what was the 60-day supply. Did it depend on the means of taking marijuana into the body? Many people testified they did not want to smoke it because of carcinogens, but rather wanted to eat it or even drink it as a juice. Some people were interested in the fact that different strains were good for different purposes. As one person stated, “Some put you to sleep; some relieve pain; some given energy; some give focus.” How could a reliable supply of each be made available in all the different counties? Was there going to be a kitchen in every treatment center, someone wondered—equal access to a cannabis kitchen?

The banality of democratic drug regulation.
Subject positions in the democratic process.

What was particularly interesting to me as an anthropologist was the use of personal stories and narratives. What position did each individual highlight and invoke, and with what corresponding moral authority did he or she speak? For example, what is the moral and cultural authority associated with being a veteran, a mother, a retired state trooper, a church-goer—as one woman describes herself, telling a story about her debilitating stroke, and how marijuana allows her to sleep so she can live her life, doing things as seemingly mundane as going to her daughter’s play. A clinical neuropsychologist talks about his allodynia, an extremely painful condition to light touch, and how marijuana alleviates some of it; his academic profession seems to give him moral and professional credibility. A young man in a wheelchair talks through a computer about having ALS and wanting a hospital to be able to administer him marijuana when he’s getting a tracheostomy. A young woman in chemotherapy talks about wanting it for her daughter. Another parent says his son uses marijuana for a bad case of ulcerative colitis and gets relief from it; he points out that 100,000 people a year die from the “legal” use of pharmaceuticals.

There was also a large presence from the addiction/substance abuse prevention communities in the greater Boston area, including MOAR as well as many neighborhood coalitions. They argued that medical marijuana should be regulated by the FDA and that marijuana should fall under the Massachusetts Prescription Drug Monitoring Board, for which tighter legislation was passed last summer. They also argue for the necessity of age limits “to keep our youth safe and healthy,” although they are careful to not deny that some people “legitimately need” marijuana. They do claim that “for every patient that comes in today, there are 100 youth abusing them.”

Another woman says “we have a huge opiate problem on the South Shore.” Someone also speaks up from the South Boston Action For Substance Abuse Prevention. She mentions how big a problem oxycontin abuse is in her neighborhood, and says, “With heroin there is a rise in drug-related crimes, fatal and non-fatal overdoses of heroin.” She also discusses how saturated with liquor stores and licenses South Boston already is. She worries that there will be “definitely a risk of home break-ins and that type of problems.”

Finally, there is a small group of law enforcement people from nearby communities. They are not in consensus about the issue. One woman, a lawyer who says she is a member of Law Enforcement Against Prohibition (LEAP) argues that the regulation makes everyone safer: “As a mother and a grandmother,” she says, “I would like to speak to the issue of children. I would make the point that our children will be much safer if marijuana is regulated as alcohol and tobacco are presently because they can obtain marijuana much more easily now than they would be able to if they had to show ID as they do to buy cigarettes and alcohol.”

Not all the people from law enforcement feel similarly. One police officer says he doesn’t agree with what happened but now he has to be on board. He argues that it should be about “public health and safety and not special interest groups”; there needs to be a distinction between marijuana as “prescription drug” and as “recreational use,” a distinction between “wanting marijuana” as opposed to “needing marijuana.” In his comments, he mentions “needle exchange programs” as a failed way that programs ran. “ID cards need to have a positive identification of the person, unlike past experiments with the needle exchange program,” he says. He argues for a conservative approach to the 60-day supply, and cards only allowed for people over 21 years old who have no prior narcotics offenses.

For those policy wonks who follow this blog, MDPH released the first draft of legislation in late March, with the final draft expected imminently. Some interesting summary tidbits from the report: the Department concluded that a 60-day supply of medical marijuana was 10 ounces but a physician could write for more if deemed necessary; the patient and the physician writing a certificate of a debilitating medical condition must have a “bona fide physician-patient relationship”; the registration card was valid for five years with the potential for renewal; if a patient was under 18 years old, he or she needed legal guardian/parental permission to register as a patient and designate that adult as a personal caregiver; individuals must register with the MDPH at one and only one medical marijuana treatment center.

Also of interest to me in those listening sessions is how marijuana was linked to “hardcore” drugs like opiates/heroin in the public imaginary. There is also an insistent, recurrent emphasis on binaries like legal versus illegal, need versus pleasure, medical versus recreational, the legitimate versus the non-legitimate. Will cultural attitudes towards opiates only harden, I wonder, as marijuana becomes more widely available through “legal” avenues? How will changing cultural perceptions and attitudes towards marijuana impact the perception of “harder” drug use?

Teen-Age Booby Trap
But to what, really?

I am fascinated by how the War on Drugs rhetoric links marijuana to heroin as a “gateway drug” (for an interesting and accessible scientific review piece, see this piece on “hash realities” in Nature Neuroscience). By contrast, some of my informants who are heroin addicts believe that if they had been allowed access to a steady supply of marijuana for pain and/or mental distress, they might never have moved to heroin and opiates.

Marijuana, as readers of this blog well know, has a critical place in the history of the War on Drugs in the United States. (See chapter 9 of Musto, An American Disease, the transcript of an interesting radio interview with historian Isaac Campos and Richard Bonnie, and a recent Huffington Post article by Drs. Sunil Kumar Aggarwal and Amanda Reiman on why marijuana is classified as a Schedule I drug for more of this fascinating history). Marijuana was a crucial drug that Harry Anslinger and the Federal Bureau of Narcotics used as a lever into American’s xenophobic and racist fears in the 1930s and the ensuing decades. The sociologist Alfred Lindesmith, in his 1965 book, The Addict and the Law, in a chapter on marijuana quotes a 1938 book by Robert P. Walton that captures some of the discourse at the time: “Marijuana often produces ‘uncontrollable irritability and violent rages, which in most advanced forms causes assault and murder…most authorities agree that permanent insanity can result from continual over-indulgence… if this abuse of this narcotic drug is not stamped out at once, the cost in crime waves, wasted human lives, and insanity will be enormous.’”

Maybe we are at a critical turning moment in the War on Drugs, where such historical notions of marijuana can seem antiquated, even silly (although they have obviously had important repercussions on many people’s lives). In the beginning of April, the Pew Research Center for the People & the Press released a report showing that the majority of Americans now favor the legalization of marijuana. The report showed that fewer people than ever before believe that marijuana is a “gateway” to hard drugs, 77% of people believe that marijuana has some “legitimate medical uses,” and the number of people who believe that marijuana is “morally wrong” went down 18 percentage points from 50% in 2006 to 32% in the most recent poll.

Here in Massachusetts, I look forward to witnessing and writing about the evolution of medical marijuana as it affects the everyday experiences of patients and individuals with addiction, as well as drug policy more generally.