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Richard Vogel, AP
In this Friday, Jan. 12, 2018 photo, a bud tender prepares marijuana for a customer at Med Men, a dispensary in West Hollywood, California. A Democratic lawmaker wants to make it easier for Californians with marijuana convictions to reduce or erase their records as the state moves into the next phase of legalized pot.

SALT LAKE CITY — Utahns who look at a map showing states that have legalized medical marijuana will see they are now in the minority. Thirty states and the District of Columbia currently have laws broadly legalizing marijuana in some form.

Eight states, including those immediately to Utah’s east and west — Colorado and Nevada — have enacted the most expansive laws, legalizing marijuana for recreational use.

The map makes it look as if it is a simple yes or no question. But the truth is marijuana laws are as diverse as the states that have enacted them.

As Utahns look at medical marijuana legislation, there are dozens of factors to consider. Everything from the number of dispensaries allowed in a state, to the list of conditions for which marijuana is approved could affect the ease of access for patients in need as well as the potential for legally sold cannabis products to find their way into the hands of teenagers.

Five bills related to medical marijuana passed in the Utah Legislature this year. HB302 lets private growers produce industrial hemp, HB197 allows the Utah Department of Agriculture to contract with private growers to produce high THC cannabis for research purposes, HB195 allows terminally ill patients the right to try medical marijuana, HB25 calls for the Cannabinoid Product Board to review expanded cannabinoid products, and SB130 sets up the regulatory framework for businesses to legally sell CBD oil. The governor's office is currently reviewing the bills.

None of these reforms are as sweeping as the ballot initiative, spearheaded by the Utah Patient’s Coalition, which will make cannabis broadly available, if the initiative acquires enough signatures and Utahns vote yes in the fall.

“There’s no clear gold standard as far as what a medical marijuana law should look like,” said Rosanna Smart, a drug policy expert with RAND Corp. “There’s a lot of unanticipated consequences that can occur that Utah may end up not wanting.”

According to Smart, every state has learned from California, the first state to legalize medical cannabis in 1996. That law led to a proliferation of marijuana grow operations and dispensaries that were difficult to regulate, she said. Since then, states such as New York and Minnesota have found different ways to more tightly control the market, such as requiring doctors to register with the Department of Health’s medical marijuana program and prohibiting smokeable products.

As Utahns make decisions about legalizing cannabis, they can study these examples, evaluate the risks and benefits of cannabis use and determine what laws will have the best outcome.

“Utah now has a lot of examples it can look to as far as what to do and what not to do,” Smart said.

Cautionary tales

In 2010, a 20-year-old woman who was 6 months pregnant walked into the office of Dr. Manuel De Jesus Aquino at the Garden Health and Wellness Center in Denver, Colorado. During the three-minute appointment, Aquino didn’t conduct any physical examination, didn’t take any notes, didn’t ask about the woman’s medical history and didn’t give any directions for follow-up care, according to a complaint to the Colorado Medical Board filed by the Colorado Attorney General’s Office. Aquino never learned that she was pregnant, and the woman left with a recommendation for cannabis.

When the woman gave birth a few months later, the baby demonstrated difficulty feeding and the woman tested positive for the drug. Although the effects are largely unknown, marijuana use while pregnant has been associated with low birth weight and developmental problems for babies. The American College of Obstetricians and Gynecologists recommends against it.

The Colorado Medical Board suspended Aquino's license. Dozens of other doctors in Colorado have had their licenses suspended for recommending large plant counts to an excessive number of patients without a legitimate need. One doctor, Gentry Dunlop, of Aurora, authorized 75 or more plants to at least 700 patients, according to 2016 news reports.

These cases raise the question: Who should be authorized to recommend cannabis? How much should they be able to recommend and for what conditions? How should it be regulated? And what should be the disciplinary process for those who don’t follow guidelines?

Keith Srakocic, AP
The checkout area of CY+ Medical Marijuana Dispensary is shown during an open house and media availability for the opening, Thursday, Feb. 1, 2018 in Butler, Pennsylvania.

Utah’s ballot initiative proposes that not only doctors, but other medical professionals, including dentists and pharmacists, be allowed to recommend cannabis.

In some states, including Maryland, nurse midwives are permitted to recommend the drug, and studies show that an increasing number of pregnant women are taking marijuana for morning sickness and anxiety.

“The first trimester is a critical time when birth defects are likely to occur,” said Christine Miller, a Maryland pharmacologist who works with the advocacy group Parents Opposed to Pot. She doesn’t think medicine without FDA approval and thorough research backing should be recommended for widespread use. “The state bears responsibility. If they circumvent the Food and Drug Administration, they need to do a risk benefit analysis themselves and let the patients know.”

Utah’s proposed law would only allow nurse midwives to recommend marijuana to patients under the supervision of a physician. But nothing in the proposition forbids medical marijuana from being distributed to pregnant women, according to Michelle Swapp, of Utah County’s Substance Misuse and Abuse Reduction Team. And it will be difficult to hold doctors accountable as the Utah ballot includes a clause saying those who recommend cannabis according to the provisions in the bill will not be subject to “civil liability, criminal liability, or licensure sanctions.”

“To me, that’s completely backward,” said Rep. Brad Daw, R-Orem, who was the chief sponsor of four of the five medical marijuana-related bills heard in the Legislature this session. “We need to look closely at the law and make sure it protects the people, not the industry.”

Success stories

Proponents of medical marijuana point to the personal stories of those who have benefited from the drug and its potential to replace more addictive substances, like opioids.

John Weddle, 33, became a medical refugee in 2009 when he moved from Tennessee to California in order to get access to cannabis. Weddle, who joined the Army reserves at age 17, was deployed to Iraq in 2003 and worked as a transportation specialist, hauling fuel across the country. In doing so, he says he was exposed to all the horrors of war. When he came home, he had severe post-traumatic stress disorder and back pain from a car accident he was in while deployed. Weddle turned to alcohol, methamphetamine and cocaine — in addition to the multiple antidepressants and opioids that were being distributed to him by the Veterans Association.

Richard Vogel, AP
In this Friday, Jan. 12, 2018, photo, customers line up for recreational marijuana outside of Med Men, a dispensary in West Hollywood, California. A Democratic lawmaker wants to make it easier for Californians with marijuana convictions to reduce or erase their records as the state moves into the next phase of legalized pot.

Weddle knew he needed to try something different. But cannabis was, and is, illegal in Tennessee. And so he moved to San Pablo, California. With the help of cannabis, Weddle was able to wean himself off of all other drugs, started taking classes at Berkeley City College, and now practices meditation to calm his anxiety.

“It changed my life,” said Weddle. “If I was living in Tennessee, I for sure would be an alcoholic. Since coming here, I haven’t been drinking at all. It’s unbelievable.”

But it came with a price. Weddle said he had to leave his home, his friends and his family, including a 13-year-old daughter whom he now only gets to see during summers.

Even in states that have legalized cannabis for medical use, some don’t recognize PTSD as an approved condition. In five states, PTSD is not listed as an approved condition for medical cannabis due to limited research into the drug’s benefits for mental illnesses.

Utah’s ballot initiative puts PTSD on the list, along with Autism, Alzheimer's, chronic pain and other conditions.

“If you limit it to AIDS or cancer-related symptoms, you close the door to people who can benefit,” said Katherine Neill Harris, a professor from Rice University. Other regulations related to dispensaries, home growing operations and doctors can also have the effect of limiting access for people in need, she said.

In several states, pain by itself is not an approved condition, because it’s not something a physician can measure. But some studies have indicated there may be a link between legalizing cannabis use for medical purposes and reduced opioid overdose rates.

Richard Vogel, AP
In this Friday, Jan. 12, 2018 photo, a bud tender prepares marijuana for a customer at Med Men, a dispensary in West Hollywood, California. A Democratic lawmaker wants to make it easier for Californians with marijuana convictions to reduce or erase their records as the state moves into the next phase of legalized pot.

Patients who are given the option to treat pain with cannabis are better able to avoid the dangerous pitfall of opioid addiction, according to Tamar Todd, legal director at the Drug Policy Alliance, a group against drug prohibition.

Hospitalization rates for opioid painkiller dependence and abuse dropped 23 percent on average in states after cannabis was permitted for medicinal use. And hospitalization rates for opioid overdoses in particular dropped 13 percent, one analysis by the University of California, San Diego showed.

“Other states have proven that it can work,” said Todd.

Too slow or too fast?

The disagreement about cannabis comes down to two attitudes — some think it’s moving way to quickly and some think it’s moving way too slowly. Those attitudes are exemplified by the two paths states can take to medical marijuana legalization: a ballot initiative or the legislature.

One path leaves the legislation up to elected representatives who are experienced with lawmaking but may move more slowly. The second path puts the decision into the hands of the public, who may not be familiar with legal specifics but can push for more rapid change.

“The difference is with the legislature, you have an opportunity for experts to talk to a smaller group of people, charged with learning about a subject,” said Miller. “With ballot initiatives, it is extremely hard to educate the public about these complex subjects.”

All the early states that legalized cannabis for medical use, including California, Alaska, Oregon, Washington, Maine, Colorado and Nevada, did so through a ballot. After these early states showed medical marijuana legislation was possible, state legislatures started taking charge, according to Smart. Hawaii, Vermont, Rhode Island and New Mexico were some of the first states to legalize cannabis through legislatures.

Keith Srakocic, AP
An open house and media availability is held for the opening of CY+ Medical Marijuana Dispensary, Thursday, Feb. 1, 2018 in Butler, Pennsylvania.

Overall, 14 of the states have gone through a ballot, while 16 states and the District of Columbia have gone through legislatures.

The original laws that passed through ballots in California, Washington and Colorado, for example, were broad and, according to Carnegie Mellon University drug policy expert Jonathan Caulkins, allowed legal use for “pretty much any adult who wanted it.”

“Propositions often produce perverse and bad laws,” said Caulkins. “Advocates who are pro-marijuana write the proposition. Then the state has no choice but a thumbs up, thumbs down.”

In November 2015, people in Ohio rejected a marijuana legalization ballot that would have given campaign donors direct rights to the state's 10 pot farms as an explicit gift for their support. It was, even legalization advocates argued, an example of members of the pot industry trying to profit from the movement.

The next year, Ohio passed a more narrow medical marijuana bill through the Legislature.

A 2017 Quinnipiac University poll found that 94 percent of U.S. voters now support “allowing adults to legally use marijuana for medical purposes if their doctor prescribes it.” The poll also found that 61 percent of American voters believe that adult use marijuana should be legalized.

“I can't think of another issue that Americans agree on more than medical marijuana,” said Todd.

A slippery slope?

All the states that have now legalized recreational marijuana started by approving medical cannabis. So, is this a “slippery slope" toward legalization?

“The total amount of cannabis that would be used by people with medical needs — is really not that much,” said Caulkins. “Repeatedly, medical laws have been the camel getting its nose in the tent and then the industry wants to expand its market.”

Some worry that the legal marijuana industry, which hit $6.7 billion in North American sales in 2016, is exerting too much influence. The Marijuana Policy Project, which has multiple board members and leaders with ties to and investments in marijuana businesses, is one of the leading national advocacy groups. The project is the Utah ballot initiative’s top donor and has contributed more than $109,000 to Utah’s legalization efforts.

“Parents and concerned citizens when they stop pro-drug legislation, they are not making money. There is a major conflict of interest for the industry that is pushing legislation,” said Kevin A. Sabet, leader of Smart Approaches to Marijuana.

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On the other hand, marijuana advocates believe the recreational programs are more likely to pass after medical legislation, not because of greedy industry leaders, but because of effective programs and people’s positive personal experiences.

“Everyone starts to see the sky hasn’t fallen and everything’s fine,” said Harris. “After you pass a medical program and people see it working, they tend to be more supportive of an adult use program.”

It’s positive public opinion that will continue to push cannabis legalization nationwide, Harris said.