Even as a proposal to legalize medical marijuana emerges in Maryland, a backlash over the burgeoning industry has developed in other states - and is likely to influence legislation here.
Last week, the Los Angeles City Council tried to rein in the growth of marijuana dispensaries, limiting the number to 70 and imposing tight restrictions on where and how they can operate. And in Colorado, towns are trying to shutter some of the hundreds of dispensaries that have popped up.
But supporters of the Maryland proposal say they have learned from problems in states that approved use of the drug without uniform regulations on the dispensaries providing it. The result, they say: Maryland's measure could be among the most stringent in the nation.
"I looked at a compendium of legislation from all the other states and I knew from being in California that we absolutely didn't want to do that," said Del. Dan Morhaim, a Baltimore County Democrat and a physician who plans to sponsor a bill that would make Maryland the 15th state to allow the medical use of marijuana. "From the physician-patient point of view, I wanted a bill that I would be supportive of as a doctor."
Advocates and some medical experts say a growing body of research shows the drug can be an effective tool to help patients struggling with some diseases. The Maryland proposal would allow marijuana to be given to patients with a "debilitating medical condition," such as seizures, severe chronic pain or severe nausea as a result of cancer treatment.
But not all physicians agree it's a good idea.
Dr. Kevin Cullen, an oncologist and director of the University of Maryland Marlene and Stewart Greenebaum Cancer Center, isn't sure the state needs a new law. He said he'd probably never recommend medical marijuana to cancer patients because other drugs are more effective.
"It's important that the lawmakers speak to the medical community directly and assess the need for this," he said. "It may be that they're having a 'me, too' reaction to other states. I have no idea who the lobby may be for this."
Unlike laws in some other states, the proposal Morhaim discussed last week would license growers and dispensaries, would allow doctors to recommend marijuana only to patients with whom they have a long-standing relationship and would control who could provide the drug to homebound patients. People would not be able to grow their own marijuana and would be limited in the amount they could buy each month as well as the ailments they could use it for.
(Sen. David Brinkley, a Republican from Frederick, is the measure's sponsor in the Senate.)
Morhaim, a longtime medical-marijuana supporter, said this legislative session is the right time to pursue the change.
Last fall, the American Medical Association urged the federal government to downgrade its classification of marijuana from a dangerous drug with no medical use, clearing the way for more clinical research of the drug and development of cannabis-based medicines.
At the same time, access to medical marijuana has been growing nationwide since the Obama administration loosened federal enforcement of the drug last fall, saying it would not prosecute users in states with medical marijuana laws. With other states legalizing medical marijuana, Maryland had an opportunity to study their successes and missteps.
In crafting the measure in the House of Delegates, Morhaim, who is originally from Los Angeles, looked at that city's experience with medical marijuana as an example of what not to do.
Because California's 1996 law legalizing medical marijuana did not regulate dispensaries or set up a means for distributing the drug, localities had to come up with rules on their own. While cities such as Oakland mandated regulation of dispensaries, including restrictions on where and how they can operate, Los Angeles left the question open; storefront dispensaries with on-site doctors flourished across the city.
"I don't want doctors who will just write an open-ended marijuana prescription to a patient they just met," he said. "I am quite aware of the L.A. problem; it's clearly out of control."
Similarly in Colorado, which has had a medical marijuana law since 2000, towns have begun trying to close dispensaries. Until last year, there were only about a dozen dispensaries statewide. Since then, hundreds have opened, serving about 40,000 patients.
But the state didn't address dispensaries in the law, creating a lack of uniformity in how they operate, said Brian Vicente, co-chair of Colorado's Sensible Patient and Provider Coalition. The coalition includes medical marijuana advocacy groups, business owners, caregivers and patients who are seeking some new regulation of medical marijuana.
The Colorado law said only that sick patients with a doctor's permission could possess and cultivate marijuana - or appoint a caregiver to do it for them if they were too sick or didn't have the expertise. One caregiver could handle many patients - the patients would merely have to designate the person as their caregiver. Some caregivers began opening stores, a boon to those who can't or don't want to grow their own marijuana and don't want to buy it "on the street or in an alley," he said.
The Maryland proposal hopes to avoid that situation by allowing caregivers to serve only one patient, Morhaim said.
Vicente said most dispensary owners are paying taxes and working to help sick people, but the coalition fears "a select handful are probably breaking some laws."
In the meantime, he said, towns have reacted differently. Denver "embraced them," and has written regulations for the dispensaries. But Centennial, Colo., tried to close its dispensary and the owners sued.
Maryland, he said, has an opportunity to set a statewide, even national, standard for how to deal with the medical-marijuana issue by establishing a system of uniform taxation and regulation of dispensaries - no squabbling over rules.
But Vicente also warns the lawmakers not to make the rules too restrictive. The state should let patients grow marijuana, because it's cheaper than prescription medication, he said, and many patients can't afford traditional health care. Also, requiring a recommendation from a long-time doctor would be a problem for patients whose physicians fear federal prosecution or just won't write a referral.
Maryland lawmakers suggest having growers be licensed by the Department of Health and Mental Hygiene and the Department of Agriculture, which would charge a licensing fee. Growers would have to submit to regular testing and monitoring.
"If you're going to have people use this, you have to make sure it's a safe and secure unadulterated supply. Grow-your-own approach opens the door to all kinds of misuses," Morhaim said.
Meanwhile, doctors disagree over whether marijuana is even helpful for their patients, and whether they would prescribe it.
Cullen, the UM cancer specialist, said marijuana is a carcinogen, and when you're treating people with cancer you don't want to expose them to more carcinogens. He also said marijuana is used as an anti-nausea medicine, but newer medicines developed in the past 10 years are better. And, finally, the active ingredient in marijuana has been made available as a pill, called Marinol, for those with chemotherapy induced nausea.
"It's rarely used because it doesn't work as well as newer medications," he said. "And most patients don't like the feeling they get from Marinol on top of chemotherapy."
Cullen said he's "fairly agnostic" on medical marijuana for other purposes, but for cancer it's not a useful drug.
Dr. Steven P. Cohen, a pain specialist and an associate professor of anesthesiology at the Johns Hopkins School of Medicine, said he would recommend marijuana to patients, but only after other therapies had failed. He'd make sure patients were responsible, compliant and informed about the risks of the drug and would agree to routine monitoring.
Marijuana, and the class of marijuana-like drugs called cannabinoids, can be effective treatment for people with central nervous system pain, such as those with multiple sclerosis and stroke, said Cohen. "For these patients, it would be great; these things are notoriously hard to treat."
But there's no research on the long-term effects of the drug and few can justify using it as a first-line treatment, he said.
"Some studies have shown efficacy in the short-term, like six weeks or two months, but what happens after a year?" he said. "Especially if you smoke, you have questions about motivation, memory problems, there may be risks for cancer, bronchitis, lung disease and emphysema."
Still, because treating pain is so complicated and few drugs offer long-term relief, Cohen doesn't see a problem with adding marijuana as another tool to help patients.
"People die from opioids, I see it all the time," he said. "They are probably inherently more dangerous than cannabinoids and they are used all the time for chronic pain. So why wouldn't you use cannabinoids?"