Marijuana: Early Experiences with Four States' Laws That Allow	 
Use for Medical Purposes (01-NOV-02, GAO-03-189).		 
                                                                 
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 medical effectiveness of marijuana, and over government	 
policies surrounding medical use. 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
physician's 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 person's debilitating	 
condition to register. Laws in these states also establish	 
maximum allowable of marijuana for medical purposes. California's
law does not establish a state-run registry or establish maximum 
allowable amounts of marijuana. Relatively few people had	 
registered to use marijuana for medical purposes in Oregon,	 
Hawaii, and Alaska. As of Spring 2002, 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,
and in Hawaii and Oregon, the two states where gender information
is collected, 70 percent of registrants were men. 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 1 percent of the approximately	 
5,700 physicians in Hawaii and 3 percent of Oregon's physicians  
out of 12,900 had recommended marijuana to their patients. Oregon
was also the only state that maintained data on the number of	 
times individual physicians recommended marijuana--as of February
2002, 62 percent of the Oregon physicians recommending marijuana 
made one recommendation. Data were not readily available to	 
measure how marijuana-related law enforcement has been affected  
by the introduction of medical marijuana laws. Officials from	 
over half of the 37 selected federal, state, and local law	 
enforcement organizations GAO interviewed in the four states said
that the introduction of medical marijuana laws had not greatly  
affected their law enforcement activities.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-189 					        
    ACCNO:   A05474						        
  TITLE:     Marijuana: Early Experiences with Four States' Laws That 
Allow Use for Medical Purposes					 
     DATE:   11/01/2002 
  SUBJECT:   Controlled substances				 
	     Data collection					 
	     Drugs						 
	     Federal law					 
	     Health care programs				 
	     Intergovernmental relations			 
	     Law enforcement					 
	     Physicians 					 
	     Program evaluation 				 
	     State law						 
	     State-administered programs			 
	     Statistical data					 
	     Alaska						 
	     California 					 
	     Hawaii						 
	     Oregon						 

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GAO-03-189

Report to the Chairman, Subcommittee on Criminal Justice, Drug Policy and
Human Resources, Committee on Government Reform, U. S. House of
Representatives

United States General Accounting Office

GAO

November 2002 MARIJUANA Early Experiences with Four States* Laws That
Allow Use for Medical Purposes

GAO- 03- 189

Page i GAO- 03- 189 State Medical Marijuana Laws Letter 1

Results in Brief 3 Background 5 Implementation in Oregon, Alaska, Hawaii,
and California 8 Few Registrants, Most with Severe Pain or Muscle Spasms
21 Few Physicians Make Marijuana Recommendations; Some

Guidance Available 26 Difficult to Measure the Impact of State Medical
Marijuana Laws

on Law Enforcement Activities 30 Agency Comments and Our Evaluation 35

Appendix I Objectives, Scope, and Methodology 40 Objectives 40 Scope and
Methodology: State Selection and Data 40 Scope and Methodology: Law
Enforcement Opinions 41

Appendix II The Supreme Court*s Decision in United States v. Oakland
Cannabis Buyers* Cooperative 44

Appendix III Medical Marijuana Registries in Oregon, Alaska, Hawaii, and
Select California Counties 46

Oregon 46 Alaska 46 Hawaii 47 California 49

Appendix IV Descriptions of Allowable Conditions under State Medical
Marijuana Laws 51

Appendix V Comments from the Department of Justice 54

Appendix VI GAO Contacts and Staff Acknowledgments 59 GAO Contacts 59
Staff Acknowledgments 59 Contents

Page ii GAO- 03- 189 State Medical Marijuana Laws Tables

Table 1: Registry Requirements and Verification Procedures in Oregon,
Alaska and Hawaii, as of July 2002 11 Table 2: Definition and Provisions
Regarding Caregivers in Oregon,

Alaska and Hawaii 15 Table 3: Allowable Conditions for Medical Marijuana
Use in Four

States17 Table 4: Permissible Amounts of Medical Marijuana and Plant

Maturity in Oregon, Alaska, and Hawaii 18 Table 5: Safety and Public Use
Restrictions in Oregon, Alaska,

Hawaii and California 20 Table 6: Medical Marijuana Registrants in Oregon,
Hawaii, and

Alaska, by Projected 2002 State Population 22 Table 7: Registrants in Four
California Counties by County

Population 23 Table 8: Registrant Age in Alaska, Hawaii and Oregon 23
Table 9: Registrant Conditions in Oregon and Hawaii 25 Table 10: Number of
Marijuana Recommendations Made by Oregon

Physicians, as of February 2002 28 Table 11: Doctor Guidance Provided by
Selected State Medical

Organizations 29

Figures

Figure 1: Example of Oregon*s Medical Marijuana Registry Card 10 Figure 2:
Example of San Francisco*s Medical Marijuana Registry

Cards 13 Figure 3: Example of Alaska*s Medical Marijuana Certification
Card 47 Figure 4: Example of Hawaii*s Medical Marijuana Registry Card 48

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

Page 1 GAO- 03- 189 State Medical Marijuana Laws

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. 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. 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

1 States* Rights to Medical Marijuana Act, H. R. 2592, 107 th 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.

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 03- 189 State Medical Marijuana Laws

data was available on patient and physician participation. 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
state*s 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.)

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. California*s law was enacted in1996. California does not
have a participant registry, but based on our preliminary work, some local
registry information was available.

Page 3 GAO- 03- 189 State Medical Marijuana Laws

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 physician's 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 person*s
debilitating condition to register. Laws in these three states also
establish maximum allowable amounts of marijuana for medical purposes.
California's 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 Oregon*s 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. California*s medical board provides informal
guidelines on making marijuana recommendations to their patients. Results
in Brief

Page 4 GAO- 03- 189 State Medical Marijuana Laws

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 DOJ*s 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

Page 5 GAO- 03- 189 State Medical Marijuana Laws

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 marijuana*s 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 DOJ*s 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 DOJ*s
comments is provided on pages 35 to 38 and we have reprinted a copy of
DOJ*s comments in appendix V.

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. 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) 5 places all federally
controlled substances into one of five *schedules,* depending on the
drug*s likelihood for abuse or dependence, and whether the drug has an
accepted medical use. 6 Marijuana is classified under Schedule I, 7 the
classification reserved for drugs that have been found by the federal

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. S:S: 801 to 971.

6 Id. S: 812( a), (b). 7 Id. S: 812( c), Schedule I (c)( 10). Background

Page 6 GAO- 03- 189 State Medical Marijuana Laws

government to have a high abuse potential, a lack of accepted safety under
medical supervision, and no currently accepted medical use. 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.
9 The CSA does not allow Schedule I drugs to be dispensed upon a
prescription, unlike drugs in the other schedules. 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. 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. 12

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. S: 812( b)( 2)-( 5).

10 Id. S: 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. S: 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 government's motion
for summary judgment.

Page 7 GAO- 03- 189 State Medical Marijuana Laws

In 1999, an Institute of Medicine study 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 Association*s
Council on Scientific Affairs also summarized the medical and scientific
research in this area, similarly calling for more research. 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.
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 state*s
statute, federal penalties remain, as determined by the Supreme Court in

United States v. Oakland Cannabis Buyers* Cooperative. 16 (Appendix II
provides more information on the Supreme Court*s 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

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 patient*s
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).

Page 8 GAO- 03- 189 State Medical Marijuana Laws

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.

Oregon, Alaska, Hawaii, and California laws allow medical use of marijuana
under certain conditions. 17 All four states require a patient to have a
physician*s 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 patient*s 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.

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

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. Alaska*s Hawaii*s and Oregon*s 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
California*s law. Implementation in

Oregon, Alaska, Hawaii, and California

States and Some Local California Jurisdictions Maintain Medical Marijuana
Registries

Page 9 GAO- 03- 189 State Medical Marijuana Laws

Department of Health and Social Services. In Hawaii, the Narcotics
Enforcement Division within the Department of Public Safety is responsible
for the state*s 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. 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 physician*s 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 state*s 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.)

18 Under Alaska*s and Hawaii*s 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 Oregon*s 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 act*s quantity and use
restrictions. See Ore. Rev. Stat. 475. 306, 475.316, 475. 319, 475.342.
Because California*s law does not establish a state- run registry, a
medical use defense may be established by any individual meeting the act*s
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 California*s medical marijuana act.

Page 10 GAO- 03- 189 State Medical Marijuana Laws

Figure 1: Example of Oregon*s Medical Marijuana Registry Card

Source: Oregon Department of Human Services.

Hawaii*s 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.

Page 11 GAO- 03- 189 State Medical Marijuana Laws

Table 1: Registry Requirements and Verification Procedures in Oregon,
Alaska and Hawaii, as of July 2002 Registry requirements Oregon Alaska
Hawaii

Completed application form x a (submitted by applicant) x (submitted by

applicant) x (submitted by physician) Written physician documentation x b
x c x d Applicant name, address and date of birth. Must include a copy of
a current photographic identification card, such as license, or ID card
number

x xx 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

x xx Sworn caregiver statement on department form regarding lack of felony
drug conviction, not on probation or parole, and over 21 x Address of site
where marijuana will be produced x x Annual renewal for registry card x x
x Minors: parents declaration form and agreement to serve as minor*s
caregiver x (must be

notarized) x x Registration fee $150 $25 first time

$20 renewal $25

Registry Verification Procedures

Doctor has a valid license in state x x x Verification call or letter sent
to doctor re: recommendation x x e x Patient contacted to validate
application information x x e x Caregiver contacted to validate
application information x e x e x e Registry checked to assure caregiver
only serves one patient x

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 patient*s 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 physician*s 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.

California*s statute does not establish a state registry or require that a
person or caregiver be registered to qualify for a medical use exception.
California*s law requires that medical use has been recommended by a
physician who has determined that the person*s 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

Page 12 GAO- 03- 189 State Medical Marijuana Laws

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 California*s law. 19 However, a bill incorporating many
of the ideas agreed upon by the task force was not enacted by the
California legislature. 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 Francisco*s
Department of Public Health. (See the following section for a discussion
of caregivers.)

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 patient*s 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.

Page 13 GAO- 03- 189 State Medical Marijuana Laws

Figure 2: Example of San Francisco*s Medical Marijuana Registry Cards

Source: San Francisco Department of Public Health.

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 General*s 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.

Page 14 GAO- 03- 189 State Medical Marijuana Laws

(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.)

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. Medical Marijuana
Patient

Primary Caregivers

Page 15 GAO- 03- 189 State Medical Marijuana Laws

Table 2: Definition and Provisions Regarding Caregivers in Oregon, Alaska
and Hawaii Oregon Alaska Hawaii

Definition of Caregiver *Designated primary caregiver* means an individual
eighteen years of age or older who has significant responsibility for
managing the wellbeing of a person who has been diagnosed with a
debilitating medical condition and who is designated as such on that
person*s application for a registry identification card or in other
written notification to the division. Designated primary caregiver does
not include the person*s attending physician.

*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).

*Primary caregiver* means a person, other than the qualifying patient and
the qualifying patient*s 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 1 2 (a primary and an alternate)
1 Limit to number of patients per caregiver Not specified 1

(exceptions may be granted by state agency)

1 Criminal record restriction on serving as caregiver Not specified Yes
Not specified

Source: Oregon, Alaska, and Hawaii medical marijuana statutes and
administrative rules.

California*s 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.

In all four states, patients must obtain a physician*s diagnosis that he
or she suffers from a medical condition eligible for marijuana use under
that state*s 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 physician*s
medical determination and marijuana recommendation in their registry
applications. This documentation must conform with program requirements,
reflecting that the physician made his or her Physician

Recommendation Requirements

Page 16 GAO- 03- 189 State Medical Marijuana Laws

recommendation in the context of a bona fide physician- patient
relationship.

California*s law does not require patients to submit documentation of a
physician*s determination or recommendation to any state entity, nor does
it specify particular examination requirements. According to California*s
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 person*s 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 Hawaii*s 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 patient*s 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 Oregon*s medical marijuana law, the patient*s attending physician
must supply physician documentation. Oregon*s 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. 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

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
patient*s primary care physician; or (d) Has reviewed a patient*s medical
records at the patient*s request, has conducted a thorough physical
examination of the patient, has provided a treatment plan and/ or followup
care, and has documented these activities in a patient file. *

Page 17 GAO- 03- 189 State Medical Marijuana Laws

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
physician*s patient file in connection with this inquiry.

The laws in all four states we reviewed identify medical conditions 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 Oregon Alaska Hawaii California

Cancer x xxx Glaucoma x xxx HIV positive status x xx AIDS x xxx Cachexia x
xx Wasting syndrome x Anorexia x Epilepsy and other seizure disorders x x
x Multiple sclerosis and other disorders characterized by persistent
muscle spasticity x x x x Crohn*s disease x Alzheimer*s disease x
Arthritis x Migraine x Severe pain x xx Chronic pain x Severe nausea x xx
Any other illness for which marijuana provides relief b x

a Oregon*s, Alaska*s, and Hawaii*s medical marijuana statutes use the term
*debilitating medical condition* to encompass the conditions eligible for
medical marijuana use. California*s statute does not use this term, but
simply lists the eligible conditions. b California*s statute does not
define *any other illness for which marijuana provides relief.*

22 For simplicity, we use the general term medical *condition* to
encompass, diseases, symptoms, and medical conditions. Qualifying State

Conditions for Use of Medical Marijuana

Page 18 GAO- 03- 189 State Medical Marijuana Laws

Source: California, Oregon, Alaska and Hawaii medical marijuana statutes
and Oregon administrative rules.

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 California*s
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 Oregon Alaska Hawaii

Allowable amount 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

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.

*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 patient*s 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 *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.

Not specified *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 act*s 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 patient*s debilitating medical
condition. Ore. Rev. Stat. 475.306( 2).

Source: Oregon, Alaska, and Hawaii medical marijuana statutes and
administrative rules.

California*s statute does not specify an amount of marijuana allowable
under medical use provisions; however, some local jurisdictions have
established their own guidelines. The statute*s criminal exemption is for
*personal medical purposes* but does not define an amount appropriate
Allowable Amounts of

Marijuana for Medical Use

Page 19 GAO- 03- 189 State Medical Marijuana Laws

for personal medical purposes. The California Attorney General*s 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 state*s 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 General*s 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.

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. 23 Table 5 reflects the various states* safety or public use
restrictions.

23 Alaska*s statute provides a one- year suspension from using or
obtaining a registry card; Oregon*s statute provides up to a 6- month
suspension from using or obtaining a registry card; Hawaii*s rules provide
for revocation of the registry certificate for an indefinite time. Safety
and Public Use

Restrictions

Page 20 GAO- 03- 189 State Medical Marijuana Laws

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

Safety restrictions Oregon*s medical

marijuana statute prohibits driving under the influence of marijuana.

Alaska*s medical marijuana statute prohibits medical use of marijuana that
endangers the health or well- being of any person.

Hawaii*s medical marijuana statute prohibits medical use of marijuana that
endangers the health or well- being of another person.

California*s 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*s 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*s 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*s medical marijuana statute prohibits the medical use of marijuana
in a school bus, public bus, or any moving vehicle; in the workplace of
one*s 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.

(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.

Oregon was the only state of the four we reviewed to have conducted a
management review of their state*s medical marijuana program. 24 The
Oregon Department of Human Services conducted the review after concerns
arose that a doctor*s 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

24 *Oregon*s Medical Marijuana Program: A Management Review* Oregon
Department of Human Services, June 11, 2001. Management Review

Results in Oregon Program Changes

Page 21 GAO- 03- 189 State Medical Marijuana Laws

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.

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.

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 doesn*t 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 state*s 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. Few Registrants, Most

with Severe Pain or Muscle Spasms

Small Number of Medical Marijuana Registrants

Page 22 GAO- 03- 189 State Medical Marijuana Laws

Table 6: Medical Marijuana Registrants in Oregon, Hawaii, and Alaska, by
Projected 2002 State Population

State State population Number of registrants Percent of registrants by
state population

Oregon 3,488,000 1, 691 0.05 Hawaii 1,289,000 573 0.04 Alaska 672,000 190
0.03

Totals 5, 449,000 2, 454 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.

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. 25 In each of these registries,
participation was 0.5 percent or less than the respective county*s
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.

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.

Page 23 GAO- 03- 189 State Medical Marijuana Laws

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

population Number of registrants

Percent of registrants by

county population

San Francisco Department of Public Health 793,729 3551 0. 44 Sonoma County
Medical Association 468,754 435 0.09 Humboldt County Department of Public
Health 127,754 182 0.14 Mendocino County 87,273 430 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.

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 Alaska Hawaii Oregon

Under 18 1 (1%) 0 0 19- 29 10 (5%) 16 (3%) 145 (9%) 30- 39 42 (22%) 70
(12%) 247 (15%) 40- 49 84 (44%) 197 (34%) 613 (36%) 50- 59 42 (22%) 216
(38%) 550 (33%) Over 60 11 (6%) 74 (13%) 136 (8%)

Total 190 573 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.

Medical Marijuana Registrant Demographics

Page 24 GAO- 03- 189 State Medical Marijuana Laws

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.

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 Hawaii* s 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 Oregon*s 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. Medical Marijuana

Registrant Conditions

Page 25 GAO- 03- 189 State Medical Marijuana Laws

Table 9: Registrant Conditions in Oregon and Hawaii Oregon Hawaii Number
of recommendations

per condition Percent with condition

Number of recommendations

per condition Percent with condition

Cancer 43 3 9 2 Glaucoma 31 2 10 2 HIV positive status or AIDS 47 3 66 12
Cachexia 18 1 - Cachexia or wasting syndrome -- 92 Epilepsy and other
seizure disorders 43 3 5 1 Multiple Sclerosis and other disorders
characterized by persistent muscle spasms, or spasticity 459 28 240 43
Alzheimer*s disease 1 Under 1 - Severe pain 915 56 172 31 Severe nausea 83
5 12 2 Severe nausea/ severe pain -- 316

Total 1640 a 554 b

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 26 and muscle spasms, 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

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.

Page 26 GAO- 03- 189 State Medical Marijuana Laws

spasms were pain, multiple sclerosis, and fibromyalgia, 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.

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.

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
state*s 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 Oregon*s medical marijuana registration programs are
relatively new, which may account for the low level of participation by
physicians in both states. Oregon*s program has operated for a year longer
than Hawaii*s, 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 drug*s medical
efficacy, and a doctor*s own philosophical stance on the use of marijuana
as medicine.

28 Fibromyalgia: Chronic pain, stiffness, and tenderness of muscles,
tendons, and joints without detectable inflammation. Fatigue and sleep
disorders are common in fibromyalgia patients. Few Physicians Make

Marijuana Recommendations; Some Guidance Available Low Physician
Participation

Page 27 GAO- 03- 189 State Medical Marijuana Laws

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. 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.* 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.

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 government*s 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 (9 th Cir. Oct. 29, 2002)

30 See Pearson v. McCaffrey, 139 F. Supp. 2d 113, 121 (D. D. C. 2001).

Page 28 GAO- 03- 189 State Medical Marijuana Laws

Table 10: Number of Marijuana Recommendations Made by Oregon Physicians,
as of February 2002

Number of recommendations Number of physicians

making recommendations Percentage of

recommending physicians

1 269 61.8 2 87 20.0 3 337. 6 4 225. 1 5 81. 8 6 20. 5 7 20. 5 9 20. 5 10
1 0. 2 11 1 0. 2 12 1 0. 2 13 2 0. 5 14 1 0. 2 18 1 0. 2 23 1 0. 2 38 1 0.
2 823 1 0. 2

Source: Oregon Department of Human Services.

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. 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

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 doctor*s recommendation is medically appropriate.

Page 29 GAO- 03- 189 State Medical Marijuana Laws

recommending marijuana to over 800 patients was disciplined. 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.

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 Guidance provided Description

Oregon State Board of Medical Examiners No Oregon Medical Association Yes
The association has a document informing members of the

legal issues facing doctors and advising them on doctorpatient discussions
and documentation concerning the use of marijuana for medicine, and
actions to avoid. Alaska State Medical Board No Alaska Medical Association
Yes Those inquiring about recommending marijuana are directed to

seek legal counsel. Hawaii State Board of Medical Examiners No Hawaii
Medical Association Yes Those inquiring about recommending marijuana are
informed

of the association*s official position against medical marijuana and
advised of the legal implications involved. Medical State Board of
California Yes 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. California Medical
Association Yes 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.

The guidance to physicians considering recommending marijuana to a patient
in Oregon, for example, includes avoiding engaging in any

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. Physician
Guidance for

Making Medical Marijuana Recommendations

Page 30 GAO- 03- 189 State Medical Marijuana Laws

discussions with a patient on how to obtain marijuana, and to avoid
providing a patient with any written documentation other than that in the
patient*s medical records. The medical association also advises physicians
to clearly document in a patient*s medical records conversations that take
place between the physician and patient about the use of marijuana as
medicine. Oregon*s medical association notes that until the federal
government advises whether it considers a physician*s 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 physician*s practice. Any subsequent action
occurs if the allegations against a doctor included violations of the
statutes regulating physician conduct.

California medical board*s 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.

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. 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

33 According to the FBI introduction to users of Uniform Crime Report
data. Difficult to Measure

the Impact of State Medical Marijuana Laws on Law Enforcement Activities

Page 31 GAO- 03- 189 State Medical Marijuana Laws

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 state*s 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. 34 Furthermore, although California*s 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. 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

34 Programs to implement the laws in Oregon, Alaska and Hawaii were
developed somewhat later. Alaska*s registry was established in June 1999,
Oregon*s program began operating in May 1999, and Hawaii issued its first
card in January 2001.

35 As described in the methodology section of UCR*s 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.

Page 32 GAO- 03- 189 State Medical Marijuana Laws

occurred. Hawaii does not have statewide prosecution data. At the time of
our review, prosecution data from Oregon*s statewide Law Enforcement Data
System was only available for 1999 and 2000.

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. 36  In Los Angeles County, an official in the District
Attorney*s 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
Department*s 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
Department*s overall strategies and objectives.

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. Perceptions of Officials

with Selected Law Enforcement Organizations Regarding the Impact of
Medical Marijuana Laws

Page 33 GAO- 03- 189 State Medical Marijuana Laws

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 37 *officials with the Humboldt County Drug
Task Force 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. 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

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 state*s law.

Page 34 GAO- 03- 189 State Medical Marijuana Laws

cases. In California, some local law enforcement officials said that their
state*s 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 patient*s 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 Hawaii*s 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
don*t 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

Page 35 GAO- 03- 189 State Medical Marijuana Laws

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. 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.

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, DOJ*s Acting
United States Assistant Attorney General for Administration commented on
the draft. DOJ*s 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

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 Oregon*s medical marijuana act, Or. Rev. Stat. 475.323(
2), federal law granted them immunity for doing so. Agency Comments

and Our Evaluation

Page 36 GAO- 03- 189 State Medical Marijuana Laws

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 government*s 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 Court*s
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 Court*s 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

Page 37 GAO- 03- 189 State Medical Marijuana Laws

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 DEA*s experience* a worsening of relations between federal,
state, and local law enforcement. DOJ*s 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. 41 We modified our draft
to include a discussion of these concerns, and have likewise included
DOJ*s comment. It is also important to note, however, that contrary to
DOJ*s suggestion, our report included a discussion about the concerns of
the law enforcement officials regarding a *softening* of the public
perception about marijuana. Finally, DOJ*s point that Oregon*s 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

41 A summary of law enforcement opinions was sent to those we spoke with
for their comments.

Page 38 GAO- 03- 189 State Medical Marijuana Laws

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 DOJ*s 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.

Page 39 GAO- 03- 189 State Medical Marijuana Laws

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, Paul Jones Director, Justice Issues

Appendix I: Objectives, Scope, and Methodology

Page 40 GAO- 03- 189 State Medical Marijuana Laws

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.

Eight states have enacted medical marijuana statutes. 1 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. California*s 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

1 These eight states were identified in the Supreme Court*s decision in
United States v. Oakland Cannabis Buyers* Cooperative, 532 U. S. 483, 502
n. 4 (2001). Appendix I: Objectives, Scope, and

Methodology Objectives

Scope and Methodology: State Selection and Data

Appendix I: Objectives, Scope, and Methodology

Page 41 GAO- 03- 189 State Medical Marijuana Laws

obtained and analyzed available information on program implementation,
program audits, and program participation by patients and doctors.

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.

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. 2 Federal
officials in each state included representatives from the office of the U.
S. Attorney and the Drug Enforcement Administration (DEA). The specific

2 As a result of phone discussions with law enforcement officials in
Alaska, and the low number of registrants in Alaska*s medical marijuana
program, we decided that interviews could be conducted by email and phone.
Data Reliability

Scope and Methodology: Law Enforcement Opinions

Appendix I: Objectives, Scope, and Methodology

Page 42 GAO- 03- 189 State Medical Marijuana Laws

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
General*s 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
Sheriff*s 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 Sheriff*s 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

Appendix I: Objectives, Scope, and Methodology

Page 43 GAO- 03- 189 State Medical Marijuana Laws

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 DOJ*s 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.

Appendix II: The Supreme Court*s Decision in United States v. Oakland
Cannabis Buyers* Cooperative

Page 44 GAO- 03- 189 State Medical Marijuana Laws

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
governmentapproved 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 Cooperative*s actions were legal under California law, they violated
the CSA. Following lower court proceedings, the U. S. Supreme Court
granted the government*s 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 California*s 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 Act*s 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. Appendix II: The
Supreme Court*s Decision in

United States v. Oakland Cannabis Buyers* Cooperative

Appendix II: The Supreme Court*s Decision in United States v. Oakland
Cannabis Buyers* Cooperative

Page 45 GAO- 03- 189 State Medical Marijuana Laws

The Oakland Cannabis case upheld the federal government*s 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.

Appendix III: Medical Marijuana Registries in Oregon, Alaska, Hawaii, and
Select California Counties

Page 46 GAO- 03- 189 State Medical Marijuana Laws

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.

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 patient*s 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 doctor*s 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 Oregon*s 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 Alzheimer*s disease. Most
of the petitioned conditions have had a psychological basis, the State
Public Health Officer said.

Alaska*s 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 physician*s 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 Appendix III: Medical Marijuana Registries in

Oregon, Alaska, Hawaii, and Select California Counties

Oregon Alaska

Appendix III: Medical Marijuana Registries in Oregon, Alaska, Hawaii, and
Select California Counties

Page 47 GAO- 03- 189 State Medical Marijuana Laws

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 Alaska*s Medical Marijuana Certification Card

Source: Alaska Department of Health and Social Services.

Alaska*s 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.

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 Safety*s 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 Hawaii*s
registry card. Hawaii

Appendix III: Medical Marijuana Registries in Oregon, Alaska, Hawaii, and
Select California Counties

Page 48 GAO- 03- 189 State Medical Marijuana Laws

Figure 4: Example of Hawaii*s Medical Marijuana Registry Card

Source: State of Hawaii Department of Public Safety.

Appendix III: Medical Marijuana Registries in Oregon, Alaska, Hawaii, and
Select California Counties

Page 49 GAO- 03- 189 State Medical Marijuana Laws

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 city*s Department of Public Health, where the
registry is maintained, and also from clinics, doctor*s offices and
medical cannabis organizations that have requested them. Applicants must
bring a physician*s 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 physician*s 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 Sheriff*s office
jointly run the County Pre- identification Program for county residents.
The Health Department accepts the applicant*s 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 patient*s lifetime. No
condition information is requested. After verifying the physician
recommendation, that section is destroyed, and the approved authorization
sheet is sent to the Sheriff*s office. The Sheriff*s office interviews
registrants and caregivers, requiring that they sign a declaration
California

Appendix III: Medical Marijuana Registries in Oregon, Alaska, Hawaii, and
Select California Counties

Page 50 GAO- 03- 189 State Medical Marijuana Laws

as to the caregiver*s role in patient care. Program identification cards
with photographs of patients and caregivers are issued by the Sheriff*s
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 patient*s physician is sent a determination regarding
whether the patient*s 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 sheriff*s
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.

Appendix IV: Descriptions of Allowable Conditions under State Medical
Marijuana Laws

Page 51 GAO- 03- 189 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.

Alzheimer*s Disease: Alzheimer*s 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.

Crohn*s Disease: Crohn*s 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. Appendix IV: Descriptions of
Allowable

Conditions under State Medical Marijuana Laws

Appendix IV: Descriptions of Allowable Conditions under State Medical
Marijuana Laws

Page 52 GAO- 03- 189 State Medical Marijuana Laws 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.

Appendix IV: Descriptions of Allowable Conditions under State Medical
Marijuana Laws

Page 53 GAO- 03- 189 State Medical Marijuana Laws 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.

Appendix V: Comments from the Department of Justice

Page 54 GAO- 03- 189 State Medical Marijuana Laws

Appendix V: Comments from the Department of Justice

Appendix V: Comments from the Department of Justice

Page 55 GAO- 03- 189 State Medical Marijuana Laws

Appendix V: Comments from the Department of Justice

Page 56 GAO- 03- 189 State Medical Marijuana Laws

Appendix V: Comments from the Department of Justice

Page 57 GAO- 03- 189 State Medical Marijuana Laws

Appendix V: Comments from the Department of Justice

Page 58 GAO- 03- 189 State Medical Marijuana Laws

Appendix VI: GAO Contacts and Staff Acknowledgments

Page 59 GAO- 03- 189 State Medical Marijuana Laws

Paul Jones (202) 512- 8777 John Mortin (202) 512- 8777

Tanya Cruz, Christine Davis, Francisco Enriquez, Evan Gilman, and Monica
Kelly made key contributions to this report. Appendix VI: GAO Contacts and
Staff

Acknowledgments GAO Contacts Staff Acknowledgments

(440091)

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