At first, the debate over medical marijuana in Utah played out as you might expect: The Republican governor declared the issue shouldn’t be on the ballot. Once it was, the state medical association steered the opposition. By August, a senior official in the Church of Jesus Christ of Latter-day Saints was warning that residents of some states that had legalized marijuana were seeing serious “health and safety consequences.”

But, then, something curious happened: Key opponents negotiated an agreement with the measure’s backers and other state leaders. Now, no matter what happens on Election Day, state lawmakers will be called into a special legislative session and plan to enact an alternate medical marijuana program.

Unless the pact falls apart, Utah, one of the most conservative states in the country, will join the more than 30 other states that have already sanctioned some form of medical marijuana.

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“There’s a lot of tailwind nationally pushing this issue,” said DJ Schanz, director of the Utah Patients Coalition, the group that worked to get the measure on the ballot. “A lot of states have experimented with medical cannabis and seen great results. The hysterical opposition has proven to be false.”

There remains plenty of opposition to ballot measures over medical marijuana in some quarters, including from the American Medical Association. But 22 years after California started the country’s first state-backed dispensaries, calls to make medical marijuana available to patients struggling with pain, anxiety, and other conditions have become more politically potent than ever, even in states once resistant to the idea.

Utah’s acceptance of medical marijuana comes just months after voters in Oklahoma approved their own program. In November, Missourians also could greenlight a program.

“The resistance to the concept of people being treated with marijuana for medical needs, the hesitation has certainly diminished over the last decade,” said Steve Hawkins, executive director of the Marijuana Policy Project, which advocates for liberalizing marijuana laws. “I think as Utah changes its law, it could very well impact what happens in some of the other states that have yet to pass medical marijuana. We see the wave continuing.”

In Utah, where early voting has begun, even opponents of the ballot initiative stressed empathy in their messaging. It wasn’t that they were against helping patients who wanted to try marijuana, they emphasized, but that the ballot measure lacked safeguards. It didn’t give doctors enough oversight of their patient’s care. Dispensaries would be run from a profit perspective, not like a pharmacy designed to help patients.

Such arguments did not seem to gain much traction. Polls over the months showed about two-thirds of Utahns planned to support the measure.

“What I think is going on is that there is a fairly strong sense among lots of people in Utah that there really are good medical uses for marijuana,” said Matthew Burbank, a political scientist at the University of Utah, who has done polling on the measure. They’ve heard stories of it helping people, but “they’ve been limited by the fact that if they want to use this product they have to go to Nevada or Colorado.”

For many medical groups, the core of the argument against medical marijuana is that medicine is meant to be tested for particular conditions and made available in specific formulations. As the AMA states in its policy statement, “scientifically valid and well-controlled clinical trials conducted under federal investigational new drug applications are necessary to assess the safety and effectiveness of all new drugs.”

In other words, doctors want to be able to recommend medicines based on reliable evidence that they work and an understanding of the corresponding risks — characteristics that are teased out during the long clinical process. Voters shouldn’t get to choose what constitutes a medicine.

There is evidence that marijuana can relieve pain, muscle spasms, and nausea, according to a 2017 National Academies of Sciences, Engineering, and Medicine review. But the review also described the accompanying harms of cannabis use, and some advocates imbue marijuana with the impression that it is a salve for all ailments even if there are no supporting studies.

This year, the Food and Drug Administration approved the country’s first medication made from a component of marijuana, for rare forms of epilepsy. It demonstrated that traditional medicines made from marijuana can reach the market. But many researchers say the restrictions on studying marijuana — which remains illegal under federal law, for medical reasons or any other — make the pursuit of marijuana-based pharmaceuticals too burdensome.

What’s left, then, is legal marijuana at the state level.

“We’re so into that mindset of pharmaceuticalization and Phase 1, 2, 3 and a development of a medical product,” said Dr. Donald Abrams, a professor of medicine at University of California, San Francisco, who served on the National Academies panel and prescribes medical marijuana. He said many physicians have a “narrow-minded” view of marijuana because it has not been put through the gauntlet of studies that that they expect of medications.

In Utah, with what seemed like overwhelming support for the ballot initiative, known as Proposition 2, the medical association saw the writing on the wall. So it and other opponents embarked on weeks of negotiations with state leaders and Proposition 2’s sponsors to hash out the plan for the special legislative session, which Gov. Gary Herbert announced earlier in October.

For the measure’s backers, the compromise alleviated concerns that state lawmakers might try to gut any program established through a ballot initiative.

Under the compromise bill lawmakers will consider, patients would need to have certain conditions in order to get a prescription from their physician. A state-run supplier would ship cannabis to local health departments for patients to pick up. Fewer private dispensaries will be authorized than would have been allowed under Proposition 2.

There would also be limits on the supply and on what form edibles can come in. Any marijuana flower would have to come in a blister pack like other medicines that might be picked up at the pharmacy — a step that aims to overcome concerns about unregulated supplies and inconsistent doses.

The compromise is “something we can live with,” said Mark Fotheringham, a spokesman for the state medical association. The group and its allies wanted to show voters that they could come up with a smarter policy than Prop. 2, he said, because they recognized public support for a medical marijuana program meant the state had to act in some form.

“If Prop. 2 fails and nothing happens, the issue’s not going to go away,” he said.

The two sides agreed to stop their ad campaigns, creating a sort of ceasefire. Yet original opponents of the measure still recommend that people vote no and the supporters are still encouraging yes votes, even though the end result will likely be the same. (There are some other hardcore foes of the measure who also oppose the legislative plan. They argue that legal medical marijuana is a runaround to eventually legalize recreational marijuana.)

Since the compromise was announced, support for Proposition 2 has actually dropped, with the most recent poll showing just a slight majority in favor. Pollsters said that enthusiasm for the measure declined because people who are generally supportive of medical marijuana — but who have concerns about Proposition 2 — can now feel comfortable voting against it, knowing that state officials intend to act either way.

Not all medical marijuana policies are the same, of course, and Proposition 2 is more conservative than what other states have rolled out. Daniel Mallinson, a political scientist at Penn State Harrisburg, who has studied state medical marijuana programs, said that recent adopters have been more restrictive in their approaches than those that first embraced medical marijuana.

As for whether states will continue to legalize medical marijuana, Mallinson said states that do not have ways for voters to put measures on the ballot are likely to be the holdouts. In Utah, past efforts to approve medical marijuana through the statehouse haven’t succeeded. But if lawmakers in the remaining states start to push their own efforts, he said, it will be evidence of just how mainstream medical marijuana has become.

“If you do see, like, an Alabama adopt,” Mallinson said, “that’s a bigger signal.”

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