One of the unique features of medical marijuana is that patients are able to precisely self-determine the required dose, unlike pharmaceutical preparation that are delivered in standardized doses administered through the delayed reaction of oral ingestion. Marijuana smokers and those using vaporizers are able to ingest the exact amount required for immediate relief of their symptoms. In medical terminology this is called "self-titration" for relief of symptoms "as needed".

Cannabis is known to take effect within a few minutes of inhalation, peaking in effect within about 20 minutes and beginning to diminish in effect after about 40 minutes. Residual effects may remain at work for hours after a large dose, but immediate therapeutic effects generally begin to fade after the first hour for most users. Many marijuana smokers and vaporizer users exercise a repetitive medicinal schedule for continued symptomatic relief. A few puffs per hour or so is a common regimen.

Medical marijuana is also consumed orally, especially by long-term medical users with acute chronic conditions. In that method, as with oral pharmaceutical preparations, medical effectiveness depends on digestion and the individual's relative ability to absorb the medicinal compounds through the stomach lining. In general, marijuana that is eaten takes several hours for full effectiveness, but once absorbed, cannabis compounds may remain active in the body for an entire day or night. Eating marijuana can be even more medically effective than smoking or vaporizing, but usually requires the use of much greater amounts. For some patients, the slightly different effects of eating marijuana can be too overwhelming. For others, oral ingestion may be less effective in symptomatic relief than inhalation.

Concurrent use of pharmaceutical drugs may influence the bioavailability of cannabis - some drugs can deaden the body's ability to absorb cannabis compounds, creating the need for a higher-than-average dose level. Other patients depend on medical marijuana to keep from vomiting up their oral medications, and so their need for a specific dose of cannabis compounds may fluctuate with their body's day-to-day reaction to those nauseating pharmaceutical drugs. Marijuana is commonly used to offset the overwhelming side-effects of other drugs, and so the applicable dose range can vary widely. And even discounting the effects of other medications, cannabis may be more easily absorbed by some patients than others due to fundamental differences in individual metabolisms.

Washington State law allows doctors to recommend medical marijuana under ten separate categories of illness. This variety of beneficial features reflects a broad range of dose-related applications. For some patients, a few puffs of a cannabis cigarette can restore their appetite, and they may need no more until the next meal time, or perhaps until the next chemotherapy session. Then again, for others, say a long-term Crohn's patient with severe hardening of intestinal tissues, instilling a healthy appetite may require a much larger dose. Other patients may need even more for relief of other symptoms. For example, one of the common arguments against medical marijuana in the treatment of Glaucoma is the scientific evidence that effective treatment depends on continued intermittent doses - about once every 3 or 4 hours. It is primarily because of that frequency of administration that the American Ophthalmology Association has opposed the use of medical marijuana, though many Glaucoma patients rely on cannabis to maintain their vision and halt progression of the disease. For other patients, such as those suffering from intractable pain, symptomatic relief may depend on a much larger dose level.as much as a whole marijuana cigarette or two every hour of the day. Marijuana patients are able to ingest relatively huge amounts of the herb because they develop a tolerance to the psychotropic effects.

Perhaps the important consideration in assessing amounts of marijuana required in modern usage is the tolerance factor. It has been well-established through medical research that ingestion of cannabis compounds builds a physical and mental tolerance to the psychoactive effects with repeated exposure - the more one uses medical marijuana, the less one feels "high", thereby attaining a greater dose and greater medical effectiveness over time. As noted by the National Institute on Health:

"After repeated smoked or oral marijuana doses, marked tolerance is rapidly acquired (after a day or two) to many marijuana effects, e.g., cardiovascular, autonomic, and many subjective effects. After exposure is stopped, tolerance is lost with similar rapidity (Jones et al. 1981). Measurable tolerance or tachyphalaxis is evident for some hours after smoking even a single marijuana cigarette."

Also published by the National Institute on Health:

"THC bioavailability, i.e., the actual absorbed dose as measured in blood, from smoked marijuana varies greatly among individuals. Bioavailability can range from 1 percent to 24 percent with the fraction absorbed rarely exceeding 10 percent to 20 percent of the THC in a marijuana cigarette or pipe (Agurell et al. 1986; Hollister 1988a). This relatively low and quite variable bioavailability results from significant loss of THC in sidestream smoke, from variation in individual smoking behaviors, from incomplete absorption from inhaled smoke, and from metabolism in lung and cannabinoid pyrolysis. A smoker's experience is probably an important determinant of dose actually absorbed (Herning et al. 1986; Johansson et al. 1989)." (See online at: www.nih.gov/news/medmarijuana/MedicalMarijuana.htm#EXECUTIVE)

Along with basic differences in individual metabolisms and differences in various degrees of a disease's development, there is also a marked difference in various types of marijuana. THC is one of the medicinal substances found in the resin of marijuana flowers. A handful of compounds called "cannabinoids" work together in a synergy of medicinal effects. As cannabis is one of the most diverse plant species cultivated, there are subtle differences in strains that may have distinctly divergent effects on various patients. One type might induce immediate sedation, and another might provoke temporary restlessness. Such differences in medical effectiveness of various types of marijuana can certainly change the amounts required in medical use. It is also clear that differences in strains and cultivation techniques can yield vastly different levels of potency, which again is an important variable in the range of quantities needed for various medicinal uses.

California NORML (National Association for Reform of Marijuana Laws) published the only reputable assay of medical marijuana in 1999. Those test results show the wide disparity in potency of available samples:

"The study, consisting of three rounds of testing by two different DEA-licensed laboratories, measured the concentrations of THC, the primary active ingredient of marijuana, and its two commonest chemical relatives, known as cannabinoids, CBD and CBN. In all, 49 samples of medicinal cannabis were analyzed for potency by standard gas chromatograph mass spectrometry.

The sample showing the lowest THC (less than or equal to 3.9%) was the government's own marijuana, grown for the National Institute on Drug Abuse (NIDA) to supply researchers and eight legal medical marijuana patients. Nearly all other samples tested over 8%, with averages in the range of 12.8% - 15.4%, and many samples above 20%. One sample of hashish (concentrated resin) tested above 44%."
(See: NIDA's Pot Exposes Patients to Excessive Smoke, or online at: www.canorml.org)

Legal authorities would like to have an exact and standardized dose limit to apply universally in every case. Yet the medical facts listed above indicate that such a precise understanding may never be attained. Some patients use vastly greater amounts than others, and patients often develop patterns of use that change with time due to numerous individual factors. Precise medical treatments depend on elaborate scientific observations. There has been inadequate scientific study of cannabis to firmly establish exact quantities for effective medical use at this time.

The California state legislature has arrived at this same conclusion. In the words of California's Attorney General Bill Lockyer, "Senate Bill 848 did not include 'guidelines' or 'standards' addressing the quantity of marijuana a person with a valid recommendation could possess. The issue was discussed and debated many times within the task force before the final legislative recommendations were drafted. However, the strong consensus of the task force was that the amount of marijuana a patient may possess might well depend on the type of illness, and is, in any event, ultimately a medical question more appropriately analyzed and decided by medical professionals." (See letter to Alameda County District Attorney, September 29th 2000)

Exact dose requirements for medical marijuana patients have not been established. But there are some general ranges that have been established by reputable medical and legal authorities. In Washington State, any attempt to identify the limits of a 60 day supply must recognize the amounts of use that have been established in current medical marijuana studies, as well as in government regulations and delivery systems.

Dr. Donald Abrams has conducted the first clinical trials of medical marijuana in a population of AIDS patients at San Francisco General Hospital. During the 21 day study, Abrams prescribed three joints per day - one joint before each mealtime - to the group of test subjects. Dr. Abrams determined that marijuana use does not interfere with retroviral AIDS drugs, and he also observed that medical marijuana smokers gained more weight than control groups taking either a placebo or THC pills. The marijuana cigarettes used in the study were obtained from the National Institute on Drug Abuse, and were the same as those used in the FDA's Compassionate Use IND Program.

South of San Francisco, in San Mateo County, the first State-sponsored medical marijuana trials are conducted at the Cannabis Research Center. Doctors there are also tracking the use of medical marijuana by people with AIDS. And as with the Donald Abrams study, researchers are dispensing marijuana from the US government grown in Mississippi under the direction of the Food and Drug Administration and the National Institute on Drug Abuse (NIDA). Researchers at the San Mateo center limit their subjects to 30 joints per week, or slightly more than 4 per day.

Three or four marijuana cigarettes per day, every day, might seem like a tremendous amount compared to the typical consumption of most non-medical pot smokers. However, the two reputable research teams that dispensed those amounts were careful and conservative in their prescriptions. Medical marijuana patients who receive this same marijuana from the federal government usually consume two to three times the amount allowed in current government-sanctioned studies.

The United States government's Compassionate Use Investigational New Drug Program has supplied a handful of patients with federally-grown medical marijuana for almost 3 decades. All of those patients have received 300 pre-rolled joints per month, every month, since entering the program. Patients suffering from chronic pain conditions receive 50% more than the others, or 450 joints per month. The weight of those joints equals approximately 0.9 grams each, not including the paper. 0.9 grams of cannabis multiplied 300 times equals 250 grams.more than one half-pound per month. The US government has established a medical marijuana dose range of between one half and three quarters of a pound per patient per month. (See: Chronic Cannabis Use in the Compassionate Investigational New Drug Program: An Examination of Benefits and Adverse Effects of Legal Clinical Cannabis)

Even marijuana advocates agree that the dose range established by the Compassionate Use IND Program is higher than average, which is fortunate for those patients, considering the low quality of the government-grown marijuana. The City of Oakland California pioneered patient protections soon after enactment of Proposition 215, California's Compassionate Use Act of 1996. After reviewing the dose range established by the federal government, Oakland set a similar limit of 6 pounds per year. Based upon that limit, the Oakland City Council then established a limit of allowable plants for both indoor and outdoor cultivation. However, after further review, the Oakland City Council adopted a revised limit of 3 pounds per year per patient, with a related plant-count limit for cultivation.

Sonoma County California is another leader in patient protections following the Golden State's landmark medical marijuana act. After many years of dialogue between patients and police, the Sonoma County Office of the Prosecuting Attorney adopted an upper limit identical to that of Oakland. Patients in Sonoma County are allowed to possess enough cannabis to support their personal use of up to 3 pounds per year - less than half of the lowest amount currently distributed to patients by the US government's IND Program. (See: S.A.M.M. Cultivation Guidelines and letter from D.A. Mike Mullins)

While politicians often steer clear of the heated debate on medical marijuana in the US, Canadian officials have already passed a number of national policies in support of medical cannabis patients. The Canadian department of health, Health Canada, has published dozens of pages of regulations on the use of marijuana as medicine. Among complicated equations for estimating the needs of marijuana patients, Health Canada has established a most pertinent provision: all patients are allowed to possess up to 5 grams per day - over 4 US pounds per year - with the standard medical authorization. Patients are not absolutely prohibited from possessing a larger amount, but in such a case they must ask their physician to sign an additional form indicating their greater-than-average medical requirements. (See Canadian health regulations online at: www.hc-sc.gc.ca/hecs-sesc/controlled_substances/pdf/regulations/marihuana_06-13-01.pdf)

California's medical marijuana law is less limited than Washington's. Not only are doctors able to write medical marijuana recommendations for any illness whatsoever, there is no set limit on allowable amounts. With no provisions similar to Washington's 60 day supply clause, many California communities have established local ordinances or official policies denoting allowable limits for medical marijuana patients. While CA State Attorney General has expressed his intention that marijuana laws should have uniform application throughout the state, such policies are individually defined by local jurisdictions at this time. Oakland California has been among the leaders in assessing the needs of marijuana patients and the gardens required to supply them. The following text on Oakland's Medical Cannabis Policy is taken from the 2001 City Council Resolutions:

"The Medical Marijuana Working Group met 4 times in preparation for this report. The Group reached easy consensus that a three month supply was a reasonable amount for a patient to possess. The Group wrestled with difficulty of defining what would be a reasonable amount of marijuana for a 3 month supply. The difficulty in determining this amount comes from interplay of a variety of factors. The nature of a patient's illness bears strongly on the amount of marijuana they need to relieve symptoms. Some illnesses will require daily medication. Others may only require occasional medication. The type of marijuana available to the patient is another factor. Some types are stronger than others are. Some can only be baked in other foods. That requires more marijuana than the type that can be smoked. Even within the same types of marijuana, there are qualitative differences in separate harvests." (See: Oakland City Council Public Safety Committee resolution of June 23rd 1998 and the revised resolution of July 24th 2001)

Below are the current limits set by local law enforcement officials on allowable amounts of medical marijuana possessed by qualified patients in various California communities:

Arcata
½ pound dried marijuana per patient.

Berkeley
2.5 pounds dried marijuana per patient, or up to 12.5 pounds for collective gardens.

Butte Co.
1 pound dried marijuana per patient.

Calaveras Co.
2 pounds dried marijuana per patient.

Colusa Co.
No firm policy; case by case review; has permitted 1.5 pounds processed marijuana

Del Norte Co.
County adopted Sonoma Co. guidelines, 1 pound possession limit (up to three pounds per year).

El Dorado Co.
2 pounds processed marijuana per patient - 1 ounce in vehicle

Humboldt Co.
New D.A. - apparently adopting limits similar to Sonoma Co.: 1 pound dried marijuana per patient.

Inyo Co.
Up to 1/2 pound dried marijuana.

Marin Co.
No specific weight limits - previous limit: ½ pound.

Mendocino Co.
2 pounds processed marijuana per patient.

Nevada Co.
2 pounds processed marijuana per patient.

Oakland
3 lbs dried marijuana per patient. (Revised Guidelines effective Nov. 2001).

San Diego
Up to 1 pound of marijuana.

San Francisco
No quantity limits.

Santa Cruz (city)
No quantity limits.

Shasta Co.
1.33 pounds processed marijuana

Sonoma Co.
DA's guidelines permit 3 pounds per patient per year (allowing for three 1 pound harvests per year).

Tuolumne Co.
Up to 1/2 pound of marijuana.

Ventura Co.
1 pound per patient

Yuba Co.
1.5 pound processed marijuana

(Source: CA Office of the Attorney General)

In those 19 California counties with specific limits, the average amount of marijuana allowed for possession at any one time equals 1.3 pounds (21 ounces) of dried marijuana per patient. There is no provision for any specific duration that such an amount might be used within, though some regulations cite the potential to produce three crops per year. The outside limit of all of those California regulations equals 3 pounds per year, which would total 8 ounces every 60 days.

The medical marijuana statutes of Washington State are much more specific than in California. Most areas of California offer extraordinary outdoor growing conditions, and legal limits for the medical use of marijuana are fixed accordingly. It is important to remember that comparing cannabis cultivation in The Golden State with cannabis cultivation in The Evergreen State is very much like comparing oranges and apples. Not only is the weather generally less hospitable, Washington's Medical Use of Marijuana Act specifically prohibits "public display", a provision that clearly limits medical marijuana cultivation in WA to the privacy of indoor gardens. The 60 day supply clause of Washington's medical marijuana law is another major distinction.

In Canada, an allowable 60 day supply would equal 10.7 US ounces. In the US federal medical marijuana program, a 60 day supply equals 8 to 12 ounces. In Oakland, Sonoma County, and other California communities, a 60 day supply once again equals 8 ounces - in fact, the current recommendation of the California State Medical Marijuana Taskforce, including both Attorney General Lockyer and Senator Vasconcellos, calls for an 8 ounce (dry, processed) limit for patients in that state. Similarly, in the 1996 medical necessity defense of Martin Martinez, a recommending physician testified that the use of 3.5 grams per day (about 8 ounces over a 60 day period) was reasonable in his professional medical opinion. Also, in a voluntary survey of over 200 legally qualified long-term medical marijuana patients in Western Washington conducted from 2001 through 2003, respondents reported an average usage of 15 grams per week, with the highest reported amounts at about twice that amount - one ounce per week, or about 8 ounces per 60 days.

All of the available data from credible sources recognizes that the majority of medical marijuana users consume under an outside range of about one ounce per week. While a few severely ill patients use more than one ounce per week, the far greater share definitely use less. Thus it is likely that justice will be served through a determination of allowable limits in that range of one ounce per week, or a total of 8 ounces in 60 days. Determination of a 60 day supply as a lesser amount would probably create a backlog of court cases, where the most severely ill marijuana patients would be subject to an uncompassionate and unreasonable legal system. Until realistic patient protections are enacted, expert legal defenses will continue to define these crucial precedents in the courthouses of Washington State.

Law Enforcement agencies would like to set a precise number of marijuana plants as a definition of the 60 day supply for all marijuana patients in Washington State. In fact, many other states have already fixed a certain number of plants allowable per patient. However, without a scientific basis, such designations are arbitrary, capricious, and may be subject to a legal challenge by qualified patients acting within the spirit of the statute. After years of negotiations with that county's law administration, it was the outcomes of The State of California vs. Alan McFarlane and The State of California vs. Ken Hayes that tipped the scales of justice in Sonoma, CA, north of San Francisco. In those cases local law enforcement discovered their preconception of a marijuana patient's medical needs and requisite garden size was unfounded and unenforceable when those cases were presented to a jury at trial. It is hoped that Washington State authorities will avoid such costly and unpopular mistakes in determining the policies surrounding Washington's affirmative defense.

The sole source of information on typical yield of marijuana plants is the June 1992 study published by the US Drug Enforcement Agency titled Cannabis Yields. Law enforcement policies and provisions governing marijuana cultivation in the United States are determined by that single study of outdoor marijuana plants. Albeit useful to law enforcement, the DEA study of outdoor marijuana farming has very little relation to the cultivation of medical marijuana under artificial lighting in basements or other interior environments. According to Cannabis Yields by the DEA, various types of outdoor cannabis plants under various outdoor planting conditions may yield averages of 236 grams, or about one half pound, to 846 grams, or nearly two pounds. In addition, the study notes data from outdoor marijuana eradication programs:

"The total number of cultivated outdoor cannabis plants eradicated in 1991 was 5,257,486. The number of sensemilla plants was 2,251,735, or 42.8% of the total, and the number of non-sensemilla plants was 3,005,751, or 57.2% of the total. A weighed average using the yields reported in Table 4 results in an average domestic plant yield of 448 grams, or approximately 1 pound per plant." (See study at: Cannabis Yields, June 1992, DEA)

The DEA estimates are not disputed; cannabis plants may reach as high as 16 feet tall or more under ideal outdoor conditions. But the best possible yield of indoor plants does not compare with the potential yield of outdoor plants on a one-to-one ratio. Indoor growers cannot possibly create the huge outdoor plants studied in Cannabis Yields by the DEA. Ceiling height and area limitations alone demand a completely different approach. In order to maintain a steady 60 day supply of medical marijuana, indoor cultivators must have a constant cycle of small plants in various stages of development. By current standards, Washington's most seriously ill marijuana patients are in the greatest peril of interdiction.

An in-depth understanding of indoor cannabis horticulture requires a wealth of background information too elaborate for this discussion. Therefore, the enclosed photographs are provided to illustrate the wide range of techniques available in indoor marijuana cultivation.

click to enlarge

Three mature marijuana plants are shown. Each is within a week or two of harvest.

click to enlarge

The plant on the far left is 26 inches tall, including its container. The smallest plant will be about two and a half months old and will yield approximately one half ounce of usable medicine at harvest. The center plant is 41 inches tall, including its container. The center plant will be about four months old and will yield approximately one and one half ounces of usable medicine at harvest. The large plant on the far right measures 44 inches tall, including its wider-than-average container. The large plant will be about six months old and will yield approximately four and one half ounces of usable medicine at harvest. Left to right, each plant yields three times more medicine than the last, although they were grown under similar conditions. This indicates that the largest indoor plants might yield about one quarter of the average outdoor plant yield cited by the DEA in 1991. Secondly, and certainly, indoor marijuana gardens cannot be accurately assessed purely on the basis of the number of plants in possession. Other factors are even more crucial to a bountiful yield. Washington State authorities determining allowable limits must account for a variety of horticultural methods in order to resolve the current 60 day supply dilemma and so preclude the costly litigious remedy.

Martin Martinez, medical marijuana expert

Marijuana patient Martin Martinez raised Washington.s medical necessity defense in 1996 and 1997 and helped shape and create The Medical Use of Marijuana Act of 1998. A member of The Oakland Cannabis Buyers Cooperative, Martinez, was one of thirty plaintiffs who petitioned the US Supreme Court in 1999. During that same period, he helped develop the landmark Sonoma County guidelines for marijuana patients in Northern California with the Sonoma Alliance for Medical Marijuana. Author of the most complete book of scientific research on the subject, The New Prescription - Marijuana As Medicine, (Quick American Archives, Oakland CA, 2000) and director of the popular website, CannabisMD.org, Martinez is one of this country's leading experts in cannabis therapeutics. He is a court-appointed expert witness called in many of the medical marijuana legal defenses presented in The Evergreen State.