The Medicalization of Marijuana

Legitimacy, Stigma, and the Patient Experience

Michelle Newhart, William Dolphin

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429833779
• Topic: Social Sciences
• Subtopic: Global Development Studies
• Index: Social Sciences

Winner of the Donald W. Light Award for the Applied or Public Practice of Medical Sociology

Medical marijuana laws have spread across the U.S. to all but a handful of states. Yet, eighty years of social stigma and federal prohibition creates dilemmas for patients who participate in state programs.

The Medicalization of Marijuana takes the first comprehensive look at how patients negotiate incomplete medicalization and what their experiences reveal about our relationship with this controversial plant as it is incorporated into biomedicine. Is cannabis used similarly to other medicines? Drawing on interviews with midlife patients in Colorado, a state at the forefront of medical cannabis implementation, this book explores the practical decisions individuals confront about medical use, including whether cannabis will work for them; the risks of registering in a state program; and how to handle questions of supply, dosage, and routines of use.

Individual stories capture how patients redefine and reclaim cannabis use as legitimate—individually and collectively—and grapple with an inherently political identity. These experiences help illustrate how stigma, prejudice, and social change operate.

By positioning cannabis use within sociological models of medical behavior, Newhart and Dolphin provide a wide-reaching, theoretically informed analysis of the issue that expands established concepts and provides new insight on medical cannabis and how state programs work.

Chapter 1
The Social Construction of Cannabis Use

The cannabis plant’s legal and cultural status has been highly contested terrain over the last hundred years, shifting from its largely uncontroversial use as a folk medicine and natural resource at the advent of the twentieth century to its designation as a heavily criminalized drug by its end. This transition was at least in part accomplished by narrowing the definition of cannabis to equate with one use and one use only—illicit use for the “high,” a use attributed no benefits, only harms. Other traditional uses—as medicine, food, fuel, and fiber—were subsumed by the focus on its potential dangers as an addictive, mind-altering substance. Policies across all levels of government enforced this single story ¹ in ways that affected science, culture, and criminality. Mainstream culture, and in large part the social, medical, and natural sciences, adopted this singular definition. Despite intermittent protest and dissenting professional opinions, debates over cannabis were successfully and repeatedly reduced to the frame of use for nonmedical, sensation-seeking purposes, and anyone who fought to retain its historical uses or otherwise revise, expand, or reframe it to suggest benefit from this plant’s use, or even less severe harm, was characterized as illegitimate and a potential “drug user” (Ferraiolo 2007).

Not only were the uses of cannabis as a traditional medicine stripped away, but the narrowed definition of cannabis use as deviant treated all use as equivalent. In reality, cannabis is used with different frequencies and purposes, and in different contexts. Naïve use is different than experienced use, and use by the young may differ substantially from use among the middle-aged or older adults. As a society, we know how to make these distinctions and regulate accordingly. We do so already in the case of alcohol, deeming some uses acceptable and others problematic based on age, context, amount, and frequency. With “marijuana,” no such distinctions are made; all use is treated as equally problematic (Benoit 2003; Zinberg 1984). In this sense, it is not the plant but its users or potential users around which the issue centers. Over the past century, cannabis users have been routinely characterized in negative and stigmatizing ways (Ferraiolo 2007; Almanzar 2003). Framing users through a lens focused only on harm has mattered greatly for how the public perceives cannabis and its place in society (Almanzar 2003).

From Hemp Medicines to Marijuana and Moral Panic

The approach to cannabis use in the first half of the twentieth century can be characterized as a transition from indifference to moral panic. The “patent medicines” of the past centuries gave way to a professionalizing and standardizing field of medicine. It is easy to forget, now that Americans spend $200 billion a year on pharmaceuticals, that only in the twentieth century has medicine been organized around standardized drugs. The proprietary medicines of the last century were typically based on some mixture of opiates, alcohol, and cannabis, in addition to other herbs and various substances. As U.S. society migrated from agrarian life toward cities, the introduction of revolutionary technologies and theories were fundamentally changing how medicine was practiced and by whom. Medical training and medicines were heading on a path of regulation and standardization that would create modern biomedicine.

Leading up to this time, the landscape of medicine was far different. Medical education and credentials were diverse, where they existed at all, and untested proprietary medicines were widely available. Medical concoctions were unregulated and very popular. With national campaigns, “snake oil” medicines were marvels of marketing and packaging, an entrepreneurial fast track that produced what Oliver Wendell Holmes referred to as “toad-stool millionaires” (Tomes 2016). These proprietary medicines—commonly known as patent medicines—relied not on patents but on copyright and trademark law, which allowed them to protect their brand name, logo, and packaging without divulging their ingredients for others to copy (or for patients and doctors to evaluate).

As the relatively new germ theory for the transmission of illnesses gained acceptance through the middle of the nineteenth century, diagnoses based on the individual’s unique attributes, personality type, and environmental conditions gave way to a view of diseases as discrete, mechanistic, and treatable with only limited consideration of the individual characteristics of the patient. This new understanding of medical conditions was accompanied by the development of new techniques for drug manufacture. Aspirin was successfully standardized in the 1890s by a chemist at Bayer in Germany. First distributed through physicians in powder form, it only became a hit as an over-the-counter tablet in 1915 (Jeffreys 2004). Aspirin was followed by standardized drugs for syphilis, insulin treatments for diabetes, and then penicillin for infections in 1928. These “magic bullet” drugs offered targeted and highly effective treatment for some diseases when compared with what had come before. As new forms of mass-produced, standardized medications proved effective and medical professionalization began to create a new expert class of physicians, concerns increased with regard to the widespread and unchecked use of patent medicines, which could result in abuse, addiction, and toxicity causing injury or death (Bonnie and Whitebread 1999). Following Britain’s lead, U.S. lawmakers enacted food and drug laws that became the precursors to modern drug regulation (Tomes 2016).

The first anti-drug campaign was concerned with opiates. Much like alcohol and cannabis, opium and drugs derived from it have been in use for much of known human history. The addictive quality of opiates was known, and in the mid-nineteenth century, the introduction of the concentrated opiate, morphine, and the new method of using hypodermic needles led to extensive use in the treatment of soldiers suffering injuries in the Civil War. Opiate withdrawal was so associated with this application that it was nicknamed the “army disease” (Bonnie and Whitebread 1999; Conrad and Schneider 1998 [1980]). It was also possible for unsuspecting customers who used patent medicines with unknown quantities of opiates to become addicted without knowing the contents of what they were consuming. Finally, the presence of deviant, underground opium smoking and trafficking of opium racialized the drug. Opium prohibitions began in the western U.S. during the 1880s and 1890s, and were closely tied to the perception of its users as immigrant Chinese who smoked this drug for the purposes of intoxication (Bonnie and Whitebread 1999). Attitudes toward opiate addiction shifted radically in the first two decades of the twentieth century (Conrad and Schneider 1998 [1980], 121). With new laws and regulations, the chances of accidental addiction became less probable, and those who persisted in using nonmedical formulations of opiates were increasingly characterized as deviants: “dope fiends” or “street users.” As Bonnie and Whitebread (1999) point out, “what had been formerly viewed as an unfortunate sickness with organic causes was now viewed as yet another immoral behavior of the criminal class” (Bonnie and Whitebread 1999, 21). This change created problems of its own, as it gave rise to a criminal subculture with its own networks for supply (Conrad and Schneider 1998 [1980]; Bonnie and Whitebread 1999).

Opiates were categorized as narcotics, a class of drug that was medically defined based on the ability to dull a person’s senses and cause drowsiness or sleep (Bonnie and Whitebread 1999, 28). In this era, many psychoactive substances were quickly grouped into the narcotics family, including plants from the belladonna group, cannabis, and peyote. Opiates were standardized and woven into formal medicine over the first half of the century, and synthetic opioid analogs were developed mid-century, but with ongoing concerns with their addictive and toxic potential. The recent epidemic of opioid-related deaths, especially among white middle-aged males in the working class, has created a new wave of concern for their place in medicine and society. Despite these concerns, opioids form an entire class of widely used and valued pharmaceutical medicines in their proper applications. The original moral panic over opiates may be seen as a template for what happened to cannabis. Much of the rhetoric about the dangers of “marihuana” was lifted directly from propaganda of the period from the 1870s to the 1900s that propelled the first great drugs scare over opiate use (Bonnie and Whitebread 1999; Chasin 2016; Himmelstein 1983; Harrison 1988).

Moral panics typically entail an outsized emotional reaction about an issue that does not correspond to actual harm, damage, or threat suggested by the evidence. In a moral panic, there is little evidence of significant practical consequences, but the sense of moral threat leads to public sensitization, exaggeration, distortion, and stereotyping (Goode 2008). The active period of concern is usually short, but actions taken in response to moral panics can be institutional and long-lasting (Goode and Ben-Yehuda 1994).

The first half of the twentieth century included a period of moral panic over cannabis, driven largely by the yellow journalism of Hearst newspapers, leading to the plant’s criminalization in a transition that has been well documented by others (Ferraiolo 2007; London 2006; Gerber 2004; Booth 2003; Bonnie and Whitebread 1999; Goode 2008; Goode and Ben-Yehuda 1994; Himmelstein 1983; Cohen 1980). By the time the temperance movement was in full swing in the 1920s, cannabis remedies had fallen out of favor (Fox, Armentano, and Tvert 2009). Then, when Harry Anslinger was named the first chief of the newly created Federal Bureau of Narcotics (FBN) in 1930, the era of reefer madness commenced (Chasin 2016; Ferraiolo 2007). Anslinger would remain at the helm of the FBN for thirty-two...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Illustrations
• Acknowledgments
• Preface
• Marijuana, Cannabis, and Hemp: A Note on Terms
• Introduction: A Tale of Two Patients
• 1 The Social Construction of Cannabis Use
• 2 The Landscape of Cannabis Policy
• 3 Becoming a Patient
• 4 Cannabis and the Doctor–Patient Interaction
• 5 Medical Cannabis Use in Everyday Life
• 6 Changing the Set: Creating Medical Routines of Cannabis Use
• 7 The Power of Place: Changes to Setting
• 8 Stereotypes, Stigma, and Mitigating Risk
• 9 Strategies for Managing and Changing Cannabis Stigma
• 10 Beyond Medicalization: Healthism and
• Conclusion: Medicalization and the Future of Cannabis Medicine
• Appendix A: Research Methods
• Appendix B: Annotated Index of Patients by Pseudonym
• Index