©Copyright 2008 Sunil Kumar Aggarwal The Medical Geography of Cannabinoid Botanicals in Washington State: Access, Delivery, and Distress Sunil Kumar Aggarwal A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Washington 2008 Program Authorized to Offer Degree: Geography University of Washington Graduate School This is to certify that I have examined this copy of a doctoral dissertation by Sunil Kumar Aggarwal and have found that it is complete and satisfactory in all respects, and that any and all revisions required by the final examining committee have been made. Chair of the Supervisory Committee: ___________________________________________________ Jonathan Mayer Reading Committee: __________________________________________________ Jonathan Mayer _________________________________________________ Richard Morrill ___________________________________________________ Craig ZumBrunnen ___________________________________________________ Gregory Carter ___________________________________________________ Ethan Russo Date:__________________________ In presenting this dissertation in partial fulfillment of the requirements for the doctoral degree at the University of Washington, I agree that the Library shall make its copies freely available for inspection. I further agree that extensive copying of the dissertation is allowable only for scholarly purposes, consistent with “fair use” as prescribed in the U.S. Copyright Law. Requests for copying or reproduction of this dissertation may be referred to ProQuest Information and Learning, 300 North Zeeb Road, Ann Arbor, MI 48106-1346, 1-800-521-0600, to whom the author has granted “the right to reproduce and sell (a) copies of the manuscript in microform and/or (b) printed copies of the manuscript made from microform.” Signature________________________ Date____________________________ University of Washington Abstract The Medical Geography of Cannabinoid Botanicals in Washington State: Access, Delivery, and Distress Sunil Kumar Aggarwal Chair of the Supervisory Committee: Professor Jonathan Mayer Geography Though rendered dormant by a post-1937 Cannabis sativa L. prohibition, the emerging field of cannabinoid medicine is growing in the United States as ever greater numbers of physicians become educated about the physiologic importance of the endogenous cannabinoid system and about the wide safety margins and broad clinical efficacies of cannabinoid drugs, available in both purely botanical and purely chemical varieties and useful for managing pain and other conditions in the growing chronically and critically ill patient population. Research presented here is focused on medical access and delivery of cannabinoid botanicals in Washington State and seeks to map the geography of this developing cannabinoid medical care system by taking medical geographic “snapshots” of two purposefully chosen locations: a rural clinic site in Washington State where patients currently access cannabinoid botanicals for medical use in the treatment of chronic pain syndromes with acceptable safety under medical supervision and another site where qualifying patients are delivered environmentally- culled cannabinoid botanicals. At the former site, retrospective chart reviews were conducted with 139 patients with chronic pain, and at the latter site, a convenience sample of 37 qualifying patients delivered a monoclonal lot of cannabinoid botanical medicine were prospectively studied using standard and tailored survey instruments. A political ecology of disease approach was employed to rationalize and depathologize patients’ mental distress at potentially facing possession-related legal problems due to their consumption of the still-contraband biota. Results provide quantitative and qualitative insight into the frail health status in both samples of qualifying patients and give a grounded understanding of the lengths that patients and care providers go, despite multiple hurdles, to access and deliver treatment with cannabinoid botanicals that relieves patients’ diverse symptoms and improves their health-related quality-of- life. TABLE OF CONTENTS Page List of Figures................................................................................................................. iii List of Tables ...................................................................................................................iv Introduction: Medical Geography and the Phenomenon of Hempen Cannabinergy........1 References for Introduction ................................................................................20 The Medical Geography of Cannabinoid Botanicals in Washington State I: Characteristics of Patients with Chronic Pain Accessing Treatment at a Rural Clinic.....................................................................................................................25 Introduction to Cannabinoid Medicine in the US...............................................25 Contesting Cannabinoid Botanical Medicines....................................................31 Authorizing the Medical Use of Cannabinoid Botanicals in Washington State................................................................................................36 Study Design and Procedures .............................................................................40 Results.................................................................................................................44 Conclusion ..........................................................................................................49 References for I...................................................................................................56 The Medical Geography of Cannabinoid Botanicals in Washington State II: Subjective Health Status of Qualifying Patients Delivered a Clonal Lot of Maturated Germplasm ....................................................................................................67 Introduction........................................................................................................67 Contesting Cannabinoid Botanical Medicines and the Human-Environment Relationship .......................................................................................................69 Study Background .............................................................................................76 Study Design......................................................................................................81 Study Procedures ...............................................................................................83 Complementary and Alternative Cannabinoid Botanical Medicines Community Clinic Characteristics.....................................................................85 Subjective Health Status in a Convenience Sample of Qualifying Patients......88 Prospective Health Data from Returned Take-Home Materials........................95 Cost of Keeping a Lot of Cannabinoid Botanical Medicine Stocked and Deliverable.........................................................................................................96 Discussion..........................................................................................................97 Conclusion .......................................................................................................100 References for II ..............................................................................................130 The Medical Geography of Cannabinoid Botanicals in Washington State III: Contraband Psychoactive Biota Consumption and the Political Ecology of Mental Distress at Facing Possession-Related Legal Problems ...................................141 Tracing the Roots of a Critical Political Ecology of Disease ..........................141 Psychoactive Biotic Substances and the Political Ecology of Mental Distress ................................................................................................145 Substance-Related Disorders Diagnostics and Possession-Related Legal Problems ..........................................................................................................152 i Banning Biota and Sowing the Seeds of Distress............................................159 Asserting the Human Right to Health..............................................................166 Therapeutic Cannabis Users’ Mental Distress at Facing Possession-Related Legal Problems: a Local Case Study...............................................................168 Discussion........................................................................................................180 Conclusion .......................................................................................................185 References for III.............................................................................................195 Conclusion: Pain Relief on Pain of Death—When Worldviews Collide .....................205 References for Conclusion...............................................................................209 Bibliography .................................................................................................................211 Appendix A: Chart Review Data..................................................................................273 Appendix B: Interview Script and Survey Instruments................................................302 Appendix C: Consent Form..........................................................................................357