FROM “GETTING HIGH” TO “GETTING WELL”: MEDICAL CANNABIS USE AMONG MIDLIFE PATIENTS IN COLORADO by MICHELLE RENEE NEWHART B.S., Sociology, University of Missouri at Columbia, 1995 M.A., Sociology, University of Colorado at Boulder, 2010 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirement for the degree of Doctor of Philosophy Department of Sociology 2013 This dissertation entitled: From Getting High to Getting Well: Identity and Legitimacy Issues among Midlife Medical Cannabis Patients in Colorado written by Michelle Renee Newhart has been approved for the Department of Sociology ___________________________________________ Jane Menken ___________________________________________ Amy Wilkins Date______________ The final copy of this thesis has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above mentioned discipline. IRB protocol # _11-0245_ ABSTRACT OF THE DISSERTATION From “Getting High to “Getting Well”: Medical Cannabis Use among Midlife Patients in Colorado By Michelle Renee Newhart Ph.D. in Sociology University of Colorado, Boulder 2013 Professor Jane Menken, Chair Professor Stefanie Mollborn, Co-chair As of 2012, Colorado is on the forefront of cannabis medicalization but medicalization remains incomplete. Between 2010 and 2012, Colorado created the most regulated medical marijuana program in the United States. Over 100,000 patients, 2.5% of Coloradans, are now registered as medical marijuana patients. This dissertation examines the effects of incomplete medicalization among middle-aged medical cannabis patients in the state of Colorado. It is a qualitative study based on interviews with 40 individuals aged 30-68 who each received a physician’s recommendation for medical cannabis use in Colorado. Interviews were conducted between June 2011 and November 2012. This period immediately followed the rapid influx of patients into Colorado’s system, but preceded the passage of Amendment 64, the constitutional amendment that legalizes all adult use in the state. At the federal level, cannabis use remains illegal and punishable by law. Medicalization is when a nonmedical issue comes to be defined and treated as medical. When medicalization is incomplete, the issue has not been fully integrated, institutionally or in terms of its cultural framing. Medical cannabis crosses into the formal system of biomedicine, but it straddles institutional boundaries between health care systems and their logics. Culturally, cannabis remains closely associated with recreational use and with stereotypes of its users. So long as medicalization is incomplete, claims that medical cannabis use and the medical patient identity are legitimate remain in contest with nonmedical frames. Incomplete medicalization affects all aspects of the medical cannabis patient experience. This dissertation looks at how patients navigate the medical cannabis system, including how they manage doctor-patient interactions, establish medicalized routines of use, and integrate cannabis into the management of illness. It also examines how patients make sense of the medical cannabis patient identity. Cultural identity operates in the lifeworld. By looking at patients in midlife, I consider the significance of life course timing and close network ties for medical cannabis patients in Colorado. I also consider how patients disclose illness and/or medical marijuana use to others, and how patients adopt a political position of pride to counteract stigma and stereotypes. iii ACKNOWLEDGMENTS There are many people to thank for their assistance with this dissertation. First, thanks to all the medical cannabis patients who included me in events and volunteered for interviews. I am truly humbled by the challenges that many patients face. Your stories encouraged me to rethink many ideas and I am incredibly grateful for your many generosities. I also owe special thanks to the larger medical cannabis community in Colorado, especially in Denver and Colorado Springs, who welcomed me to events, helped me network, and provided so many useful suggestions, and helped me reach patients, and generally supported my research with your interest and encouragement. I wish to thank my advisors Dr. Stefanie Mollborn and Dr. Jane Menken for their guidance and assistance with this dissertation. A special thanks to Dr. Mary Jo Neitz, my undergraduate mentor and dissertation committee member. You helped me discover sociology and encouraged me to attend graduate school in the first place. Now you have seen me through from start to finish. Thanks also to Dr. Amy Wilkins and Dr. Stefan Timmermans, who provided me with support by serving on my dissertation committee. I am also especially grateful to Todd Geoffrey Miller for making me pancakes, feeding the cats, listening to my fledgling ideas, and generally being helpful and patient. Thanks also to Mike Jerry for his transcription assistance, and Robin Madsen for her moral support. My gratitude to Ed Rosenthal and Jane Klein, who introduced me to the fascinating topic of cannabis. Finally, thanks to my mother, Cathy Newhart, who has always been my biggest fan, but has with time become one of my most trusted friends, and to my father Rick Newhart, who believed in me. I would not have made it through graduate school, or much else in life, without their encouragement, understanding, humor, and above all, love. iv CONTENTS Title Page i Signature Page ii Abstract iii Acknowledgments iv Table of Contents v List of Tables viii CHAPTERS Chapter 1: Understanding Medical Cannabis Use . 1 Aims of the Dissertation . 11 Background on Cannabis Use in the U.S. 17 Making Sense of Cannabis Policies . 29 Criminalization and Medicalization in the Twenty-First Century . 35 Normative Stance for this Project . 39 Overview of Chapters . 40 Chapter 2: Research Methods . 43 Entering the Field . 45 Focusing on Patients . 47 Recruitment and Sample Considerations . 51 Collecting Data: The Interview-based Qualitative Approach . 56 Analytical Approach . 61 The Study Sample: Colorado Patients at Midlife . 64 v Chapter 3: Literature Review . .68 Literature on Medical Marijuana Patients and Patient Programs . 68 Using Concepts from the Sociology of Health and Illness . 74 Theories about Drug Use . 82 The Relevance of Life Course Literature . 83 Literature on Stigma Management and Networks . 85 Chapter 4: Becoming a Medical Cannabis Patient in Colorado . 90 Introduction. 90 Qualifying for Medical Cannabis . 92 Deciding to Try Cannabis Medically . 96 Giving Medical Cannabis a “Test Run” . 105 Experiences with Doctors in the Recommendation Appointment . 109 Face-work in the Recommendation Setting . 124 Conclusion . 127 Chapter 5: Medical Cannabis Use in Everyday Life. 133 Interpreting Cannabis Effects . 134 Adaptations of Drug, Set, and Setting in Medical Use. 138 Changing the Set: Medical Routines of Cannabis Use . 142 Changes to Setting . 164 Life Course as Setting . 173 vi Chapter 6: Cannabis and Trends of Health, Medicine, and Pharmaceutical Intervention . 179 Defining Healthism and Pharmaceuticalization . 179 Healthism & Harms . 184 Healthism as a Pluralistic Space . 191 Cannabis, Pain, and Big Pharma . 193 Patient’s Opinions of Pharmaceuticalizing Cannabis . 202 Conclusion . 204 Chapter 7: Cannabis & Stigma . 206 Introduction . 206 Stereotypes & Stigmas . 211 Illness as Stigma . 212 Identifying with Cannabis: Practical Risks . 220 “Coming Out” for Cannabis: Stigma & Disclosing Cannabis Use . 226 Cannabis: From Shame to Pride . 228 Medical Marijuana as a “Thought Community” . 233 Shifting the Game: From Stigma to Prejudice . 238 Conclusion . 243 Chapter 8: Conclusion . 244 Summary of Findings . 244 Limitations & Recommendations for Future Research . 253 Conclusion. 256 References 259 vii TABLES Table 1: Drug Schedules……………………………………………………………………………… 31 Table 2: Patient Summary Statistics ……………………………………………………………. 67 Table 3: Patients by Year of First Doctor’s Recommendation …………………………. 95 viii CHAPTER 1: Understanding Medical Cannabis Use Karen uses medical cannabis1 for her migraines. Even though she and her husband were social users in their teens and early 20s before they started a family, that was a long time ago. Karen, a Hispanic wife and mom in her early 50s, lives in a small bedroom community outside the Boulder/Denver metro area. Her children are now the age she was when she last used cannabis. It never would have crossed Karen’s mind to try cannabis as a treatment for her migraines. It isn’t something that shows up in her world, and anyway, she would not have believed it would work, or that it was a very intelligent choice out of the available treatment options. What changed her mind? Her husband of over 30 years, Marcus, and his car accident. Back in 2000, Marcus was driving home from work. Another driver ran a stop sign and nailed the front end of his car, swinging his vehicle around until it landed on its side in a ditch. As dramatic as it sounds, the damage seemed to be mostly to the vehicles. Marcus, a healthy and athletic man, walked away from the accident, seemingly unscathed. When the ambulance arrived on the scene, he deferred medical treatment, but within days it was evident that he had suffered a serious closed head injury. Ultimately this injury was the source of a great deal of suffering: blinding headaches and unyielding back and neck pain that transformed his life completely. He was forced to