Oregon retiree Ernest Alexander damaged spinal discs decades ago when a chair collapsed and he landed on his tailbone. Now he treats his chronic back pain with a homemade concoction of coconut oil and low-grade marijuana.
He tried prescription drugs, but needed large doses, he says. "I was hurting a lot of the time, and when I wasn't hurting, I was all doped up. I didn't like either.''
Alexander, 64, is not alone. Pain is the engine that drives medical marijuana.
AIDS and cancer patients may use pot for nausea. People with chronic anxiety say pot calms their nerves. Palmetto pot advocate Cathy Jordan says it has kept her alive with Lou Gehrig's disease for 27 years.
But these conditions represent only a small slice of medical pot cases. States that keep statistics show that 90 percent of patients or more list severe pain as one of their qualifying symptoms. Two thirds to three quarters list pain as their only symptom.
As Florida approaches a vote on allowing medical marijuana, pain has become a focal point for debate. A proposed constitutional amendment would allow doctors to recommend pot for debilitating conditions, including severe pain. And pain, critics worry, can be faked.
"I don't make light of pain. I know that chronic pain can be miserable,'' says Calvina Fay, executive director of St. Petersburg-based Save Our Society From Drugs. "But we also know that pain is a subjective term, and not something that can be proven. It's an easy way for a person to abuse the system'' for recreational use.
Fueling suspicion is the demographic profile of medical pot users.
Doctors' offices are often dominated by seniors, with women frequently outnumbering men. With medical pot, male patients typically outnumber females 2-1, and many are fairly young. Arizona, Oregon, Colorado and Rhode Island provided the Tampa Bay Times with age breakdowns from their 2013 or 2014 patient registries. At least half of medical pot users in those states were 50 or younger. In Colorado, half were 40 or younger.
With recreational pot users tending to be in their teens, 20s and 30s, dispensing marijuana for a pain diagnosis can lead to abuse, Pinellas Sheriff Bob Gualtieri suggested at a recent medical marijuana debate.
"This isn't about people with cancer and other conditions,'' Gualtieri said. A person "can say, 'Doc, I need a certificate because my head hurts or my neck hurts' and you will get an unlimited supply'' of pot.
Ben Pollara is campaign manager for United for Care, the group that drafted the ballot language and funded the petition drive to get medical marijuana on the November ballot in Florida.
He said medical marijuana patients tend to be younger and male for a reason: People unfamiliar with marijuana are less likely to seek it out as a treatment for illness.
"The whole concept of medical marijuana is relatively new,'' Pollara said. "The broader population has less experience with it.''
That may be changing.
Twenty-one states and the District of Columbia have now approved medical marijuana. Baby boomers, who grew up in an era when pot became more popular, are facing age-related illnesses.
A RAND study of California medical pot patients estimated that only 13 percent were 55 or older in 2005. Arizona, Oregon and Rhode Island now say nearly half their users are 50 or older.
Pollara acknowledged that allowing pain to qualify a patient for medical pot will lead to some abuse, just as people now use bogus symptoms to get opiate painkillers.
"In any large system,'' he said, "whether it is Social Security, Medicaid or medical marijuana, there are going to be some abuses.''
But he disputed the argument that the predominance of pain diagnoses in other states signal widespread fakery. Severe pain is a common symptom of many illnesses and injuries, Pollara said. "In what sense is chronic pain not a debilitating condition?''
Barth Wilsey, a pain researcher at the University of California Davis, has studied neuropathic pain, which stems from spinal cord injury, stroke and other serious conditions. About 40 to 60 percent of patients respond poorly to prescription medications, including opioid-based painkillers, antidepressants and anti-inflammatories.
Wilsey had patients smoke two kinds of pot and a placebo. The marijuana eased pain — and not just by making people mellow, Wilsey said. The placebo did not.
Some cigarettes had marijuana containing 7 percent THC, a psychoactive ingredient that created temporary mental effects, including confusion. Cigarettes with less THC offered almost as much relief with few or no mind-altering effects.
Pot smokers may build up tolerance with prolonged use, Wilsey said. Pregnant women should not use pot, nor should teens because their brains are still developing. People at risk of heart attack also shouldn't use it because it can affect heart rate, he said.
For patients who find pot useful, Wilsey said, "I am advocating that people use as low concentrations (of THC) as possible, so they don't have a problem with thinking.''
Ernest Alexander needs no convincing. He doesn't like getting high, he said.
He heats leaves, stems and seeds in a pressure cooker for 20 minutes along with coconut oil, then strains out the fiber. Those parts of the plant contain much less THC than the buds that street pot comes from.
Pot chemicals dissolve in fat, not water, so Alexander stores his concoction in the refrigerator, where the coconut oil containing the pot solidifies and separates from water. Alexander then throws out the water, reheats the oil/pot mix to a liquid and fills capsules with an eyedropper.
He takes a few capsules during the day, knowing that they may take 20 to 30 minutes to kick in, and one just before going to bed, so he can sleep.
If pain hits him unexpectedly, Alexander said, he inhales burning marijuana bud through a vaporizer and it gives him relief within seconds.
For a while, Alexander tried Marinol, a synthetic THC prescription drug. It did not work well, he said, and cost $1,200 a month, way more than marijuana, though he wouldn't say what he pays for pot.
Money is not the main point, he said.
"The pain relief is much better than with opioids,'' he said. "Given a choice of paying for pot out of pocket or growing it myself, or getting opioids for free, I'll take marijuana every day.''
Stephen Nohlgren can be reached at firstname.lastname@example.org.