Contract No: ADHS12-017291

Report to Arizona
Department of Health
Services: First Annual
Medical Marijuana
Report A.R.S. §36-2809

November 8, 2012

Health and Wellness for all Arizonans
Janice K. Brewer, Governor
State of Arizona
Will Humble, Director
Arizona Department of Health Services

MISSION
To promote, protect, and improve the health and wellness of individuals and communities in Arizona.
Prepared by:
Arizona Department of Health Services
Bureau of Public Health Statistics
&
University of Arizona
Mel & Enid Zuckerman
College of Public Health
714 E. Van Buren Street
Campus PO Box: 245105
Phoenix, AZ 85004
http://www.azdhs.gov/medicalmarijuana/
Acknowledgements: The Arizona Department of Health Services acknowledges the contribution of the
University of Arizona and comments on this report. The University of Arizona acknowledges ADHS for
providing information related to the Medical Marijuana Program.
This publication can be made available in alternative format. Please contact the Arizona Department of
Health Services at (602) 542-1025.
Permission to quote from or reproduce materials from this publication is granted if the source is
acknowledged.

Table of Contents
Page
Executive Summary ..........................................................................................................

1

1. Introduction .................................................................................................................

2

1.1 Arizona Medical Marijuana Timeline and Passage of Proposition .....................

2

1.2 Overview of the Arizona Medical Marijuana Program Requirements ................

3

1.3 Comparison of Arizona’s Medical Marijuana Act with Other States and
Districts ................................................................................................................

11

2. Methodology ..............................................................................................................

15

2.1 Data Sources .........................................................................................................

15

2.2 Measures ..............................................................................................................

15

2.3 Analytic Procedures ..............................................................................................

16

3. Results ........................................................................................................................

17

3.1 Characteristics of Qualifying Patients and Designated Caregivers ......................

19

3.2 Nature of the Debilitating Medical Conditions of the Qualifying Patients ..........

21

3.3 Registry Identification Card(s) Revoked ..............................................................

25

3.4 Characteristics of Physicians Providing Written Certifications............................

26

3.5 Registered Non-Profit Medical Marijuana Dispensaries ......................................

30

3.6 Non-Profit Medical Marijuana Dispensary Agents ..............................................

30

4. Discussion and Recommendations .............................................................................

31

Appendices
A. Arizona Medical Marijuana Program Revenue and Expenditures .............................

33

B. Arizona Medical Marijuana Program Governing Documents ....................................

34

C. Random Selection Protocol for Dispensaries .............................................................

36

D. Independent Accountant’s Report on Applying Agreed-Upon Procedures ...............

40

End Notes .........................................................................................................................

43

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List of Tables
Page
1. Arizona Medical Marijuana voting results by county ................................................

2

2. Summary of U.S. states and districts with medical marijuana legislation ..................

11

3. Comparison of qualifying conditions among states and districts with medical
marijuana legislation ...................................................................................................

14

4. Demographic characteristics of qualifying patients and caregivers ..........................

19

5. Arizona medical marijuana qualifying patients, designated caregivers and their
cultivation status by county of residence ....................................................................

21

6. Reported debilitating medical conditions by qualifying patients of medical
marijuana.....................................................................................................................

22

7. Debilitating medical conditions for qualifying patients who are minors ....................

24

8. Notification of clinical studies for by qualifying patient’s age, gender, and
debilitating medical conditions ...................................................................................

25

9. Characteristics of physician certifications by type/specialization ..............................

27

10. Twenty-four most frequent recommending physicians of medical marijuana ...........

29

11. Debilitating medical conditions by recommending physician type ............................

30

Page | iii

List of Figures
Page
1. Arizona Medical Marijuana qualifying patient monthly applications of active
cardholders from April 2011 through June 2012 ........................................................

17

2. Arizona Medical Marijuana designated caregivers monthly applications of active
cardholders from April 2011 through June 2012 ........................................................

18

3. Arizona Medical Marijuana qualifying patients’ and caregivers’ cultivation status
by gender .....................................................................................................................

20

4. Debilitating medical conditions by age of the qualifying patient ...............................

23

5. Debilitating medical conditions by gender of the qualifying patient ..........................

23

6. Most frequent recommending physicians by licensing board ....................................

28

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Executive Summary
As required by Arizona Revised Statues (A.R.S.) §36-2809, the Arizona Department of Health
Services (ADHS) is submitting this first annual comprehensive statistical report for the Arizona
Medical Marijuana Program from April 2011 to June 2012. The report was prepared by ADHS
in conjunction with the University of Arizona, Mel & Enid Zuckerman College of Public Health.
In November 2010, Arizona voters passed a ballot initiative making Arizona the fourteenth state
to adopt a medical marijuana law. Of the 16 states and District of Columbia that have enacted
medical marijuana programs prior to June 1, 2012, nine have been by ballot initiatives similar to
Arizona and eight have been through legislative means not requiring voter approval.
Despite being given a short timeline to develop the program, ADHS posted draft rules about a
month after the initiative's passage, sought public input on the initial rules, posted revised draft
rules based on comments received, and acquired additional comments during four public hearing
sessions. The final rules were published on March 28, 2011, and the Arizona Medical Marijuana
Program went into effect on April 14, 2011. ADHS’ goal throughout the process was to ensure
the development and administration of the pre-eminent program in the country for medical use of
marijuana.
For a patient to be eligible to receive a Registry Identification Card, the Arizona law requires that
the patient first obtain a medical recommendation from a physician who attests that the patient
meets specified medical criteria. This report refers to this recommendation as a “certification” of
a “qualifying patient.”
During April 2011 to June 2012, ADHS received a total of 41,476 applications and approved
approximately 98% of the applications (40,463). Out of the 40,463 approved applications,
33,060 (82%) were new applications and 3,689 (9%) were application for renewals. There were a
total of 29,804 active cardholders, which included 28,977 qualifying patients and 827 caregivers.
Of the total qualifying patients, approximately 26% (n = 7,702) were female qualifying patients
and of the total caregivers, 20% (n = 168) were female caregivers. During April 2011 to June
2012 slightly over 80% (n = 24,191) of the qualifying patients and caregivers (n = 701) were
authorized to cultivate. Qualifying patients per 1,000 residents were highest in Gila County (9.2),
followed by Yavapai (8.7) and Coconino (8.4), while Yuma (0.9), Santa Cruz (1.6), and Apache
(1.9) had the lowest qualifying patients per 1,000 residents.
The majority of the qualifying patients (n = 22,357; 77%) had one debilitating medical condition
with the remaining 23% reporting two or more conditions. Approximately 70% of the qualifying
patients (n = 19,631) indicated “severe and chronic pain” as the only debilitating medical
condition. Four-hundred seventy-five physicians provided certifications to 28,977 patients during
this time period (a median value of two certifications per physician; however, 10 physicians
certified 13,336 [~46%] of all patients).
From April 2011 through June 2012, one qualifying patient and six designated caregiver Registry
Identification Cards were revoked. During this time period, no dispensary agent cards were
issued, and no dispensaries were approved to operate.
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Introduction
1.1

Arizona Medical Marijuana Timeline and Passage of Proposition

As shown in Table 1, in November 2010, voters passed the Arizona Medical Marijuana Act
(AMMA). The citizen initiative (Proposition 203) required the Arizona Department of Health
Services (ADHS) to create a medical marijuana program within 120 days from the certification
date of official election results. The goal was to create the first truly medical marijuana program
in the country.1 Staff from across the Department joined together to create a plan. The
challenging undertaking included Information Technology systems for applications, reporting,
and validating. Staff combed through the rules in other states to help write the Arizona rules for
how the program would work, how Arizona residents could apply for the different types of
licenses, when they could apply, and how to add new debilitating diseases, among other
important elements. Even though the initiative allowed ADHS to avoid the normal rulemaking
process, staff asked twice for written public comment and held four public hearings to gather
public input. On December 17, 2010, ADHS posted the medical marijuana informal draft rules
for public comment and received comments via an online survey during the comment period
from December 17, 2010 to January 7, 2011.1 On January 31, 2011, ADHS posted the official
medical marijuana draft rules for public comment, and received comments via an online survey
during the comment period from January 31 to February 18, 2011. ADHS also received
comments at four public meetings held during February 14 to 17, 2011.1
Table 1. Arizona Medical Marijuana voting results by county
County
Apache
Cochise
Coconino
Gila
Graham
Greenlee
La Paz
Maricopa
Mohave
Navajo
Pima
Pinal
Santa Cruz
Yavapai
Yuma
Total

Proposition 203 (Arizona Medical Marijuana)
Yes
No
Total
Count
Percent Counts
Percent
6,816
36.8%
11,726
63.2%
18,542
18,466
46.8%
20,979
53.2%
39,445
20,625
53.7%
17,761
46.3%
38,386
7,800
44.9%
9,554
55.1%
17,354
2,926
33.1%
5,906
66.9%
8,832
1,101
46.9%
1,248
53.1%
2,349
2,023
46.6%
2,319
53.4%
4,342
480,564
49.8% 484,591
50.2%
965,155
25,779
49.3%
26,526
50.7%
52,305
9,918
35.1%
18,328
64.9%
28,246
174,591
57.1% 131,017
42.9%
305,608
36,942
48.7%
38,928
51.3%
75,870
4,840
51.5%
4,560
48.5%
9,400
35,839
44.9%
44,066
55.1%
79,905
13,118
40.2%
19,499
59.8%
32,617
841,348
50.1% 837,008
49.9%
1,678,356

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1.2

Overview of the Arizona Medical Marijuana Program Requirements

Licensing Authority
The AMMA designates ADHS as the licensing authority for the Arizona Medical Marijuana
Program. Along with developing the rules and administrative components for the program,
ADHS is responsible for issuing Registry Identification Cards for qualifying patients (QPs),
designated caregivers (CGs), and dispensary agents (DAs) and for selecting, registering, and
providing oversight for nonprofit medical marijuana dispensaries. See Appendix B for reference
to the Arizona Administrative Code (A.A.C.) and specific time frames for components of the
program.1
Qualifying Patient Applications for Registry Identification Cards
Qualifying patients (QP) began applying for Registry Identification Cards on April 14, 2011. For
a QP to be eligible to legally possess and purchase marijuana for medical use under Arizona law,
they must possess a Registry Identification Card. To obtain a Registry Identification Card, a QP
must submit to ADHS an application for a Registry Identification Card in the ADHS online
application system. Applicants must provide:
•
•
•
•
•
•
•
•
•

Personal demographic information
Designated CG information (if the applicant is designating a CG)
The certifying physician’s information
An attestation pledging not to divert marijuana and that the information submitted is true
and correct
An identification document (Arizona Driver’s License, Arizona Identification Card,
Arizona Registry Identification Card, U.S. Passport Page)
A current photograph
Physician Certification
Documentation for Supplemental Nutrition Assistance Program (SNAP) (if claiming
SNAP eligible)
The application fee

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Additionally, the QP must answer whether s/he is requesting authorization for cultivating
marijuana plants for medical use. Qualifying patients may be authorized to cultivate if they live
at least 25 miles from the nearest operating dispensary. Registry Identification Cards expire each
year, and the QP must be re-evaluated by a physician and submit applications (including fees)
yearly.
Debilitating Medical Conditions
Debilitating medical conditions for use of medical marijuana in Arizona are the following:
cancer, glaucoma, HIV, AIDS, Hepatitis C, Amyotrophic Lateral Sclerosis, Crohn’s disease,
agitation of Alzheimer’s disease, or a chronic or debilitating disease or medical condition (or the
treatment of such a condition) that causes cachexia or wasting syndrome, severe and chronic
pain, severe nausea, seizures (including those characteristic of epilepsy), severe or persistent
muscle spasms (including those characteristic of multiple sclerosis), or a debilitating medical
condition or treatment approved by ADHS under A.R.S. §36-2801.01 and A.A.C. R9-17-106.
Pursuant to A.A.C. R9-17-106, ADHS accepts petitions to add
a debilitating medical condition to the list of debilitating
medical conditions for the Medical Marijuana Program in
January and July of each year. In January 2012, ADHS
reviewed several conditions from petitions received including
Post Traumatic Stress Disorder (PTSD), Depression,
Migraines, and Generalized Anxiety Disorder. ADHS held a
public hearing on May 25, 2012 to collect public comments on
these medical conditions. After consideration of the evidence
submitted and the public hearing, ADHS rejected these
petitions to add new qualifying conditions to the list of
debilitating medical conditions. In July 2012, ADHS again
accepted petitions but no conditions moved forward to a public
hearing. ADHS will next accept petitions in January 2013.
To assist ADHS in the decision-making process of adding debilitating medical conditions, the
University of Arizona’s College of Public Health completed an evidence review on each of the
four debilitating medical conditions submitted for consideration: PTSD, migraines, anxiety, and
depression. These reports are posted on the ADHS website and were presented to the ADHS
Medical Committee prior to their submission to the ADHS Director for his consideration. The
University also established a system of surveillance for new studies on these four topics so that
any new evidence will be located monthly and placed into a data bank. Additionally, they have
begun three new evidence reports: two on safety issues including cyclical vomiting and
psychosis and one on effectiveness of medical marijuana on wound healing.
Page | 4

Physicians
As part of the application for a Registry Identification Card as a QP, an individual must have a
written certification from a physician making or confirming diagnosis of the debilitating medical
condition(s). Certifying physicians may be:
•
•
•
•

a doctor of medicine (Allopath) who holds a valid and existing license to practice
medicine, pursuant to Title 32, Chapter 13 or its successor
a doctor of osteopathic medicine who holds a valid and existing license to practice
osteopathic medicine pursuant to Title 32, Chapter 17 or its successor
a naturopathic physician who holds a valid and existing license to practice naturopathic
medicine pursuant to Title 32, Chapter 14 or its successor
a homeopathic physician who holds a valid and existing license to practice homeopathic
medicine pursuant to Title 32, Chapter 29 or its successor

The certifying physician must document on the physician certification form that s/he has
performed the following for each QP:
•
•
•

•

•
•
•

Has made or confirmed a diagnosis of a debilitating
medical condition
The physician must attest, by
Has established and is maintaining a medical record for
signature, that it is the
the QP
physician’s professional
Has conducted an in-person physical exam within the
opinion that the qualifying
last 90 calendar days appropriate to the QP’s presenting
patient is likely to receive
symptoms and the debilitating medical condition
therapeutic or palliative
diagnoses or confirmed
benefit from the patient’s
Has reviewed the QP’s medical records including those
medical use of marijuana.
from other treating physicians for the previous 12
months
Has reviewed the QP’s profile on the Arizona Board of Pharmacy Controlled Substances
Prescription Monitoring Program database
Has explained the potential risks and benefits of the medical use of marijuana
Whether s/he has referred the QP to a dispensary (this has not been applicable since there
were no operating dispensaries during this report period)

The physician must also attest, by signature, that it is the physician’s professional opinion that
the QP is likely to receive therapeutic or palliative benefit from the patient’s medical use of
marijuana.
Clinical Trials
When QPs apply for a Registry Identification Card, they may ask to be notified of any available
clinical trials. Every quarter, ADHS sends an email to those individuals who have selected to
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receive this information. The email refers the QP to the United States National Institutes of
Health (NIH) website for clinical trials (www.clinicaltrials.gov). NIH has developed a
searchable online site to facilitate distribution of information on clinical trials. The database is
searchable by disease or condition or by intervention (such as cannabis use) or other factors such
as the physical location of the study. Additionally, the University of Arizona has provided a list
of available clinical trials which is posted on the ADHS website.
Minor Patients
Minor patients (younger than 18 years of age) can qualify for the Arizona Medical Marijuana
Program. However, minor patient requirements include two physician certifications during the
application process. Additionally, the minor patient’s custodial parent or legal guardian must be
designated as the minor patient’s designated caregiver (CG). This CG provides parental consent
to the minor patient’s use of medical marijuana and controls the dosage, acquisition and
frequency of use.
Designated Caregiver Applications for Registry Identification Cards
Designated caregivers (CGs) must also hold Registry Identification Cards for each QP who has
designated them as a CG. In Arizona, CGs, who must be at least 21 years of age, are limited to
serving no more than five QPs. The CG can cultivate, if authorized to do so by his or her QPs,
up to 12 marijuana plants per patient.
Similar to QP applications, an individual being designated as a CG by a QP must provide
personal demographic information, an identification document, and a current photograph. The
CG must also provide the application number from the patient s/he is linking with and complete
a signed statement agreeing to assist the QP with the medical use of marijuana, pledging not to
divert marijuana to any person who is not allowed to possess marijuana, and stating that the
individual has not been convicted of an excluded felony offense. The CG must also submit two
original sets of fingerprints to ADHS to complete the application. If the CG is found to have had
an excluded felony offense on his or her criminal history, ADHS will seek to revoke the
designated CG’s card(s).
Registration Fees
The fees are listed in the A.A.C. R9-17-102 and include:
•
•
•
•
•

$150 for an initial or a renewal Registry Identification Card for a QP. QPs may be
eligible to pay $75 for initial and renewal cards if they currently participate in SNAP.
$200 for an initial or a renewal Registry Identification Card for a CG for each QP (up to
five patients).
$500 for an initial or a renewal Registry Identification Card for a DA.
$5,000 for an initial dispensary registration certificate.
$1,000 for a renewal dispensary registration certificate.
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•
•

$2,500 to change the location of a dispensary or cultivation facility.
$10 to amend, change, or replace a Registry Identification Card.

Non-Profit Medical Marijuana Dispensaries
Non-profit medical marijuana dispensaries (dispensaries) are
entities that acquire, possess, cultivate, manufacture, deliver,
transfer, transport, supply, sell, and dispense medical marijuana.
For the first year, legal action delayed the dispensary
application and registration process in Arizona. The Arizona
Medical Marijuana Act and the supporting Administrative Code
delineates the process and regulations for medical marijuana
dispensary certification, policies, medical director
responsibilities and functions, DA registration, and other
restrictions and precautions.

Non-profit medical marijuana
dispensaries (dispensaries) are
entities that acquire, possess,
cultivate, manufacture, deliver,
transfer, transport, supply, sell,
and dispense medical
marijuana.

ADHS may not issue more than one dispensary registration certificate for every ten licensed
pharmacies in Arizona, except if necessary to ensure ADHS issues at least one dispensary
registration certificate in each county. In 2011, the maximum number of potential dispensaries
in Arizona was 126.
From May 14 through May 25, 2012, ADHS accepted applications for non-profit medical
marijuana dispensaries. Four hundred eighty-six applications were received. Applicants were
required to submit an application including components such as policies and procedures, a
business plan, zoning compliance and property ownership documentation, and an application fee.
Additional evaluation criteria were also accepted and included whether any individual who had a
20% or more interest in the dispensary was not the applicant or principal officer or board
member of the dispensary and whether the applicant submitted proof of possessing $150,000 to
begin operating.
For the first year of the initial allocation process (2012), dispensary registration certificates were
issued based on one dispensary per Community Health Analysis Area (CHAA). If there was
more than one dispensary registration certificate application for a CHAA that was complete and
in compliance, ADHS issued dispensary registration certificates using a random selection
process. ADHS held a lottery on August 7, 2012, and a total of 98 registration certificates were
allocated through this process. The lottery process was shown live via streaming video through
the ADHS website. ADHS utilized an outside auditing firm to oversee the lottery process.
Appendix C describes the Medical Marijuana Dispensary Application Drawing Procedures.
After the conclusion of the drawing, the outside auditing firm also provided a review of how
ADHS applied these operating procedures (Appendix D, Independent Accountant’s Report on
Applying Agreed-Upon Procedures).

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Prior to opening, dispensaries that received dispensary registration certificates are required to
submit an application to operate at least 60 days before the expiration date of the certificate
(August 7, 2013). Additionally, Approval to Operate (ATO) applications submitted to ADHS
must include elements such as site plans, floor plans, conditional use permits, special use
permits, or certificates of occupancy. The dispensary must also receive an inspection during
which ADHS will verify, among other requirements, the inventory control system, security,
systems to establish, maintain, and ensure confidentiality of QP records, authorized personnel
verification, product labeling and analysis, and cleanliness and sanitation.
The second annual report will cover appropriate dispensary information once dispensaries in
Arizona are operational.
Non-Profit Medical Marijuana Dispensary Agents
Non-Profit Medical Marijuana Dispensary Agents (DAs) are principal officers, board members,
employees or volunteers of non-profit medical marijuana dispensaries, and must be at least 21
years of age. Dispensary Agents perform many functions including:
•
•
•
•
•
•
•
•

Dispensing medical marijuana
Verifying QP and CG Registry Identification Cards before dispensing
Maintaining QP records
Maintaining an inventory control system
Ensuring that medical marijuana has the required product labeling and analysis
Providing required security
Ensuring that edible food products sold or dispensed are prepared only as permitted
Maintaining the dispensary and cultivation site in a clean and sanitary condition

DAs, similar to CGs, cannot have been convicted of an excluded felony offense. ADHS collects
two original sets of fingerprints and processes the fingerprints to determine if the individual has
an excluded felony offense. A DA is required to be registered with ADHS before volunteering
or working at a dispensary. Dispensaries must apply for a Registry Identification Card for each
DA.
During the time period for which the data have been analyzed provided in this report (April 14,
2011 through June 15, 2012), there were zero DA Registry Identification Cards issued.
Appendix A provides an overview of the revenue and expenditures since the program’s inception
in April 14, 2011 until June 30, 2012.
Program Project Contracts and Interagency Service Agreements
Since the program’s inception, ADHS has partnered with external agencies, private firms, and
institutions to assist in program development and execution. Below is a summary of some of the
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major work projects associated with the initial development and continued implementation of the
medical marijuana program.
•

•

•

•

•

An Invitation for Bid (IFB) was conducted in 2011 to secure Medical Marijuana
Registration Cards, Supplies and Equipment. The Contract issued subsequent to the IFB
was for the purchase of pre-printed card stock, color printers, holographic image laminate
overlay, software to integrate with the ADHS ITS database, technical support, equipment
maintenance, training and printer supplies. The Contract was awarded to Electronic
Security Concepts on March 21, 2011. It is valid through March 20, 2014, and has two
one-year extensions available. To date, ADHS has spent $152,860.65.
In preparation for the August 7, 2012
dispensary lottery process, three Atomic
Table Top Bingo Blowers (one for testing,
one for use at the Dispensary Drawing and
one backup) and 15 sets of bingo balls were
purchased for $4,279 with the Procurement
Office Purchasing Card. Internet research
was conducted to find a certified machine
that would randomly dispense lottery-type
balls for the 126 CHAAs and that was also
cost effective. Some of the larger freestanding machines cost up to $10,000 each.
In preparation for the August 7, 2012 dispensary lottery process, Chain-of-Custody
Evidence Bags were purchased using the Finance Office for Public Health Prevention
Purchasing Card. The bags cost $99. Procurement provided the research and
quotes. These 15” by 20” clear, tamper-proof evidence bags were used to seal the groups
of balls for each CHAA drawing and the non-awarded balls were sealed back into a new
bag by CHAA number. The Automatic Table Top Bingo Blowers and sealed evidence
bags were kept under lock and key in the Office of Procurement at ADHS.
A Purchase Order under State Contract SCC060006-2 with Henry & Horne, CPA was
established for $10,159. The CPA firm provided two individuals to assist with
development and review of the dispensary random selection process, establishment of
secure bags of balls for each CHAA drawing, attendance at the Medical Marijuana
Dispensary drawing to ensure that the written procedures were followed, and provision of
a final Management Report of the entire process.
An Interagency Service Agreement (ISA), ADHS12-017291, for Research and
Evaluation Services was executed with the University of Arizona College of Public
Health on February 12, 2012 for five years. The intent of the ISA is to provide agencywide services, but currently the focus is on medical marijuana. The University assists
with review of clinical trials, review and evaluation of requests to add new debilitating
medical conditions, preparation of Continuing Medical Education curriculum for
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•

•

physicians related to medical marijuana, and review and evaluation of medical marijuana
data and preparation of the Annual Report. The value of the medical marijuana portion
of the ISA is $200,000.
An ISA, HS352036, with the Arizona Board of Pharmacy was executed on September 21,
2012 for five years (if funding is available). The ISA funds upgrading of the Controlled
Substances Prescription Monitoring Program database to improve physicians’ ability to
register online and check the patient’s profile on the database. The funds allow for one
(1) Full-time Equivalent (FTE) Pharmacist to manage data and provide research, analysis,
ad hoc queries and expanded reporting, including necessary office equipment. The
current amount encumbered is $284,325.00.
An ISA, ADHS13-028141, with The Center for Toxicology and Pharmacology Education
and Research (CTPER) was sent to the University of Arizona this October for review and
input. This ISA is still pending. The intent is to provide a collaborative venue between
the Poison and Drug Information Centers at the University of Arizona (Contractor)
College of Pharmacy and Banner Good Samaritan Medical Center in Phoenix. The
objective of the ISA is a multi-organizational collaborative center of excellence to
provide expertise, education and research in the areas of medical toxicology,
pharmacology, and medication safety utilizing the 24-hour access of specially trained
healthcare professionals to provide medication and patient safety information to the
licensed users and dispensers in Arizona. The current projected budget is $900,000 per
year.

Arizona Medical Marijuana Program Outside Counsel and Lawsuits
The majority of the medical marijuana program’s legal matters are handled by the Arizona
Attorney General’s Office (AGO). However, in order to avoid the potential of overtaxing the
limited resources of ADHS and AGO, in August 2012,
ADHS made a request for the appointment of outside
counsel. The appointment was requested to allow outside
counsel to assist ADHS with the numerous medical
marijuana-related administrative appeals and lawsuits, as
well as possibly represent ADHS in informal settlement
conferences, administrative hearings and court
proceedings. Therefore, in late August 2012, through the AGO, the law firm Sherman &
Howard, L.L.C. was appointed as outside counsel to ADHS.
Several lawsuits have been filed concerning the implementation of the Arizona Medical
Marijuana Act. A scanned copy of the complaint for each lawsuit is available on the ADHS
website. As of the date of this Annual Report, the current lawsuits include:
•
•

Johanna Dispensaries v. ADHS: LC2012-000544
Charise Voss Arfa v. ADHS: CV2012-014816
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•
•
•
•
•
•
•
•
1.3

Arizona Organix v. ADHS: CV2012-054733
White Mountain Health Center v. ADHS: CV2012-053585
Serenity v. ADHS: LC2011-000410
Elements v. ADHS: CV2011-011288
Compassion First v. Arizona: CV2011-011290
Sobol v. Arizona: CV2011-053246
Arizona v. 2811: CV2011-014508
Arizona v. USA: 11-01072
Comparisons of Arizona's Medical Marijuana Act with Other States and Districts

Arizona was the fourteenth state to pass medical marijuana legislation. Currently, sixteen other
states and the District of Columbia (DC) have adopted legislation.3 Since the 1970's, numerous
cases of marijuana possession and use for medicinal purposes proceeded through the courts with
varying outcomes.2 In 1996 with a 56% majority vote on a ballot initiative, California was the
first state to pass legislation allowing for medical use of marijuana. At this time, an additional
twelve states have legislation that has been introduced or proposals in process.2 A summary is
provided in Table 2.
Table 2. Summary of U.S. States and districts with medical marijuana legislation3-7
Year
1996
1998

1999
2000
2003
2004
2006
2007
2008

Passage Margin
56%
AK - 58%
DC - 69%
NV - 65%
OR - 56%
WA - 59%
ME - Legislature
Co - 54%
HI - HI Legislature
Legislature
MT - 62%
VT - VT
Legislature
RI - RI Legislature
NM - NM
Legislature
62%

State Passing Medical Marijuana Legislation
California
Alaska; District of Columbia - intervention by Congress -law did not
go into effect until July 2010; Nevada - legislation additions in 20006;
Oregon; Washington
Maine – affirmative defense legislation broadened by public law in
20094
Colorado; Hawaii
Delaware - limited affirmative defense legislation broadened in 2011
Montana - additional restrictions added in 2011; Vermont
Rhode Island7
New Mexico5
Michigan

Page | 11

Year
2009

Passage Margin
61%

State Passing Medical Marijuana Legislation
Maine – passed public medicinal use legislation, fully clarified and
implemented program in 20104
Arizona; New Jersey

AZ - 50.1%
NJ - NJ Legislature
DE - DE Senate
2011
Delaware, cards to be issued in 2012; dispensaries in 2013; Maryland
MD - MD General
affirmative defense legislation
Assembly
CO – Initiative
2012
Colorado – Legalization not limited to medical usage
Passed, margin
TBD
Connecticut (6/1/12)2
CT - Senate bill
WA – Initiative
Washington – Legalization not limited to medical usage
Passed, margin
TBD
States with proposed Medical Marijuana Legislation as of 8/22/122:
Arkansas; Illinois; Massachusetts; Missouri; New York; Ohio; Pennsylvania
States with Medical Marijuana Legislation that failed in 20122:
Alabama; Idaho; Indiana; Iowa; Kansas; Maryland (currently affirmative defense only); Mississippi;
New Hampshire; Oklahoma; Tennessee; West Virginia; Wisconsin
2010

Within the sixteen states and District of Columbia with legislation, the acts are variable,
including primary issues such as the entity that oversees the programs, use of patient or CG
identification cards, physician and/or CG oversight, cultivation and dispensary limitations,
qualifying conditions for use, and protection limits and access.3 The legislation passed in
Maryland does not set up a medical marijuana program per se, but provides an affirmative
defense and potential sentencing mitigation for possession. Maryland also does not require a
physician's certification. Within the legislation passed in California, physicians can recommend
marijuana use for any condition. In all other jurisdictions with legislation, physicians must
certify patients for medical marijuana use for one or more of a set list of qualifying conditions.3
All states with the exceptions of Maryland and Washington utilize or are creating a system to
issue identification cards for medical marijuana QPs and CGs, if appropriate. For patients in
California and Maine, identification cards are optional.3 The administrative entity that has the
authority to issue identification cards varies among the states. For the majority of states, a
Department of Health entity is the authority. However, for Hawaii and Vermont, it is the
Department of Public Safety, and for Michigan it is the Department of Licensing and Regulatory
Affairs.3
Physicians play an important role in either recommending the medical use of marijuana or
certifying that a patient has one or more of the serious conditions or symptoms specified in the
legislation/initiative to qualify for its use in every state except Maryland (affirmative defense
legislation only). An affirmative defense in such a situation would allow someone charged with
Page | 12

criminal possession/use of marijuana to present evidence of
medical qualifications to avoid conviction.2 In California,
physicians can recommend medical marijuana for one or
more of several listed conditions and "...any other illness for
which marijuana provides relief."

Physicians play an important
role in either recommending
the medical use of marijuana
or certifying that a patient has

one or more of the serious
Additional legislation in the states and District of Columbia
conditions or symptoms
specify requirements for minor (under 18 years of age)
specified in the legislation to
patients. In Washington, the parent or legal guardian is
responsible for a minor patient. In Alaska, Oregon, Maine,
qualify for its use….
Hawaii, Nevada, Rhode Island, New Mexico, New Jersey,
and the District of Columbia, the minor only qualifies with
parent/legal guardian consent and if the adult controls the dosage, acquisition and frequency of
use.3 In Vermont, the minor patient must have a parent or guardian also sign the application.
Arizona is similar to Colorado, Montana, and Michigan in requiring the minor to have two
physician authorizations along with parental consent.1-3 Additionally, the adult must control the
dosage, acquisition and frequency of use. In Delaware, all medical marijuana patients must be 18
years of age or older. As Maryland does not currently have a medical marijuana program per se,
the potential for legal medicinal marijuana use among minors is unclear.

On November 6, 2012, Colorado and Washington passed by voter initiative legalization of
marijuana not limited to medical usage. Final vote counts were not yet available at the time of
this publication.
Debilitating and qualifying conditions also vary among states and the District of Columbia that
have enacted medical marijuana programs. Table 3 on the following page provides a summary of
qualifying debilitating conditions by state/District. As of November 6, 2012, no condition is
required to qualify an individual to consume marijuana in Colorado and Washington, and
therefore, these states were removed from this table.

Page | 13

Table 3. Comparison of qualifying conditions among states and districts with medical marijuana legislation2-7
Condition
AIDS
ALS
Alzheimer’s
Cancer
Cachexia
Chronic/intractable /Severe Pain
Cirrhosis
Crohn's
Epilepsy
Glaucoma
Hepatitis C
HIV
Hospice admittance / terminal ill
Inflammatory bowel disease
Migraine
MS
Muscle spasms
Nail patella
Nausea
Peripheral neuropathy
PTSD
Seizures
Spasticity / Spinal cord damage
Treatment w/ AZT, chemo,
protease inhibitors, or radiotherapy
Intractable vomiting
Other: Doctor states

AK AZ CA DE DC HI ME MD MI MO NV NJ NM OR RI VT
X
X
X
X
X
X
X
X
X
X
X X X
X
X
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X
X
X
X
X
X X X
X
X
X
X
X
X
X
X
X X X
X
X
X
X
X
X
X
X
X
X
X X X
X
X
X
X
X
X

X

X
X
X

X

X
X

X
X
X

X

X
X

X
X
X

X

X

X
X
X

X

X

X
X
X

X

X
X

X
X
X

X

X

X

X

X

X
X

X

X
X

X

X

X

X
X
X

X

X
X

X

X
X
X

X

X
X
X

X
X

X

X

X
X

X

X

X

X

X
X

X

X
X

X
X
X

X
X
Page | 14

Methodology
Data on all cardholders (i.e., QPs and CGs) are collected via a secure electronic web-based
application system. The information collected by ADHS for purposes of administering the
program is confidential by statute (A.R.S. §36-2810), exempt from public records requests under
A.R.S. Title 39, Chapter 1, Article 2, exempt from requirements for sharing with federal agencies
under A.R.S. §36-105, and not subject to disclosure to any individual or public or private entity,
except as necessary for authorized employees of ADHS to perform official duties of the
department.
2.1

Data Sources

The data for this annual report are derived from the information collected via an electronic webbased system for QPs and CGs. A de-identified dataset for the period starting April 14, 2011 to
June 15, 2012 was provided by ADHS to the University of Arizona. The de-identified dataset
contained information for all active cardholders during this time period. This de-identified
dataset contained 29,804 records that included both QPs (n = 28,977) and CGs (n = 827) and
information relevant to their application as required by A.R.S. §36-2809 for preparation of the
annual report.
2.2

Measures

The measures reported here were pre-populated by ADHS to ensure confidentiality and mostly
relate to the QPs’ and CGs’ characteristics:
•
•
•
•
•
•
•
•

•
•
•
•

Gender of the QP and CG;
Age in years for QPs and CGs (<18, 18-30, 31-40, 41-50, 51-60, 61-70, 71-80, and 81+);
County of residence;
Authorized to cultivate or cultivation status of a QP;
Application type (new, renewal);
Card status (active, revoked, date of issue, date of expiration);
Entity type (i.e. QP, QP minor, CG, CG minor);
Debilitating medical conditions (i.e. Alzheimer, Cancer, Glaucoma, HIV/AIDS, HEPC,
Sclerosis, Crohn’s Disease, Cachexia, Severe and Chronic Pain, Nausea, Seizures,
Muscle Spasms and other specific conditions);
Clinical trial status;
SNAP eligibility;
Homelessness status; and
Physician specialization

Most of the measures in this report comprise of simple frequencies (counts) and percentages.
However, where appropriate, measures of center and spread (i.e. averages, standard deviation,
Page | 15

median, and inter-quartile ranges) are included along with rates. ADHS analyzed data on
physicians due to confidentiality considerations, and the analysis has been included in this report
to satisfy the requirements of the annual report.
During this time period, no dispensary was authorized by ADHS to operate, and hence, the report
does not discuss this in detail.
2.3

Analytic Procedures

Where applicable both univariate and bivariate statistics are presented. Rates and chi-square
tests were estimated using SAS v9.2 2008 software. Population denominators for 2011 were
obtained from ADHS vital statistics8. ADHS estimated ‘physician certification rates’ based on
data obtained from the Arizona Medical Board, Arizona Board of Naturopathic Medicine, and
Arizona Board of Homeopathic Medicine for all active licenses as of May 2012. The
denominator is comprised of all qualified physician certifiers of medical marijuana as defined in
A.R.S. §36-2801(12). As of May 2012, there were a total of 25,664 physician certifiers in the
four categories: Doctor of Medicine (MD; n = 22,111), Doctor of Osteopathic Medicine (DO; n
= 2,594), Doctor of Naturopathic Medicine (NMD; n = 1,765), and Doctor of Homeopathic
Medicine (HMD; n = 84). Physician certification rates were estimated using actual number of
physicians providing certifications for qualifying medical marijuana patients (i.e. numerator)
divided by the total number of physicians in the population that could provide a certification in
that specific category or specialization.

Page | 16

Results
Cumulative reports posted by ADHS for all QP applications received from April 14, 2011 to
June 30, 2012 were based on applications alone. During this period, a total of 41,476
applications were received and approximately 98% of the applications (40,463) were approved.
Out of the 40,463 approved applications, 33,060 (82%) were new applications and 3,689 (9%)
were applications for renewals. Along with QP and CG initial and renewal applications, any
change in primary information or status (such as designating/changing a CG or requesting a
change in authorization to cultivate) requires submission of an application. A key difference in
the numbers of applications received versus the number of active cardholders is the fact that an
individual can have more than one application while cardholders are typically individuals and
usually counted once in the system.
The results discussed in this report provide an overview of the active cardholders from April
2011 to June 2012. During this time period, there were a total of 29,804 active cardholders that
included both QPs (n = 28,977) and CGs (n = 827). Figure 1 below and Figure 2 on the
following page provide an overview of the monthly applications of active cardholders during the
April 2011 through June 2012 time period.
Figure 1. Arizona Medical Marijuana QP monthly applications of active cardholders from April
2011 through June 2012
Arizona Medical Marijuana monthly counts of Qualifying Patients April 2011 to June 2012
6000

# of Qualified Patients (QPS)

5000

4831

3965

4000
3466

3000

2680
2276
2024

1979
2000

1902
1613

1429

1419

1393

Nov-11

Dec-11

1000

0
Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Note: April 2011 and May 2011 counts were combined into June 2011 and June 2012 counts was combined into May 2012 to
preserve scalability.

Page | 17

It is evident from Figure 1 that there has been an increase in the number of cardholders for QPs
from December of 2011 until April of 2012 (~184%). The same increasing pattern is evident for
designated CGs (see Figure 2). The number of cardholders increased monthly by approximately
78% from December 2011 until April of 2012. It is important to note that a CG can have up to
five QPs, and further, an individual can be a QP and/or a CG. Hence, they may be counted as a
QP and a CG. Because the CG status can change with time, to estimate a ‘true count’ of the
number of individuals who are both CGs and QPs is difficult. One estimate from ADHS suggests
that at any given time there are 500 individuals who are both QPs as well as CGs.
Figure 2. Arizona Medical Marijuana designated caregiver monthly applications of active
cardholders during April 2011 to June 2012
Arizona Medical Marijuana monthly counts of Designated Caregivers during April 2011 to June 2012
160
138

140

120
# of Designated Caregivers

107
97

100

80
65

63

60

59

55

62

60
54

42
40
25
20

0
Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Note: Counts for June 2012 were combined with May 2012 to preserve scalability.

The following sections detail the characteristics of QPs, CGs, and certifying physicians.

Page | 18

3.1

Characteristics of Qualifying Patients and Designated Caregivers

The Arizona Medical Marijuana Program collects a variety of patient data at the time of
application that includes date of birth, gender, county of address, debilitating conditions, and
details of recommending physician as per AMMA requirements. Table 4 outlines the
demographic characteristics of QPs and CGs by age and gender. Twenty-six percent of the QPs
were females (n = 7,702) and 20% of the CGs were females (n = 168) while a majority of the
QPs and CGs were males. On average, females were more likely to be older compared to males,
irrespective of whether they were a QP and/or a CG.
Table 4. Demographic characteristics of qualifying patients and caregivers

Age groups

Qualifying Patients
(N = 28,977)

Caregivers
(N = 827)

Female
Males
Female
Male
<18 years
2 (0.0%)
18 (0.1%)
NA
NA
18-30 years
1,492 (19.4%) 6,186 (29.1%)
32 (19.0%)
186 (28.2%)
31-40 years
1,383 (18.0%) 4,728 (22.2%)
34 (20.2%)
195 (29.6%)
41-50 years
1,624 (21.1%) 3,616 (17.0%)
40 (23.8%)
120 (18.2%)
51-60 years
2,117 (27.5%) 4,033 (17.0%)
44 (26.2%)
104 (15.8%)
61-70 years
893 (11.6%) 2,350 (11.0%)
15 (8.9%)
50 (7.6%)
71-80 years
151 (2.0%)
301 (1.4%)
3 (1.8%)
4 (0.6%)
81+ years
40 (0.5%)
43 (0.2%)
0
0
State Totals
7,702 (26.6%) 21,275 (73.4%)
168 (20.3%)
659 (79.7%)
Mean (SD )*
45.4 (14.1 )
41.5 (14.7 )
44.2 (12.5 )
39.9 (12.5 )
Note: An individual can be both a qualifying patient and a designated caregiver
*Average age of qualifying patients and caregivers was significantly higher for females
compared to males.

Approximately, 16% of the QPs (n = 4,689) applied under SNAP eligibility for a reduced fee for
a card during this time period. Of those who were SNAP eligible, the majority (n = 2,916 or
62%) were males.
Figure 3 on the following page gives an overview of the cultivation status by gender for QPs and
designated CGs. The AMMA does not stipulate the place of cultivation for a QP and/or a
designated CG, and therefore, one cannot infer that an individual cardholder actually cultivates
marijuana in the same place as his or her residence. From April 2011 to June 2012, slightly over
80% (n = 24,191) of the QPs and CGs (n = 701) were authorized to cultivate. Males were more
likely than females to receive authorization to cultivate marijuana, irrespective of whether they
were a patient and/or a CG.

Page | 19

Figure 3. Arizona Medical Marijuana qualifying patients’ and designated caregivers’
cultivation status by gender

Table 5 on the following page provides an overview of QPs and CGs by county of residence
along with their cultivation status. Expressing the number of medical marijuana QPs as a
proportion of the population in the county is a more appropriate reflection of the prevalence of
cardholders than a simple proportion. For instance, while Maricopa County had the largest
percent of QPs (n = 18,001; ~62%), followed by Pima County (n = 3,480; 12%), they are not
reflective of the total population. As per ADHS estimates, the estimated population for Maricopa
County in 2011 was 3,843,370.8 Maricopa County had 4.7 QPs per 1000 residents, and Pima
County had 3.5 QPs per 1000 residents, compared to the state average of 4.5 per 1000 residents.
Per capita QPs was highest in Gila County (9.2 per 1000 residents), followed by Yavapai (8.7
per 1000 residents), and Coconino (8.4 per 1000 residents), while Yuma (0.9 per 1000 residents),
Santa Cruz (1.6 per 1000 residents), and Apache (1.9 per 1000 residents) had the lowest rates
among the counties.
The same was true for cultivation status with Gila County (8.3 per 1000 residents), followed by
Yavapai (7.6 per 1000 residents), and Coconino (6.9 per 1000 residents).

Page | 20

Table 5. Arizona medical marijuana qualifying patients, designated caregivers and their
cultivation status by county of residence8
Qualifying Patients (QPs)
Caregivers
Estimated
QPs per
Caregivers
Residence County Population in
Counts Percent 1000 Counts Percent per 1000
2011
residents
residents
Apache
Cochise
Coconino
Gila
Graham
Greenlee
La Paz
Maricopa
Mohave
Navajo
Pima
Pinal
Santa Cruz
Yavapai
Yuma
Unknown
State Totals

3.2

71,991
130,537
134,162
53,577
37,710
8,380
20,730
3,843,370
200,417
107,226
986,081
384,231
48,088
211,247
200,431
6,438,178

138
344
1,124
494
113
43
95
18,001
1,393
446
3,480
1,012
77
1,842
190
185
28,977

0.5%
1.2%
3.9%
1.7%
0.4%
0.1%
0.3%
62.1%
4.8%
1.5%
12.0%
3.5%
0.3%
6.4%
0.7%
0.6%
100

1.92
2.64
8.38
9.22
3.00
5.13
4.58
4.68
6.95
4.16
3.53
2.63
1.60
8.72
0.95
4.47

0
7
28
7
3
1
2
600
14
6
73
29
5
48
2
2
827

0.0%
0.8%
3.4%
0.8%
0.4%
0.1%
0.2%
72.6%
1.7%
0.7%
8.8%
3.5%
0.6%
5.8%
0.2%
0.2%
100

0.0
0.1
0.2
0.1
0.1
0.1
0.1
0.2
0.1
0.1
0.1
0.1
0.1
0.2
0.0
0.12

Authorized to cultivate
Counts

Cultivation
Percent status per 1000
residents

131
293
927
445
96
39
90
14,760
1,306
414
2,871
856
58
1,594
170
141
24,191

94.9%
85.2%
82.5%
90.1%
85.0%
90.7%
94.7%
82.0%
93.8%
92.8%
82.5%
84.6%
75.3%
86.5%
89.5%
76.2%
83.5%

1.82
2.24
6.91
8.31
2.55
4.65
4.34
3.84
6.52
3.86
2.91
2.23
1.21
7.55
0.85
3.76

Nature of Debilitating Medical Conditions among Qualifying Patients

As per AMMA requirements, ADHS collects information about 13 debilitating medical
conditions: (i) cancer; (ii) Hepatitis C; (iii) cachexia; (iv) seizures; (v) glaucoma; (vi) sclerosis;
(vii) Alzheimers; (viii) severe and chronic pain; (ix) muscle spasms; (x) HIV; (xi) AIDS; (xii)
Crohn's disease; and (xiii) nausea. Certifying physicians can select more than one of these 13
conditions. Table 6 on the following page provides an overview of the unique debilitating
medical conditions of the QPs during this time period.
From April 2011 to June 2012, a majority of the QPs (n = 22,357; 77%) had one qualifying
debilitating medical condition, followed by approximately 19% (n = 5,379) having two
conditions, and approximately 4% (n = 1,241) having three or more conditions. By way of
comparison, 67.7% of the QPs (n = 19,631) indicated “severe and chronic pain” as the only
debilitating medical condition while other top unique debilitating medical conditions included
Hepatitis C (n = 605; 2.1%), Cancer (n = 467; 1.6%), muscle spasms (n = 420; 1.4%), and
nausea (n = 389; 1.3%). Among those who indicated multiple conditions, the majority of the QPs
had at least two of the listed debilitating conditions, with severe and chronic pain as one of those
two conditions.
Page | 21

Table 6. Reported debilitating medical conditions by qualifying patients of medical marijuana
Qualifying Patients
Count
Percent
Unique conditions†
22,357
77.20%
Cancer
467
1.6%
Hepatitis C
605
2.1%
Cachexia
34
0.1%
Seizures
233
0.8%
Glaucoma
272
0.9%
Sclerosis
7
0.0%
Alzheimers
9
0.0%
Severe and chronic pain
19,631
67.7%
Muscle Spasms
420
1.4%
HIV/AIDS
148
0.5%
Crohn's Disease
142
0.5%
Nausea
389
1.3%
Multiple conditions‡
6,620
22.8%
Two conditions
5,379
18.6%
Three conditions
1,090
3.8%
Four conditions
131
0.5%
Five conditions
19
0.1%
Six conditions
1
0.0%
State Totals
28,977
100%
†
Conditions are unique as in, of the 28,977 qualifying patients 467 indicated cancer as the
only debilitating medical condition.
‡
Multiple conditions are two or more conditions specified by a qualified patient as in, of the
28,977 qualifying patients 6,620 indicated having at least two or more of the listed
debilitating conditions.
Nature of Debilitating Conditions

With regards to debilitating medical conditions, age and gender play a significant role, and the
following paragraphs detail the nature of debilitating conditions for QPs from April 2011 to June
2012 time periods. For purpose of brevity, debilitating medical conditions were classified in two
broad categories: a) unique; and b) two or more conditions. This type of classification allowed
examining any association between age and gender with one or more debilitating condition.
Figure 4 and Figure 5 on the following page display the debilitating medical conditions of the
QPs by age and gender. Qualifying patients who indicated only one unique debilitating medical
condition were more likely to be younger (average age 42 + 14.6 years). Seventy eight percent of
the males indicated one unique debilitating condition compared to 74% of females, while 26% of
females indicated having two or more debilitating conditions compared to 22% of males. In
general, females were 26% more likely than males to indicate two or more debilitating
conditions, and the difference was statistically significant with χ2 = 57.99 (1) p < 0.001.

Page | 22

Figure 4. Debilitating medical conditions by age of the qualifying patient
Debilitating Medical Conditions of Qualifying Patients by Age
One condition
(n = 22,357)

Two or more conditions
(n = 6,620)

100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
27.7%
20.0%

22.4%

21.5%

24.2%
19.8%

17.7%

19.4%

20.4%

10.0%
0.0%

10.9% 12.1%
0.1% 0.1%
<18 yrs
(n = 20)

18-30 yrs
(n = 7,678)

31-40 yrs
(n = 6,111)

41-50 yrs
(n = 5,240)

51-60 yrs
(n = 6,150)

61-70 yrs
(n = 3,243)

1.5% 1.8%

0.3% 0.3%

71-80 yrs
(n = 452)

81+ yrs
(n = 83)

Figure 5. Debilitating medical conditions by gender of the qualifying patient
Debilitating Medical Conditions of Qualifying Patients by Gender
Females
(n = 7,702)

Males
(n = 21,275)

100.0%
90.0%
80.0%
78.3%
70.0%

74.0%

60.0%
50.0%
40.0%
30.0%
26.0%

20.0%

21.7%

10.0%
0.0%
One debilitating condition
(n = 22,357)

Two or more debilitating conditions
(n = 6,620)

Page | 23

Table 7 gives an overview of debilitating medical conditions for QPs less than 18 years of age in
order of frequency. In 50% of the cases (n = 10) “any debilitating medical condition that results
in severe and chronic pain” was listed as a unique debilitating condition, followed by 25% (n =
5) of the cases with two or more debilitating conditions, followed by 10% (n = 2) indicating
nausea.
Table 7. Debilitating medical conditions for qualifying patients who are minors
Minor Qualifying Patients
(<18 years)
Nature of Debilitating Condition
Count
Percent
Unique conditions†
15
75.0%
Cancer
1
5.0%
Hepatitis C
0
0.0%
Cachexia
0
0.0%
Seizures
0
0.0%
Glaucoma
0
0.0%
Sclerosis
0
0.0%
Alzheimers
0
0.0%
Severe and chronic pain
10
50.0%
Muscle Spasms
1
5.0%
HIV/AIDS
0
0.0%
Crohn's Disease
1
5.0%
Nausea
2
10.0%
Multiple conditions‡
5
25.0%
State Totals
20
100%
†
Conditions are unique as in, of the 20 minor qualifying patients 10 indicated "severe and
chronic pain" as the only debilitating medical condition.
‡
Multiple conditions are two or more conditions specified by a qualified patient as in, of the
20 qualifying patients 5 indicated having at least two of the listed debilitating conditions.

The AMMA allows (see A.R.S. §36-2804.02(B)) individual QPs to be notified of any clinical
studies on voluntary basis. During April 2011 to June 2012, out of the 28,977 QPs, 10,172
(~35%) QPs requested to be notified of clinical studies. Table 8 provides an overview of the
notifications of clinical studies by QP’s age, gender, and debilitating conditions. There were two
important findings concerning QP’s selection of notification for clinical studies. First, females
were 11% more likely than males to request clinical study notifications, and this difference was
statistically significant χ2 = 15.28 (1) p < 0.001. Second, QPs with two or more conditions were
20% more likely than those with one unique debilitating medical condition to request clinical
study notifications, and this difference was statistically significant χ2 = 69.38 (1) p < 0.001. This
finding was consistent with the earlier finding on gender differences in debilitating conditions
among QPs that suggested that females were more likely than males to report two or more
debilitating conditions and hence, the ‘propensity’ to request clinical study notifications was
higher among females than males.
Page | 24

Table 8. Notification of clinical studies by qualifying patient’s age, gender, and debilitating
medical conditions

Qualifying patient characteristics

Clinical study notification
Yes
No
(n = 10,172)
(n = 18,805)
Count
Percent
Count
Percent

Age (in years)
<18 yrs
18-30 yrs
31-40 yrs
41-50 yrs
51-60 yrs
61-70 yrs
71-80 yrs
81+ yrs

5
2,488
2,106
1,928
2,272
1,178
164
31

0.0%
24.5%
20.7%
19.0%
22.3%
11.6%
1.6%
0.3%

15
5190
4005
3312
3878
2065
288
52

0.1%
27.6%
21.3%
17.6%
20.6%
11.0%
1.5%
0.3%

Gender†
Females
2,844
28.0%
4,858
25.8%
Males
7,328
72.0%
13,947
74.2%
Debilitating conditions‡
Unique condition
7,564
74.4%
14,793
78.7%
Two or more conditions
2,608
25.6%
4,012
21.3%
†
Statistically significant difference between females and males. Females more likely than
males to elect for for clinical study notifications.
‡
Statistically significant difference between qualifying patients with only one unique
condition compared to those with two or more. QPs with two or more were more likely than
those with only one condition to elect for clinical study notifications.

3.3

Registry Identification Card(s) Revoked

17,902

During the time period of other data reflected in this report, one Qualifying Patient Registry
Identification Card was revoked and six Designated Caregiver Registry Identification Cards were
revoked (for two total designated CGs who were issued more than one card).
There are several types of revocations for Registry Identification Cards.
•

•

•

Designated Caregiver Revocations (Excluded Felony Offenses) – ADHS will seek a
revocation when a designated CG has been found to have an excluded felony offense and
is thus prohibited by statute to be a CG under the AMMA.
Law Enforcement Revocations – A revocation may be sought when ADHS receives
information from a law enforcement entity that a cardholder has violated a provision(s)
under the AMMA.
Credit Card Dispute Revocations – A revocation may be sought when an applicant has
disputed the credit card charge for the application fee. ADHS may seek to revoke the
card (once the funds have been returned to the credit card company).
Page | 25

3.4

Characteristics of Physicians Providing Written Certifications

Table 9 on the following page provides an overview of the total
number of medical marijuana certifications during April 2011
to June 2012. The total certifications in the table reflect the
total number of patients certified by each physician type. Fourhundred seventy five (n = 475) physicians certified 28,977
patients during this time period with an overall average of 61
patients per physician. A closer examination of Table 9
indicates that 80 NMDs certified 18,057 patients during this
time period with an average certification of 226 patients per
NMD, while 332 MDs certified 8,574 patients with an average
of 26 certifications per MD during the same time period.
Similarly, 61 DOs certified 2,329 patients with an average certification of 38.2 per DO, and two
HMDs certified 17 patients with an average of 8.5 per HMD.
It is evident from Table 9 that the distribution is heavily skewed towards a select few categories
of physicians. Sixty-two percent of the patient certifications (18,057 / 28,977) were issued by
NMDs, followed by approximately 30% (8,574 / 28,977) by MDs; although, MDs accounted for
almost 70% (332 / 475) of the total physician certifiers.
To evaluate the most frequent physician certifiers of patients, a 95th percentile was used as a cutoff. Because only two HMDs completed a total of 17 patient certifications they were excluded
from the analysis. Based on this criterion, the “24 most frequent physician certifiers” were
identified and are displayed in Table 8. For instance, six MDs certified 5,279 patients accounting
to approximately 61% of the total patient certifications in the MD category, while 17 NMDs
accounted for 14,128 patient certifications accounting to approximately 78% of the total patient
certifications in the NMD category. One DO accounted for 1,749 patient certifications
accounting for 75% of the total patient certifications in the DO category. In total, 24 physicians
certified over 21,000 patients that accounted for almost 75% of the total patient certifications.

Page | 26

Table 9. Characteristics of physician certifications by type/specialization

Type of Physician Certifier

Doctor of Medicine (MD)
Doctor of Naturopathic Medicine (NMD)
Doctor of Osteopathic Medicine (DO)
Doctor of Homeopathic Medicine (HMD)
Overall State Totals

Medical Marijuana certifications during April 2011 to June 2012
Total number of
Rate*
Counts of Total number of Average
eligible
(Certifiers per
physician certifications by number of
physician
1000
†
‡
§
certifiers
physician type certifications certifiers in the
physicians)
¶
State
332
8,574
25.8
22,111
15.0
80
18,057
225.7
1,765
45.3
61
2,329
38.2
2,594
23.5
2
17
8.5
84
23.8
475
28,977
61.0
24,789
19.2

24 most frequent certifiers of Medical Marijuana
Counts of most
Number of
frequent
certifications by
physician
physician type
certifiers
6
17
1
NA
24

5,279
14,128
1,749
NA
21,156

Percent of total
φ

certifications
61.6
78.2
75.1
NA
73.0

†

Counts are unique by type of physician certifiers and are identified using license number.

‡

Total number of physician certifications for patients during April 2011 and June 2012. For example 332 MDs certified 8,574 patients and 80 NMDs certified 18,057 patients.

§

Average number of certifications is total number of certifications in each category divided by the unique count of physicians in that category (i.e. 8,574/332 = 25.83). On average each
MD certified by 26 patients.

¶

Data for total number of physicians is periodically obtained from Arizona Medical Board, Arizona Board of Naturopathic Medicine, Arizona Board of Homeopathic Medicine. The total
numbers reflect data available as of May 2012 of active licensees.
*Rates are calculated as the unique count of physicians who provided certifications to medical marijuana patients divided by total number of eligible physicians in that category (for
example, 332/22,111 = 15.02) per 1000.

φ

Percent of total certifications reflects the total number of certifications by most frequent physician certifiers divided by total number of physician certifications completed during the timeperiod. For example, four MDs accounted for 61% of the total certifications in the MD category (i.e. 5,279/8,574).

Page | 27

Figure 6 below displays the most frequent physician certifiers by type to further illustrate the
point made in Table 9.
Figure 6. Most frequent recommending physicians by licensing board
Arizona Medical Marijuana Patient Certifications by Physician Type during April 2011 to June 2012
Least frequent
(n = 451 Physician Certifiers)

Most Frequent
(n = 24 Physician Certifiers)

20,000
18,057
18,000
17 NMDs

# of Patient Certifications

16,000

14,000

12,000
14,128
10,000
8,574
8,000

6,000

6 MDs
5,279

4,000
2,329
2,000

3,295

3,929

0
MD

NMD

1,749

1 DO

580

17

DO

HMD

Table 10 on the following page lists the most frequent recommending physicians in order of
number of certifications from April 2011 to June 2012. On a bi-annual basis, ADHS conducts an
analysis of the most frequent physician certifiers and works with the Arizona Board of Pharmacy
to assess whether these certifying physicians have been accessing the controlled substances
database. Based on the recommendations from the Arizona Board of Pharmacy, each Arizona
physician licensing board is notified of any discrepancies and possible further action. Since the
program’s inception in April 2011, ADHS has referred 11 physicians to the respective physician
licensing boards for this issue.

Page | 28

Table 10. Twenty-four most frequent recommending physicians of medical marijuana

#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

24 Most Frequent Certifiers of Medical Marijuana
Percent within
Physician type
Patients certified
most frequent
NMD
2,557
12.1%
DO
1,749
8.3%
NMD
1,561
7.4%
MD
1,286
6.1%
NMD
1,225
5.8%
MD
1,079
5.1%
MD
1,077
5.1%
NMD
1,068
5.0%
MD
882
4.2%
NMD
852
4.0%
NMD
754
3.6%
NMD
720
3.4%
NMD
668
3.2%
NMD
668
3.2%
NMD
665
3.1%
NMD
592
2.8%
NMD
572
2.7%
MD
515
2.4%
NMD
504
2.4%
NMD
474
2.2%
MD
440
2.1%
NMD
436
2.1%
NMD
433
2.0%
NMD
379
1.8%

Total Certifications§
21,156
100%
§
These certifications account to 73 percent of all the certifications during April 2011 to
June 2012.

Table 11 on the following page provides an overview of the physician recommendations for
different debilitating medical conditions. The counts exclude HMDs due to small sample size. As
noted earlier, severe and chronic pain is consistently the highest reported debilitating medical
condition irrespective of the physician type. However, approximately 78% of the DOs (n =
1,809) recommended severe and chronic pain as a unique debilitating medical condition
compared to MDs (~66%) and NMDs (~67%). Both MDs (~26%) and NMDs (~23%)
recommended two or more debilitating medical conditions, while only 14% of the DOs
recommended two or more conditions.

Page | 29

Table 11. Debilitating medical conditions by recommending physician type

Physician Certifications for Debilitating Medical Conditions
Nature of Debilitating Medical
Conditions§

DO

MD

Count Percent

NMD

Count Percent

Count

Percent

Totals

Percent

Cancer

49

2.1%

99

1.2%

318

1.8%

466

1.6%

Hepatitis C

30

1.3%

125

1.5%

450

2.5%

605

2.1%

Cachexia

7

0.3%

13

0.2%

14

0.1%

34

0.1%

Seizures

21

0.9%

51

0.6%

161

0.9%

233

0.8%

Glaucoma

29

1.2%

58

0.7%

185

1.0%

272

0.9%

Sclerosis

0

0.0%

1

0.0%

6

0.0%

7

0.0%

Alzheimers

1

0.0%

2

0.0%

6

0.0%

9

0.0%

1,809

77.7%

5,671

66.1%

12,144

67.3%

19,624

67.8%

28

1.2%

139

1.6%

253

1.4%

420

1.5%

9

0.4%

46

0.5%

93

0.5%

148

0.5%

Crohn's disease

15

0.6%

29

0.3%

98

0.5%

142

0.5%

Nausea

16

0.7%

103

1.2%

270

1.5%

389

1.3%

315

13.5%

2,237

26.1%

4,059

22.5%

6,611

22.8%

2,329

100.0%

8574

100%

18,057

100%

28,960¶

100.0%

Severe and chronic pain
Muscle spasms
HIV/AIDS

Two or more debilitating conditions
Overall State Totals
§

Conditions are unique debilitating medical conditions unless noted otherwise.
17 HMDs are not included in the totals.

¶

3.5

Registered Non-Profit Medical Marijuana Dispensaries

From April 14, 2011 through June 2012, ADHS did not issue any certificates for non-profit
medical marijuana dispensaries. ADHS will report these required data elements in the second
annual report.
3.6

Non-Profit Medical Marijuana Dispensary Agents

From April 14, 2011 through June 2012, ADHS did not issue any DA Registry Identification
Cards. ADHS will report these required data elements in the second annual report.

Page | 30

Discussion and Recommendations
Since the program’s inception in April 14, 2011 until June 30, 2012, there were a total of 29,804
active cardholders that included both QPs (n = 28,977) and CGs (n = 827). At the close of its
initial year in operation, ADHS has been administering the
program to support Arizona residents for whom medical
At the close of its initial year in
marijuana may provide therapeutic and palliative benefit. The
operation, ADHS has been
majority (n = 19,631; 67.7%) of the QPs indicated “severe and
administering the program to
chronic pain” as the unique debilitating condition and
support Arizona residents for
approximately 7% of the patients had other conditions that
whom medical marijuana may
included Cancer (n = 467; 1.6%), Hepatitis C (n = 605; 2.1%),
provide therapeutic and
Muscle Spasms (n = 420; 1.4%), and Nausea (n = 389; 1.3%).
palliative benefit.

It is possible to estimate in further detail the ‘true incidence’ of
debilitating medical conditions by examining other data
available at ADHS. However, there are statutory restrictions that require ADHS to maintain
confidentiality of the medical marijuana registry data. Any public health analysis of this data will
be limited in scope, unless the Arizona Medical Marijuana Act (AMMA) statutory elements are
amended (i.e. in furtherance of the act) to conduct any epidemiological analysis to understand
public health and safety implications. For instance, although causality was difficult to determine,
a recent study, found that residents of states with medical marijuana laws had higher likelihood
(odds) of marijuana use (OR:1.92; 95% CI: 1.49–2.47) and marijuana abuse/dependence (OR:
1.81; 95% CI: 1.22–2.67) than residents of states without such laws.9
Since the passage of the law, in two instances (Laws 2011, Chapter 112 and Laws 2011, Chapter
336), modifications to AMMA were put in place to clarify ADHS’ authority to share doctor
information with the various medical boards and required ADHS to allow employer access to the
medical marijuana database to verify if employees were valid cardholders. Additionally, Laws
2011, Chapter 94 modified the controlled substances database to include medical marijuana to
allow physicians to make more informed decisions about patient care. Without these
modifications, it would have been difficult to assess the high frequency physician certifications
noted in this report and/or to report them to their respective medical boards. Results found in this
report on frequent physician certifications raise concerns about high volume certifiers.
Some of the findings in this report lend support to the following recommendations that can
further improve administration of AMMA:
Recommendation 1: Develop intensive training for physicians who are high volume certifiers in
conjunction with respective licensing medical boards for better patient provider coordination and
adherence to AMMA statutory requirements. Leverage existing contracts with the Arizona
Board of Pharmacy to more quickly identify physicians who may be making false attestations on
physician certifications.
Page | 31

Recommendation 2: Given the overwhelming recommendations for patients with “severe and
chronic pain”, explore the feasibility of further examining the nature of debilitating conditions.
For instance, the current incident rate for cancer in Arizona (5-year average) was 390 per
100,000 (CI: 387.8–392.1) with an average annual count of 25,432 cases.10 However, in the
medical marijuana database there were only 467 patients with Cancer as a unique debilitating
condition.
Recommendation 3: Explore the feasibility of temporary suspensions of cards. For revocations,
the current AMMA statute provides only two possibilities with a cardholder status as either
active and/or revoked. For instance, during the reporting period there was one revocation for a
QP and two revocations for designated CGs. In either case, there are a series of administrative
actions that need to occur before a card is revoked, including the possibility of appeals through
Administrative Hearing and Superior Court. During this time lag, a card remains in “active”
status (i.e. the cardholders are protected by the AMMA) until a final decision is made; thus,
providing immunity to potential misuse of AMMA provisions.
Recommendation 4: Explore the feasibility of conducting epidemiological analysis of medical
marijuana users through amendment of AMMA statute to understand public health and safety
concerns. For instance, epidemiological analyses can shed light on: a) whether use of medical
marijuana has an effect on opiate dependency; b) whether use of medical marijuana has an
impact on motor vehicle traffic injuries; and (c) whether use of medical marijuana has an impact
on pregnancy outcomes or breastfeeding.

Page | 32

Appendix A
Medical Marijuana Fund
Program Inception through FY 2012
4/14/2011 to 6/30/2012
Revenues:
Application fee for a Registry Card
Application fee for a Dispensary
Total Revenues

$5,525,277
$2,420,000
$7,945,277

Expenditures:
Salaries, Wages and Benefits
Operating Expenditures
Capital Equipment Expenditures
Total Expenditures

$570,972
$1,505,023
$304,464
$2,380,459

Fund Balance

$5,564,818

Note: ADHS utilizes the fund balance to fulfill the program's outstanding obligations. See
Program Project Contracts and Interagency Services Agreements Section for details.

Page | 33

Appendix B
Arizona Medical Marijuana Program Governing Documents
Arizona Revised Statutes (A.R.S.) that Govern the Arizona Medical Marijuana Program
The Arizona Revised Statutes (A.R.S.) represent the statutory laws of the state of Arizona. The
A.R.S. and the Arizona Medical Marijuana Rules each contain requirements applicable to the
Arizona Medical Marijuana Program. Accordingly, to fully understand all the requirements
applicable to the Arizona Medical Marijuana Program, the A.R.S. and the Arizona Medical
Marijuana Rules should be read in conjunction with each other.
A.R.S. Title 36
CHAPTER ARIZONA MEDICAL MARIJUANA ACT
36-2801
Definitions
36-2801.01 Addition of debilitating medical conditions
Arizona Medical Marijuana Act; limitations
36-2802
36-2803
Rulemaking
36-2804
Registration and certification of nonprofit medical marijuana dispensaries
36-2804.01 Registration of nonprofit medical marijuana dispensary agents; notices; civil
36-2804.02 Registration of qualifying patients and designated caregivers
36-2804.03 Issuance of registry identification cards
36-2804.04 Registry identification cards
36-2804.05 Denial of registry identification card
36-2804.06 Expiration and renewal of registry identification cards and registration
36-2805
Facility restrictions
36-2806
Registered nonprofit medical marijuana dispensaries; requirements
36-2806.01 Dispensary locations
36-2806.02 Dispensing marijuana for medical use
36-2807
Verification system
Notifications to department; civil penalty
36-2808
36-2809
Annual report
36-2810
Confidentiality
36-2811
Presumption of medical use of marijuana; protections; civil penalty
Discrimination prohibited
36-2813
36-2814
Acts not required; acts not prohibited
36-2815
Revocation
36-2816
Violations; civil penalty; classification
36-2817
Medical marijuana fund; private donations
36-2818
Enforcement of this act; mandamus
36-2819
Fingerprinting requirements

Page | 34

Arizona Medical Marijuana Administrative Code (Rules)
The rules in the Arizona Administrative Code (A.A.C.) that apply to the Medical Marijuana
Dispensary portion of the Arizona Medical Marijuana Act were filed on April 11, 2012. ADHS
accepted applications for Medical Marijuana Dispensary Registration Certificates from May 14
through May 25, 2012.
ADHS used an emergency rulemaking process to incorporate the changes required by a recent
Superior Court Ruling. This process requires subsequent rulemaking using the regular
rulemaking process. An unofficial draft of the rules being made through regular rulemaking
combines the amendments contained in the Express Rulemaking with the Medical Marijuana
Program Rules.

Page | 35

Appendix C
Random Selection Protocol for Dispensaries

Page | 36

Page | 37

Page | 38

Page | 39

Appendix D
Independent Accountant’s Report on Applying Agreed-Upon Procedures

Page | 40

Page | 41

Page | 42

End Notes:
1. Arizona Department of Health Services website.
2. ProCon.org (2012, August 13). 17 Legal Medical Marijuana States and D.C.: Laws, Fees,
and Possession Limits. Retrieved from
http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881.
3. Marijuana Policy Project (2011, Fall last update) The Seventeen States and One Federal
District with Effective Medical Marijuana Laws. Retrieved from
http://www.mpp.org/legislation/state-by-state-medical-marijuana-laws.html.
4. Commissioner's Office Maine Department of Health and Human Services (2011, March)
Maine Medical Use of Marijuana Program Annual Report.
5. Medical Cannabis Program Update for the Medical Advisory Board Meeting (2011,
November 19) Office of the Secretary, Santa Fe, NM, http://www.nmhealth.org.
6. Nevada Health Division Medical Marijuana Program (2012, September 10) Nevada Medical
Marijuana Report.
7. Charles Alexandre, PhD, RN Chief, Health Professions Regulation (2011, February 1) Rhode
Island Medical Marijuana Report.
8. ADHS population estimates, by county for year 2011, ADHS Bureau of Vital Statistics (2012,
3 April), http://www.azdhs.gov/plan/menu/info/pop/pop11/pd11.htm.
9. Cerdá C, Wall M, Keyes KM, Galea S, and Hasin D. Medical marijuana laws in 50 states:
Investigating the relationship between state legalization of medical marijuana and marijuana
use, abuse and dependence. Drug Alcohol Depend. 2012; 120(1-3):22-27.
10. State Cancer Profiles. Retrieved from http://statecancerprofiles.cancer.gov/cgibin/quickprofiles/profile.pl?04&001#incdEAPC accessed on November 5th 2012.

Page | 43