EDMONTON — Margaret Marceniuk inhales her medical marijuana through a pharmaceutical puffer and a head-shop pipe. Tamara Cartwright vaporizes her pot with a machine called a Volcano, then inhales three to four bags of the vapour while locked away in her bedroom, away from her toddler. Ian Layfield in Victoria swallows cannabis-infused oil capsules he makes himself, frying olive oil with pot leaves, then straining it with cheese cloth and pouring it into gel caps. He also mixes cannabis into a topical cream he rubs into his left foot and ankle, which was crushed in October 2006 after being rolled over by a grader. Todd Kaighin, an HIV patient in downtown Toronto, largely smokes traditional joints, while Janice Cyre outside Edmonton presses her marijuana leaves into steeped tea. Many users also nibble on the odd brownie or cookie baked with cannabis leaves, pot-infused oil or canna-butter. All have their federal licences to legally take medical marijuana to help dull pain, boost appetite and curtail nausea or diarrhea associated with multiple sclerosis, colitis, severe arthritis, HIV or fibromyalgia. But all laugh disdainfully at the dried marijuana grown by the federal government in a mine in Manitoba, describing it as “dust” or “catnip in a bag” that has little therapeutic benefit and brings headaches. They either buy their medical pot illegally through compassion clubs or legally grow their own plants in their basements, with some occasionally and reluctantly forced to buy from street dealers when their supply runs low. Marceniuk, who recently moved to a small community west of Edmonton, has never smoked cigarettes and didn’t rebel as a teenager by getting high on pot. She refused to try medical marijuana for her constant pain while working as a school teacher and wasn’t keen on using it while her two sons were still living at home. But since she’s been on disability for seven years, Marceniuk has slowly incorporated marijuana into her daily routine to help her with the debilitating effects of multiple sclerosis. She’s one of 108 with the disease in Alberta — 480 across Canada — who can legally use marijuana under Health Canada’s medical marijuana program, according to 2001 to 2007 data. More multiple sclerosis patients are allowed to use medical marijuana than any other patient group in Alberta. They make up 29 per cent of those with government approval. The next highest group, at 13 per cent of the total, are those with severe arthritis. Diagnosed with MS at age 28, Marceniuk has experienced blindness, migraines, balance issues, chronic pain and fatigue. At 55, conventional medications only hold the pain at bay for so long. “I have breakthrough pain,” said Marceniuk, who is currently on 13 different medications, including one conventional pain killer. About seven years ago, she started using marijuana, first with Sativex, a legal synthetic marijuana she inhales in a puffer form similar to an inhaler for asthmatic patients. Her doctor prescribes it like any other pharmaceutical and doesn’t have to apply to Health Canada for a medical marijuana licence or use triplicate subscriptions, which are needed for opiates and narcotics such as morphine that have the potential for misuse or abuse. A vial of Sativex lasts about one month for Marceniuk, who inhales four puffs for each daily treatment. Three to four hours later, the associated high brings relief and dulls the pain.

But the Sativex didn’t seem to help that much until Marceniuk began smoking dried marijuana in a pipe, about once a week. The relief from smoking was almost immediate, and the doctor believes the smoked leaf opened pathways that allowed the synthetic compound to work better. “It doesn’t get rid of the pain completely. As my son says, it makes me not care about the pain,” she said. “It helps me get through the pain.” Marceniuk can legally take both forms of marijuana, since she has received approval from the federal government, but it took her two years to find a doctor willing to spend the time to fill out the lengthy forms for a licence. In January 2010, figures from Health Canada suggested 153 Alberta physicians supported marijuana prescriptions, compared to 685 in British Columbia and 939 in Ontario. Marceniuk only smokes her pipe at home, occasionally supplementing with cannabis-infused brownies made with special oil. When out with friends, she takes Sativex, a more socially acceptable option that can be discreetly used in the washroom and leaves no odour. She purchases her pot illegally from a compassion house in Vancouver she visits once or twice a year. Until recently, she wasn’t even aware Edmonton has had its own compassion house since 2004, easily found on the Internet, but quietly and purposefully kept under the radar. “The stuff coming from the government is literally just dust,” Marceniuk said. “I’m not impressed by it.” Nor are others, who say when the government harvests its crop, workers separate the cannabis leaves and buds from the crystals, the snowflake-like compounds that grow on the bud and contain most of the active ingredient called tetrahydrocannabinol, or THC. The extracted THC is then made into a tincture or liquid form, and sprayed back onto the plant so that the THC levels are standard in all the product, at about 12.5 per cent, according to the Health Canada website. But critics say tests have shown levels far lower, at six per cent. They suggest variety in strength and plant types is important for patients with different medical needs. Growers say leaves at the top of marijuana plants are naturally stronger than those at the bottom, so THC levels range from about 15 per cent to 22 per cent in marijuana available at most compassion clubs. Batches may vary, so clubs try to get to know their suppliers, who can estimate THC levels, since chemical testing is expensive and prohibitive. While the government offers only one strain, compassion clubs offer many more so patients can personalize their prescriptions. Marceniuk took her licence to a West Coast compassion club where a list of marijuana types is posted on the wall, including Sativa strains that infuse a person with energy and Indica strains that tend to make a person sleepy. Then, Marceniuk said, it was up to her to figure out how much of what kinds she needed, even relying on basic advice from her sons, now in their late 20s, since she wasn’t so naive as to believe they had never smoked pot.

She still doesn’t know how many grams she uses each day, but likely an amount that falls safely inside the Health Canada guidelines of one to three grams of dried marijuana. A typical joint contains between 0.5 and 1.0 gram of cannabis plant matter, Health Canada states. But the guesswork is part of what troubles physicians like Edmonton’s Dr. Rufus Scrimger, who has worked as an oncologist for 25 years. Scrimger said he doesn’t feel comfortable prescribing medical marijuana for his cancer patients because doctors are given no training to understand the different strains, strengths or types of marijuana they should be prescribing for each ailment. Nor can doctors control the supply, which could be tainted with other ingredients. “There’s not a lot of good medical data out there to support its use, evidence that says it’s better than all the other medications that we have available to us for nausea or pain,” said Scrimger, the Alberta Medical Association’s section head for oncology. “We don’t know how to prescribe it. There’s no real accepted dose. There’s no standardized strength. There’s an ignorance, I guess, on the part of most doctors, to prescribe it even if they wanted to.” He said he doesn’t discourage patients who tell him their pain or nausea is controlled by smoking pot. But he said it goes against the culture of his training in cancer prevention. “I basically spend all day treating people who have cancer as a result of smoking,” Scrimger said, adding he didn’t know about other methods to consume cannabis. “It’s hard for me to prescribe something that is highly carcinogenic, even though (I sometimes know) it probably isn’t going to make a difference to somebody who is already dying of cancer.” The College of Physicians and Surgeons of Alberta recommends physicians not prescribe medical marijuana because scientific research hasn’t proven its clinical benefits. The Alberta Medical Association strongly urges doctors to “think twice” before prescribing or dispensing marijuana, a stance laid out in association president’s letters in 2001 and 2003. The topic hasn’t been revisited since, but the letters describe the Health Canada 2001 regulations as unacceptable because they place doctors in an untenable situation. If patients receive a prescription, then experience dangerous side effects, can the physicians be held liable? Palliative doctors, who may be more likely to consider medical marijuana as a final option to reduce pain in the last weeks of life, are also advised against prescribing pot. “Research in the palliative population is urgently needed as the regulations have outstripped research in this area, due to restrictions on smoked marijuana,” reads the position statement from the Edmonton zone palliative care program, developed in 2001, then revised in November 2010. “Until such a time that stronger evidence is available, the Edmonton Regional Palliative Care Program will not support the application for permission to use marijuana for medicinal purposes under the new regulations.” “We just don’t see the important role for it,” said Dr. Robin Fainsinger, a palliative care doctor and medical director for the Edmonton zone palliative care program. “We have so many other options for it that are very effective.”

Over the last 20 years, Fainsinger has only prescribed the pharmaceutical pill form of cannabis called Nabilone for five to six patients. He has never prescribed it in leaf form. Dr. Brian Knight, an anesthetist with expertise in chronic pain medicine, said he wouldn’t call marijuana an important tool, but his “third-line option,” largely prescribed only after his patients have had little success to manage chronic pain through physiotherapy, psychology, anti-depressants, anti-convulsants and opioids, which are controversial themselves. Knight also prescribes the pharmaceutical pill or inhaler before trying the leaf variety of cannabis, even though the synthetic marijuana doesn’t usually work for patients, or brings more side effects than smoking a joint, he said. The problem, Knight said, is that even though an estimated 30 per cent of the population suffers from chronic pain, there aren’t sufficient resources such as therapy to help them to the same extent as for those with other chronic health issues such as diabetes. “We don’t have a lot of tools available to us,” he said. And patients already wait about one year to see him in his pain clinic at the Misericordia Hospital in Edmonton or at the HealthPointe Medical Centre. “Right off the bat, when we’re talking about treating a (pain) patient, we’re really starting behind because we really don’t have access to the multi-disciplinary care that the patients really need.” That becomes a problem when Knight does a thorough history and examination of patients, gathering background documents and ordering urine tests that reveal they have cocaine in their blood and suffer from addictions or a mental illness in addition to chronic pain. When that’s the case, Knight generally doesn’t prescribe medical marijuana. “I don’t give a rubber stamp to everyone who comes in the door. I like to get to know them first,” said Knight who, back in 2001 when the federal government first allowed marijuana prescriptions, had a lot of men in “leather ball caps” complaining of back pain and asking for pot. Knight wouldn’t prescribe. “I think a lot of people are using medical marijuana as an end run around legalization.” But a few months ago, he felt pressure to prescribe marijuana for a man whose parole officer had given him Knight’s name. Knight said he doesn’t like to advertise the fact that he prescribes marijuana. But the man, who suffered pain after a work injury, had been caught with marijuana and was told by the judge he would get a complete discharge if he could get a doctor to authorize his marijuana use as medical. “That’s putting a little bit of pressure on me,” said Knight, who wrote the man a prescription but resented being “blackmailed” into helping the patient avert jail time. “I said, ‘I normally don’t do authorizations on the first visit. I like to examine you and get to know you a bit.’ He was quite desperate.” Most of the patients for whom Knight authorizes legal marijuana use are those he has seen for several years who arrive one day saying they shared a toke with a friend and felt pain relief. Such personal stories are what encouraged Knight to try marijuana for patients in the first place. At the time, he said he worked at a different Edmonton hospital pain clinic under a director who prohibited physicians from prescribing the drug.