Fourteen years since Californians passed the first-in-the-nation medical marijuana law, pot is not just for the sick. Hundreds of medical marijuana doctors, operating without official scrutiny, have helped make it available to nearly anyone who wants it.
They are practicing a lucrative and thriving specialty, becoming the linchpins of a billion-dollar industry. And yet they do not have to report to whom they recommend the drug to, how many referrals they give or for what ailments.
"There is something inappropriate about doctors being the gatekeepers," said Timmen Cermak, president of the California Society of Addiction Medicine. "They are secretaries here ... All they are doing is telling the police to keep their hands off."
As voters go to the polls Tuesday to decide if they want California to be the first to legalize recreational pot use and sales, the medical marijuana system they helped establish in 1996 has effectively become a legal cover to smoke pot.
The system also stands as a cautionary example for other states crafting their own laws. Among them are Arizona and South Dakota, which have medical marijuana on Tuesday's ballot.
Under California's law, medical doctors and osteopaths can recommend the drug for any illness "for which marijuana provides relief," a category that has come to encompass conditions such as alcoholism, anxiety, asthma and insomnia.
Obtaining approval in the other 13 states that allow pot for medical use is far more difficult.
Those states limit the drug to residents suffering from one or more specific serious conditions, such as AIDS or cancer. Most require patients to register, creating a paper trail for tracking both users and their physicians.
In California, however, there is no central database to track doctors or patients. Beyond a medical license, the pot physicians do not need to have any relevant training, familiarity with the scientific literature on pot's benefits and side-effects or special certification.
They can simply hang a shingle, and start practicing.
Because there are no reporting requirements, figuring out who these doctors are is difficult.
There are more than 100,000 licensed doctors in the state, and medical marijuana advocates estimate that roughly 1,500 of them have recommended pot to at least one patient.
Of those, advocates say, 400 to 500 doctors account for the majority of recommendations.
To identify them, The Associated Press scoured online directories maintained by marijuana advocacy groups; ads in alternative weeklies and pot-themed periodicals; and clinic websites. Interviews with clinic managers or doctors who own the clinics provided additional names.
The AP's list of 233 doctors is not exhaustive, nor can it be, given the lack of information with the state.
An analysis of the names and state medical board files showed that most marijuana doctors on the list have clean records.
But there were also 68 physicians who have run afoul of regulators. Some of the disciplinary actions against them included fraud, mis-prescribing drugs, abusing prescription or illicit drugs themselves, as well as and negligence.
The pot practitioners with blemished backgrounds include:
_ A San Francisco doctor who received four years probation after she failed to heed a psychiatrist's request to reconsider her marijuana recommendation to a 19-year-old patient suffering from depression. The patient committed suicide six months later. The doctor now operates medical marijuana practices in eight cities. She declined to discuss the case.
_ A Glendale obstetrician-gynecologist who pleaded guilty last year to billing Medicare for $77,000 worth of diagnostic tests he never performed while working in Texas. Since moving to Los Angeles, he helped set up pot evaluation offices in 11 locations. He said that moving to California and becoming a medical marijuana doctor was not related to his criminal case.
_ A Fresno osteopath who was arrested in June 2008 for driving under the influence of alcohol and whose urine tested positive for marijuana, anti-anxiety drugs and a prescription stimulant. Two months later, he was arrested again for driving with a suspended license and involuntarily hospitalized as a suicide risk. He was convicted in both cases, and the U.S. Drug Enforcement Agency revoked his authority to prescribe narcotics. He is now giving pot recommendations at his private practice. His attorney said he declined to comment.
"It doesn't surprise me people who would be in trouble before are now turning to something that is easy, doesn't require staff privileges at a hospital and doesn't require malpractice insurance," David Thornton, the state medical board's former executive director.
"All they need is a medical license and places that will hire them," he said.
Supporters of medical marijuana stress that, unlike physicians prescribing pharmaceutical drugs, pot doctors are not enabling people to use a potentially fatal substance. But they acknowledge that some doctors abuse their authority to extend pot-using privileges.
"We have standards to uphold. I really try to uphold those standards," said Dr. Jean Talleyrand, founder of MediCann Inc., the state's largest chain of medical marijuana evaluation clinics. "There are a lot of doctors who are not upholding those standards."
Clinics typically charge $50 to $150 per visit for new patients. Seeing 10 patients a day, pot doctors can earn hundreds of thousands of dollars a year. Some battle it out for customers with ads in alternative newsweeklies offering discounts for older patients and two-for-one specials.
Still, many pot doctors maintain low profiles.
They work at one or more of 140-plus clinics that opened in the last few years, only a handful of which identify their physicians in marketing materials. Some of the largest clinics, including Talleyrand's, declined requests from the AP to give their staff doctors' names.
Even as the number of these doctors has soared into the hundreds, the risk of getting in trouble for improper recommendations is low.
The state medical board and the companion panel that polices osteopaths have restricted the licenses of 13 pot doctors, about one per year, since the landmark law's passage. Two had their licenses revoked, the most serious discipline available.
Disciplinary action is rare because the state board lacks the staff and launches investigations when complaints are brought, said Julie D'Angelo Fellmeth, a University of California, San Diego law professor who spent two years as the board's independent enforcement monitor.
The people they rely upon to submit those complaints are patients.
They "are not going to be filing the complaints," she said. "They are happy as clams."
Another reason the doctors may avoid scrutiny is because investigators focus on areas of medicine that are viewed as a greater threat to public safety _ incompetent surgeons or physicians who over-prescribe painkillers on which patients can overdose, Thornton said.
Current medical board officials declined to be interviewed for this article, but said in answers to written questions that the agency gives medical marijuana practitioners the same scrutiny as other doctors, even though it has inadequate staff to closely monitor them.
Under California law, physicians who prescribe controlled substances such as painkillers must report all such prescriptions to a central state database each week.
Marijuana does not fall under this requirement because as a Schedule 1 controlled substance under federal law _ a drug the federal government says has no medical value _ it cannot legally be prescribed, only recommended.
To avoid state scrutiny, doctors need to only follow a few simple rules _ review patients' prior medical records for proof of the existing ailment, perform "good faith" physicals, develop treatment plans, and talk to them about the risks and potential side effects of using pot.
But dispensary owners, patients and practitioners say even those guidelines are routinely ignored, or at least pushed to the limits.
In Los Angeles, the situation got so out-of-control this year that the city's pot shops stopped selling to about 30,000 customers with paperwork from 10 doctors at three clinics. Two closed, almost overnight. The third changed its telephone number and location after being swarmed by angry customers demanding refunds.
Michael Backes, director of the Cornerstone Collective, said he put together and circulated a list of doctors to other pot shops after noticing people trying to join the co-op with suspicious-looking physicians' approvals.
"We started to notice a lot of recommendations that weren't even signed by physicians anymore," he said. "They were rubber-stamped, literally rubber-stamped."