Dr. Sam Hawk, osteopath, has seen patients dealing with severe spinal pain who were no longer helped — and likely were being hurt — by opiate drugs

“It’s a great acute medication, but long-term, it’s nerve-toxic,” Hawk said. “It can affect their pain threshhold … then going off it is even that much harder. You’ve conditioned the nerves, and so there’s withdrawal, and trying to get their body off that, that’s hard.”

Me Fuimaono-Poe, an advance practice nurse, related a similar tale, recalling her years working in an oncology clinic. This was in San Francisco, some years ago, she said, when nothing else was relieving the symptoms and it was time to offer an alternative.

“The code word there was that ‘they could go outside,’” she said.

Legal or illegal?

That meant cannabis. Medical marijuana. Pot. By whatever term, clinical or slang, the federal government classified it as illegal. The fact that it remains so, while Hawaii and other states have legalized its use to some degree, has left the states dealing with various aspects of the legal ambiguity.

That was evident recently when Honolulu police officials contemplated denying a gun license to anyone on the state’s medical cannabis registry, a policy proposal that since has been shelved. And it is clear especially to anyone who ventures into Hawaii’s fledgling medical cannabis world.

Although the use of marijuana for defined medical purposes was enabled by state law in 2000, it’s only been in the last few years that dispensaries were authorized, the first one, Maui Grown Therapies, opening in August. Two Oahu locations followed — Aloha Green and Noa Botanicals, both in central Honolulu; a third, Cure Oahu, will be located on Kapahulu Avenue.

First there’s the location issue: Under state law, dispensaries cannot be located within 750 feet of schools, playgrounds or public housing complexes. That’s more limiting than it might seem, so it’s not surprising that Aloha Green and Noa dispensaries lie within a stone’s throw, on South King and Young streets, respectively.

Then there’s access. In order to enter the sales area in a dispensary, one must have what’s called a “329”card, named for the medical marijuana statute, Chapter 329. Or, those with official business other than purchasing cannabis as a patient must have a security clearance, meaning that repair crews and other service employees a dispensary summons have to come from an approved list.

There are no photos or recordings permitted inside, except what’s taken by security cameras placed strategically. This is to avoid security breaches by anyone casing out the place to plot a route to the merchandise. A fairly modest purchase of an ounce of cannabis can run a couple hundred dollars.

Public vs. private

The price point also makes the patients nervous about talking publicly. One said he worried about giving burglars incentive to break in.

“This is valuable stuff,” he said. “You could have $500 carried around with you and nobody would notice the bulge in your backpack.”

On top of all that, there’s the stigma. Buying medical cannabis may be a legal activity here, but so much has not shaken out yet. What would an employer do with the information about the kind of medicine an employee is taking? What will anyone, for that matter, think?

Brian Goldstein, CEO at Noa Botanicals, said his staff mulled over the issue and acknowledged the challenge of rebranding cannabis — that is its scientific, original name and preferred in the industry. Patients come in for a consultation, but a loved one can be sitting alongside, their arms crossed and wearing a frown: Not everyone is on the same page about this.

There’s a lot to overcome, he said, which is the reason why when people walk in, they see the mission statement displayed, lettered right onto the wall:

“Redefining cannabis as a natural choice for our community — free from stigma.”

Getting certified

The Honolulu Star-Advertiser’s way into the dispensary world to learn more, plain and simple, was to have a writer go through the whole process of applying for a 329 card. That document is issued by the state Department of Health after patients are evaluated and then recommended for the certification as having a condition that qualifies under the law.

To be placed on the Hawaii Medical Cannabis Registry and receive a card, patients go through an interview appointment to assess the reason for seeking a cannabis card. The patients pay a $35 registration fee, but the health care providers could charge a range of fees for the certification appointment.

Out-of-pocket costs could vary widely, depending on whether the patient’s insurance is accepted — or whether the insurance carrier accepts the program. (Kaiser Permanente providers, for example, will not participate in the 329 program, by company policy). One provider quoted a $100 fee, without insurance, others can be higher than that. It pays to shop around.

This reporter’s route led to Fuimaono-Poe, whose Malie Cannabis Clinic ushers patients through an interview appointment to assess the qualifying condition, creating an electronic health record. This might come in handy in a year when it comes time for a renewal application.

There is some counseling on the types of products, the difference between strains of cannabis, the distinctions between them. Then Fuimaono-Poe completes the state Health Department application for the card and submits it; the wait time, according to DOH, is about 10 days, a turnaround that was borne out in this case.

There are explanations about various strains and the difference between the components tetrahydrocannabinol (THC), which produces the high and helps counter some symptoms, and cannabidiol (CBD), which is not psychoactive but is useful with specific conditions.

Fuimaono-Poe said patients can bring medical records themselves to show, but does not require them. Answering the questions about the conditions will suffice, she said. There may be times when she does not certify a patient because the drug will not address their specific problem, she added, but not because she discerns that they are “faking it.”

“I don’t believe people fake symptoms,” she said. “I choose to believe my patients.”

Providers on the state’s list likely are inclined to feel the same way. Hawk, for example, is one.

“I like to give people the benefit of the doubt,” he said. “I want patients to be able to try this medication to see if it’s helpful for them.”

An inside look

Helen Cho is director of integrated strategy for Aloha Green, coming to that job after working with technology startups in New York.

There have been the expected growing pains with this kind of startup, she said: learning what people want to know when they call in (what products are available, how to get a card, etc.), and getting production and demand to align. Increased production over time should improve that, and lower the price point, she said.

The law, guided by the state’s anti- smoking policies, also constrains dispensaries from selling the delivery systems — gear for smoking or vaping the drug — so both Aloha Green and Noa Botanicals provide education on options available elsewhere.

“It’s more about learning how to work around regulations, learning how to provide for the patients as much as we can without crossing that line,” she said.

Both dispensaries the Star-Advertiser visited looked professional, devoid of any of the head-shop type of drug-culture ambiance some might expect.

Goldstein, who also came from the software world, said he hopes refinements in the law might ease some of the requirements for entry to the dispensaries: Hawaii is the only state that by law restricts access so stringently.

Countering the restrictive process, he said Noa’s aim was a pleasant, welcoming design to offset the discomfort an uninitiated patient might feel.

“If I’m getting stressed out from the business up here, I’ll just go downstairs and spend a while in the waiting room, just talking to people,” Goldstein added. “The best part is when people leave, they’re happy. Everyone leaves here happy.”