Capital District of Old San Juan, Puerto Rico.Puerto Rico’s medical cannabis industry was built up fast, but there are not nearly enough registered patients to support it. More than three years after the US territory’s first regulations for a medical cannabis program were released, the estimated 100,000 or more patients the infrastructure was built to support is serving a patient population closer to 40,000.
A perfect storm of factors has contributed to the lack of registered patients on the island: a focus on medical cannabis for tax stimulus amid Puerto Rico’s serious economic crisis; an education gap in conservative communities; more competitive pricing on the illegal market; and, of course, one of the worst natural disasters in the island’s history. In the wake of Hurricane Maria, a lot of patients with the means to leave have already left.
Like the estimated 130,000 Puerto Ricans who left the island after Hurricane Maria struck in 2017, Narely Cortes relocated to the mainland United States. Leaving home had literally become a matter of life and death for Cortes and her husband, both US military veterans with serious diagnoses that require medical treatments, which became unavailable after the storm struck. (Parts of the island remained without power for nearly a year.)
Cortes has been a driving force behind Puerto Rico’s medical cannabis law as one of the first patient advocates to lobby the legislature and share her story with the media. She stood behind Governor Ricardo Rosselló as he signed medical marijuana into law. Today, she is the only patient representative on Puerto Rico’s Medical Cannabis Regulatory Board (MCRB), but she commutes to her meetings from her home in Boulder, Colorado. She is pushing to make the program more patient friendly and ultimately provide a path home for other medical refugees who, like her, rely on medical cannabis.
But can Puerto Rico’s medical-only program truly meet patients’ needs and also generate the economic benefits the local government and industry seek? The conflicting goals of the program have pitted patients against profits, and adult-use legalization could resolve the disconnect.
Medical Marijuana Becomes Law In Puerto Rico
On May 3, 2015, then-Governor Alejandro García Padilla signed an executive order directing the secretary of the Department of Health, Dr. Ana Rius Armendáriz, to authorize the use of medical cannabis and issue regulations for a system allowing for the cultivation and distribution of cannabis products. The initial regulations were restrictive. Issued in late 2015, Reglamento 155 limited cannabis flower and business opportunities, and excluded people who had previously been convicted of a drug-related crime.
What Padilla’s executive order didn’t do was codify the program into law, and Padilla was planning to leave office after the 2016 election, adding a layer of uncertainty to the emerging medical cannabis program. At Padilla’s urging, patients like Cortes secured doctors’ recommendations in order to strengthen the defense of a program once he left office; she became just the fifth patient registered on the island.
Just six months after taking office in July 2017, Padilla’s successor Governor Rosselló signed Ley 42-2017 into law, officially codifying the medical cannabis program, and repealing and replacing Reglamento 155, thus opening up the market for flower production (albeit vaping only) and to visiting tourists who have a valid doctor’s recommendation from legal US states.
“[The law is] not perfect, but we have a law and that is important for us to have because once we do, we can amend it. Just having a law is a big issue,” Cortes says.
Cortes was appointed by the Senate to represent patients on the MCRB established under the law. She is not just a patient, but a trained US Air Force medic, making her a difficult patient to replace. Cortes has been essential in opening up the marketplace to flower sales, pushed back against raising the 11.5 percent sales and use tax on medical, and has worked toward employment protections for patients.
The first year of medical cannabis sales brought in only $58,000 in taxes for Puerto Rico’s Department of Treasury, although initial governmental forecasting predicted from $14 million up to $100 million when the industry fully matures. Shortly after, in April 2017, there were efforts to raise the tax to 16.5 percent, although that push failed. By July 2018, tax revenues had hit $14 million — $36 million short of projections of $50 million for year two of legal sales. It is unclear how the taxes are being spent by the government. (The Health Department was reached by email and referred the matter to the Treasury Department, who has not yet responded to requests for a breakdown of current tax spending.)
Cortes points to the tax and the dispensary prices, which are already higher than street prices, as a cost prohibition that has kept the sickest patients out of the legal system. She also points to an education gap about the plant itself for the island’s majority conservative Catholic population. She is pushing to make the program work so she and other medical refugees can come home.
What It’s Like To Be A Medical Marijuana Patient In Puerto Rico
Cortes describes herself as an army brat who was born in Kentucky while her parents were enlisted. She spent her early childhood in Pennsylvania before moving to her parents’ native Puerto Rico when she was eight years old.
Cortes joined the US Air Force in 2007 and was granted a medical discharge in 2010. During her time with the Air Force, she worked as a nurse and medic and designed a successful program to streamline medical procedures she was overseeing.
While enlisted, she was exposed to stressors that damaged her immune system, resulting in 22 separate conditions diagnosed by the US Department of Veterans Affairs. The VA formally referred to her diagnoses as “service connected,” although beyond the VA’s diagnoses, Cortes is unable to further discuss the origins of her illnesses.
The layered conditions are essentially all autoimmune diseases, and specifically rheumatoid arthritis, fibromyalgia, multiple sclerosis and Parkinson’s disease. Her treatments included a cocktail of medications that left Cortes bedridden. She gained nearly 100 pounds on medication and was unable to actively participate in the lives of her two young daughters.
“It was just too much. In the mornings, I remember taking a handful of pills, a mouthful of pills, and I was so full I didn’t want to eat. Still, I was bloated and I had to move around with a wheelchair and use all kinds of walking aids,” she recalls. “I got scared when my grandma started taking pictures of me so she could remember me when I died. I knew I needed to do something.”
She had never tried cannabis before but when a doctor on the mainland suggested she look into it, Cortes’s husband started doing his research online and encouraged her to try it. In 2011, she reluctantly smoked some flower she had obtained from a friend to see if it would relieve the nausea she was experiencing due to a combination of the painkiller Tramadol, opiates and Methotrexate.
“I tried it just for that and was like, ‘Oh my God,’ I had relief of pain in my shoulders off the first hit. I thought, ‘I don’t deserve this, what is this?’” she remembers.
Next, Cortes started eating a clean diet, juicing and infusing her own at-home coconut oil, butter and tinctures with cannabis. While she maintains cannabis is not a cure-all, it is effectively managing her symptoms enough to stop taking most of her medications and get out of bed and move without walking aids. She also started studying the traditional Hindu medicine ayurveda and ethnobotany, and now produces her own herbal treatments that have further stabilized and allowed her to reclaim a quality of life.
“I was like, ‘Wow, these plants that you kill every day with Roundup are helping me. They are growing all around you and I didn’t know this,” Cortes says.
As she regained her quality of life, Cortes began sharing her story with the public and pushing the local government toward a medical cannabis solution.
The Pot Patient Problem In Puerto Rico
Cortes says the primary factor behind the lack of patients in Puerto Rico is undoubtedly due to Hurricane Maria. After the storm, many VA hospitals on the island closed to everyone except for federal employees working the cleanup.
Cortes is on a special diet for her kidneys and doctors suggested if she had family on the mainland United States, she should relocate there, because eating canned foods (the only option at the time) could send her into dialysis. Her husband, also a military veteran, has chronic obstructive pulmonary disease, which requires regular treatments with a nebulizer. With a lack of electricity — and no access to gasoline that would power their car nebulizer — their situation became critical. A little over a week after the hurricane, their doctors wrote recommendation letters, saying that they be allowed to leave Puerto Rico for medical treatment.
“I left as a medical refugee,” she explains. “If you had the chance to leave, you left. Right now, so many [patients] are receiving better care [off the island].”
Flights off the island were grounded during the storm’s aftermath and the only people able to leave in the first few weeks of the cleanup were those with severe medical conditions, like Cortes and her husband.
Initially, they planned to temporarily relocate with friends in California, but after two months, the VA still hadn’t reopened. That’s when they started looking at a more permanent move to Colorado. Not only was it easier to get what they needed immediately in Colorado’s adult-use market, they were able to get competitive products at competitive prices that Puerto Rico’s local industry has yet to match.
In Puerto Rico, high-quality flower is easy to obtain in dispensaries and increasingly affordable, Cortes explains, but there are few options for extracted and concentrated products, and those that are available are still expensive. It may take more time — many of the license holders began to plan their operations before the storm hit, and most were set back for up to a year in the rollout. While there are dispensaries and cultivation facilities, the expansion of product lines has been slow, but progressive.
“I have plans to go back to the island as medical treatments end in Colorado. I want to be on the island and be near family. It is hard to be here as a medical refugee; I left everything back home,” Cortes says.
Puerto Rico’s Cannabis Cash Cow
Puerto Rico is known for medical tourism outside of the cannabis space. Cosmetic surgeons entice patients with low prices and the opportunity to recover in paradise. Thanks to the ingrained pharmaceutical industry, patients can come to try experimental treatments in clinical trials.
In Old San Juan, a major tourism mecca, advertisements in English guide visitors to dispensaries and doctors who will approve their out-of-state medical recommendations. One of the larger dispensary chains, BWell Healing Center, is located right next to the cruise ship docks specifically to capture medical cannabis tourism.
Puerto Rico is looking to tourism in the medical cannabis industry to alleviate its economic crisis, but a number of factors have prevented it from taking off, including cost-prohibitive temporary permits that must be obtained by tourists in order to simply enter a store and make a purchase. It costs up to $150 for a temporary permit, and then there is an 11.5 percent tax on the medical purchase as well.
José A. Rivera Jiménez, president of the Members of the Medicinal Cannabis Industry, told Caribbean Business, “[The government is] not thinking; this is economy 101. … The concern is that [regulators are] responsible for promoting cannibalism in the market, which ends up directly affecting the patient, when half the businesses have to close operations because they do not have the capacity to cover a nonexistent market. The licenses that are already granted are enough to serve a market of over 200,000 patients, but we barely have a market of 37,000 patients. … We are concerned that the excess supply causes a dislocation in the market and that translates into a voracious fight to see who survives in a market that has 37,000 patients.”
Could opening up the existing infrastructure designed for medical to all cannabis consumers over the age of 21 solve the patient problem, while also generating the tax revenues Puerto Rico seeks? Maybe, by moving the tax from patients to adult-use consumers, businesses can grow, expand their product bases and lower the prices for patients.
Karen Castro González, professor of business administration at the University of Puerto Rico’s Río Piedras Campus and author of an analysis titled “Fiscal Impact of Medical Cannabis in Puerto Rico,” is critical of how the government is looking to generate revenue off medical cannabis and suggests that if the goal is to generate tax revenue, Puerto Rico should look to adult-use legalization.
“I believe the projections are very optimistic or maybe they are thinking about recreational cannabis, which is where we have seen other jurisdictions capitalize. Of course, my conclusions indicate there will be a positive impact on government revenue, but it seems to me the government’s estimates are too optimistic,” González told an audience at the Puerto Rico Economists Association in 2017, according to Caribbean Business. “To generate what the government estimates, the sales of medical cannabis that would need to be generated would have to be between $250 [million] and $520 million. We are talking about a lot of cannabis; everyone would be medicated in Puerto Rico.”
“I am always asked this question [about legalization],” says Cortes. “Patients need a medical program in place, one that allows us to talk to our medical providers about the healing properties, a program that allows us to buy the quantities patients need and help us with a reduction in the taxes and prices. The recreational market sometimes helps lower the prices and [increase the] availability for the product, but we need to keep medical programs in place.”
With reciprocity, Cortes invites all medical patients to visit Puerto Rico. “Now, you are able to visit our beautiful island and have your medicine. It’s hard to vacation when you are a cannabis patient.”
