Every night, Boyd Nelson is jarred awake by the sound of his wife Bonita's scream.

Her cry of pain, usually occurring around midnight or 1 a.m., alerts him it's time to get up and fix Bonita's medicine, a tea made from ground marijuana. After boiling water and the marijuana together in a pan, he strains it and adds a bit of milk and honey to cut the bitterness.

Since the 87-year-old Bonita suffered a debilitating stroke that caused severe nerve damage to her left side three years ago, Boyd has become her caretaker. In addition to preparing her tea, which she needs to drink every five to eight hours, he has assumed most of the household responsibilities, with help from their son, John. A former farmer, Boyd, also 87, still hays his Manhattan fields every summer, a job that requires about a week of 12-hour days outside.

Although she is now basically homebound and has limited mobility on her left side, Bonita and Boyd said that before she started using marijuana in April, her health was much worse. Even morphine wouldn't break the grip of her pain, which is still audible in her faint, wavering voice.

"It really helped her," Boyd said. "It's just been a godsend."

Bonita Nelson is one of thousands of Montanans - almost 20,000, according to the Montana Department of Public Health and Human Services - who has legally registered to use marijuana. In 2004, Montana voters easily passed an initiative allowing "certain patients with specific medical conditions" to use marijuana to alleviate their symptoms.

In the year after the law took effect, 112 people registered with the state and obtained "green cards," allowing them to purchase, possess and use a limited amount of marijuana at any given time.

But since fall 2009, when the Obama administration announced it would not actively investigate or prosecute people using medical marijuana in states where it was legal, the number of people allowed to use pot in Montana has exploded. From the start of 2009 to July 1 of this year, about 14,000 patients were added to the state's registry.

The effects of the federal decision have been especially pronounced in Gallatin County.

Although it is the third-largest county in the state, with a population of about 89,000, Gallatin County has the second-highest number of medical marijuana patients at 2,729. That's just below Missoula County, which has 2,924 patients out of 107,000 residents.

With about 3 percent of the population holding green cards, Gallatin County far outpaces Yellowstone County, the largest county in the state, which has 1,942 registered users out of 142,000 people, about 1.4 percent.

Towns and cities within the county have been grappling with how to address the influx of growers, storefronts and the accompanying questions of abuse that these numbers have produced. In Helena, a special legislative committee is discussing potential changes to the law, including a licensing system for caregivers and more specific recommendation standards for doctors.

The city of Bozeman recently drafted an ordinance to cap the number of medical marijuana providers within the city limits to 32. Two weeks ago, the Belgrade City Council voted to ban the businesses altogether, as did the Manhattan Town Council.

Whatever new rules the Legislature passes at its next session in 2011, the changes are likely to have a profound effect in Gallatin County, on the patients, caregivers and medical providers who recommend medical marijuana, and on local governments working to address the issue.

WHO'S USING IT

For most of her life, Jehnet Carlson's exertion-induced asthma was manageable, albeit with careful monitoring and an oral steroid regimen. But in 2007, a bad case of the flu landed Carlson in the hospital, where she would return several times a year over the next three years.

"After that, my lungs just never recovered," she said.

The 58-year-old, who is also a diabetic, said she developed severe anxiety about suffering an asthma attack while working on her Dry Creek ranch, away from her husband or other help. Combined with the chronic pain associated with the neuropathy she developed after so many years of taking steroids, "I became a couch potato," she said.

But medical marijuana changed that. Though her doctors were unsure how she would react to the drug, Carlson went to a registration clinic at a local hotel last fall. She uses a both a tincture - an acidized, liquid version of the drug - and a vaporizer to take her marijuana.

"You don't get high," she said. "You don't get the head rush."

Carlson said she experiences no side effects from the drug, and has lost about 40 pounds that she gained while using the steroids.

She said her doctors approve of her choice of medicine, as long as it's working.

Carlson hasn't been hospitalized for nearly a year. In addition, her anxiety is now controlled without the use of anti-depressants, and she has returned to a limited level of strenuous work around the ranch.

"Was it coincidence?" she said on a recent sunny day, referring to the improvement in her symptoms since she started using marijuana. "I don't think so."

Several local caregivers say the bulk of their patients are people like Carlson: middle-age, with chronic illnesses and little or no prior use of marijuana.

"A majority of my patients are 50-plus," said Valerie Sigler, owner of Big Sky Patient Care in Four Corners.

She cited cancer, Parkinson's disease and multiple sclerosis as common diagnoses. Her employees, all licensed caregivers, also see quite a few people with chronic pain complaints.

Sigler said her business is largely set up around the premise of providing quality care to these types of patients, who may be uncomfortable or scared about obtaining marijuana. She operates out of a former veterinary clinic, which has "a medical feel" with its private rooms and separate lab area.

"Patients tell us there's a lot of anxiety about trying to find their medicine," she said. "This kind of setup makes them feel more comfortable."

The most recent data available shows the average age of Montana's medical pot user is 41, according to DPHHS. Those ages 51 to 60 years old make up the second-largest share of the total, with 4,300 people, or 22 percent.

However, the largest group of patients, 25 percent of the total, are between 21 and 30; 5,000 people in this age group use medical marijuana.

The state said it doesn't track demographics of users by county, but Buck Taylor, director of Community Health Partners Bozeman, said the 21-to-30 figure makes sense, given the makeup of Gallatin County's population and what many criticize as overly lax guidelines for getting a green card.

"Demographically, Gallatin County is a very young population. I think the word has gotten out like wildfire that it's pretty easy to get your card. If they were maybe using marijuana recreationally and maybe worried about the implications about the legality ..." Taylor said, his voice trailing off.

Then he continued, "It certainly seems like people can get their card for any number of medical complaints."

In a request for participation in this article, several people in their 20s responded, but did not wish to be named to avoid judgment by peers or employers or, in one case, possible legal repercussions.

WHO'S RECOMMENDING IT

The most high-profile group working to register new patients is the Missoula-based Montana Caregivers Network, headed by Jason Christ.

Just last month, the organization, known for registering hundreds of patients at its traveling clinics, decided to discontinue its "cannabis caravan" practice. MCN has been criticized by many, including the Montana Board of Medical Examiners, for bringing in out-of-state doctors who spend only a limited amount of time with potential patients before recommending medical marijuana.

Chris Arneson, MCN's public information officer, said the group set out to fill a void created by the unwillingness of Montana doctors to write recommendations.

With the end of the clinics, MCN plans to set up permanent locations in several communities, including Bozeman. It also holds teleconferencing clinics, where patients use the Internet to speak with a doctor based in another state.

"The business model has changed," he said. "We can serve our patients better if we have a true clinic type setting."

Arneson said there were "no doctors in Bozeman that we know of" who write recommendations for medical marijuana. "Most hospitals have a policy against primary care physicians or pain management specialists who are allowed to prescribe medical marijuana. Essentially, DPHHS has figures that 95 percent of doctors in Montana won't prescribe medical marijuana."

The Bozeman Clinic has a policy of not recommending medical marijuana, but not Bozeman Deaconess Hospital, said Connie Martin, the hospital's director of marketing and communications.

"There is no written policy for or against medical marijuana," she said. "Our doctors are allowed to practice within the limits of state and federal laws to provide the best quality care for patients."

Dr. Kathryn Borgenicht, who practices internal and palliative medicine at BDH, is one doctor who will recommend medical marijuana "in very specific situations," she said.

"I do a complete evaluation of a patient, then they have a follow-up with either myself or someone in my office," she said.

She has found that some of her patients undergoing chemotherapy experience fewer side effects if they use marijuana. She will also consider recommending it for patients undergoing end-of-life care who have "persistent" pain.

"For some of these people, medical marijuana has fewer side effects than opiate options," she said.

But it is overused, she said, and a lack of solid scientific research on the medicinal properties probably makes other physicians uncomfortable with it. The industry also needs more regulation.

"I think it would be helpful if there were some good guidelines to follow for physicians," she said.

Bonita Nelson's primary care doctor wrote her a recommendation, but she declined to name him.

Some doctors in private or group practices are afraid of becoming known as "the pot doctor," said Charles "Stonewall" Thomas, who operates Honest John's Farmacy in Belgrade, the only storefront dispensary in the city.

Thomas said he prescreens people before helping them set up appointments with physicians. He also refers patients to Premier Networking in Four Corners, which uses Skype, an Internet video-networking site, to facilitate appointments between patients and out-of-state doctors.

Thomas said he has turned people away for not having medical records, including some "young people with back pain," he said.

"There's people out there who want the medicine for the wrong reasons," he said. "They were not the type of client we wanted."

WHAT THE GOVERNMENTS ARE DOING

The issue of how to regulate medical marijuana within municipal boundaries has been heavily discussed in recent months by the governments of Bozeman, Belgrade, Manhattan, Three Forks and West Yellowstone.

Citing a reluctance to have a "Main Street full of marijuana," Belgrade officials passed one of the more restrictive ordinances. Growing, selling or distributing marijuana is banned within city limits, but caregivers with a valid city business license may still deliver to their patients with a valid city business license, said Mayor Russ Nelson. Patients are still allowed to grow their own plants in their homes.

Manhattan also recently passed a ban on commercial medical marijuana operations within city limits. Three Forks and West Yellowstone are still working on their regulations, but Three Forks Mayor Gene Townsend and West Yellowstone Town Manager Jamie Greene said they are studying Bozeman's recent effort to cap the number of businesses within city limits, as well as require facility inspections and prohibit smoking in public.

Townsend said that while public meetings on the matter have drawn proponents of a ban like Belgrade's, he doesn't think it's a good idea to "zone them out of business." There are currently no dispensaries or grow operations licensed in Three Forks.

"Instead of pushing it out in the county, or pushing it underground, do you at least try to come up with an ordinance where you can inspect them, have police inspect them and regulate them?" he said. "The legitimate people will step up to the plate and make it right, and hopefully the people who aren't will get out of the business or get out of town."

Townsend, like the other government officials interviewed, said he wished the state had done a better job of clarifying the law before it reached the local level.

"It's really throwing the cities and towns into a loop," he said.

The Gallatin County Commission has no plans to address the issue, said Commissioner Steve White.

"It's really important to understand that quite a bit of the county is already zoned," he said.

For instance, Four Corners - where some grow operations have set up shop to avoid Bozeman's new regulations - already has zoning in place, and medical marijuana is an allowed use.

And no Four Corners' residents have asked to change that, White said.

"The solution really is in Helena," he said. "This was something the people voted for. We can only do the things the Legislature gives us power to do.

"You still have to provide the opportunity for legal businesses to operate. You've got to allow it, you've just got to figure out where."

For their part, both Sigler and Thomas said they support some of the changes to the law being batted around in Helena, like establishing a licensing process for caregivers.

"Everyone just wants to know what to do," Sigler said.

But the most fundamental change, she said, must come with doctors being more willing to recommend marijuana for their patients.

"Some of the alternatives have gotten out of hand, like those traveling clinics," she said. "(But) there's a bottleneck because there are not enough doctors to write recommendations. In a perfect world, their doctors will do it for them. We need to educate doctors so they're not afraid to write them."

Sigler said she is encouraging Big Sky Patient Care's patients-she has about 200-to register to vote and get involved in the political discussion.

"Patients need to understand that this is a fragile system for them," she said.

Lauren Russell can be reached at lrussell@dailychronicle.com or 582-2635.

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