When Arizona voters approved medical marijuana in 2010, the traditionally conservative state did so tentatively: The "yes" campaign garnered 50.1 percent of the vote.
So what's happened since?
State officials now call Arizona's system a model for other states, and members of the pro-legalization campaign deem the system a big success.
"If you walk up to a person on the street and say, 'Did you know there are weed shops here?' most people that I've encountered that aren't really related to the medical marijuana world don't even know," said Carlos Alfaro, Arizona political co-director for the Marijuana Policy Project, the Washington, D.C.-based group that spearheaded Arizona's medical marijuana campaign.
"It has gone so smoothly and so well that there haven't been any major hiccups," Alfaro said.
However, opponents of marijuana legalization said the system is "cloaked in secrecy" and questioned whether Arizona is a model state, pointing to factors like its high number of medical marijuana cardholders. They also raise concerns about a lack of transparency and question whether the system has hindered drug cartels as supporters claimed it would.
Now, just five years after voters approved medical marijuana, pro-legalization groups have once again targeted Arizona as a state that could legalize recreational marijuana in 2016. A Marijuana Policy Project-backed campaign is gathering signatures for a ballot initiative to legalize weed for anyone over 21.
Some local marijuana advocates who oppose the project's initiative have broken away from that effort and are pushing a competing initiative that would call for fewer restrictions for consumers and for potential recreational dispensary owners.
And opponents to marijuana legalization are pushing back at public events, on billboards and in local media. Two of the state's biggest anti-drug advocates, Yavapai County Attorney Sheila Polk and Maricopa County Attorney Bill Montgomery, have formed a group to combat any attempts at marijuana legalization in 2016.
Critics: Medical marijuana cards too easy to obtain
Prescott resident Sally Schindel said she became involved in opposing marijuana legalization after her son committed suicide, leaving a note that said marijuana killed his soul and ruined his brain. Since the death of her 31-year-old son, Schindel has become treasurer for Arizonans for Responsible Drug Policy, the political action committee working to defeat any recreational legalization efforts.
Schindel, whose son had a medical marijuana card, said she doesn't oppose medical marijuana itself. But she said it's too easy to obtain a card.
As of June, more than 76,000 people had active medical marijuana cards in the state, according to a monthly report from the Arizona Medical Marijuana Program. Arizona has 14 qualifying conditions to get a card, ranging from cancer and hepatitis C to severe and chronic pain. Patients must provide a doctor with 12 months worth of medical records before they can get a written certification and obtain a card.
Will Humble served as the director of the Department of Health Services and oversaw implementation of the system. Humble, who now works for the University of Arizona, had at one point estimated only 20,000 people would likely qualify for medical marijuana cards because of the state's stringent rules.
Humble said the program's regulations attempted to capture the essence of what voters had approved in 2010.
"I think we did a decent job of putting together a set of regulations that makes it easy for a 'real' cardholder, a person who is legitimately seeking marijuana for a medical reason," Humble said, "while at the same time, making it inconvenient for the recreational user to get a card."
Critics of the system said that listing severe and chronic pain as a qualifying condition opened the door to legal use by individuals who want to use marijuana for recreational reasons. In Arizona, 90 percent of the state's cardholders listed chronic pain as at least one factor on their applications. And most of them were male, ages 18 to 30, according to the Arizona Medical Marijuana Act 2014 End of Year Report.
Ed Gogek, author of "Marijuana Debunked: A Handbook for Parents, Pundits, and Politicians who Want to Know the Case Against Legalization," said he doubts the majority of Arizona's cardholders legitimately need medical marijuana. Gogek told News21 via email that nationwide, most pain patients are female, and older in age, while the average Arizona medical marijuana cardholder claiming pain is young and male.
"The best explanation for such skewed numbers is that most medical marijuana recipients are drug abusers who are either faking or exaggerating their problems," Gogek wrote in a 2012 New York Times op-ed.
Gogek, an addiction psychiatrist who lives in Prescott, Arizona, said during a phone interview that several of his patients told him they received medical marijuana cards after going to a doctor and making up a story.
"It's very unlikely that even a majority of these patients are genuine," Gogek said. "What's going on is drug dealing under the guise of medical care."
Humble said the system's weakest links are a handful of physicians who issue a disproportionate share of certifications, and the limited ability of the Department of Health Services to hold those physicians accountable.
"There's really very limited disciplinary actions that (the department) can take against any physicians who are signing certifications without fully complying with the requirements," Humble said. "That enforcement is left up to those licensing boards."
More than a dozen businesses in the Phoenix area advertise online to potential patients: "No records? No problem!" or "Get a medical marijuana card for only $99."
According to department reports, fewer than 500 of the state's more than 27,000 eligible physician certifiers actually wrote certifications.
Naturopathic doctors, whose medical practices emphasize prevention and holistic treatments, wrote more than 75 percent of the total certifications. These doctors issued an average of 275 patient certifications per year compared to an average of 21 certifications per doctor of medicine.
Dr. Craig Runbeck, former executive director of the Arizona Naturopathic Physicians Board of Medical Examiners, said naturopathic doctors are more comfortable writing certifications because of naturopathy's inclusion of plant-based medicines.
"Marijuana is an herb, something we are trained to deal with," Runbeck said. "Compared to the side effects of many narcotics, marijuana is a safer alternative."
State medical boards have filed multiple complaints against naturopathic physicians since medical marijuana became legalized. Runbeck said several naturopathic doctors originally reprimanded by the Arizona Naturopathic Physicians Medical Board did not understand how to correctly use the state's controlled substances database, which allows physicians to see if patients have prescriptions to other controlled substances. Doctors must access the system before writing certifications for medical marijuana.
In 2012, the board reprimanded Dr. Christine Strong for failing to physically examine eight patients before certifying they qualified for medical marijuana and writing four certifications for chronic pain that the patients' medical records did not support, according to a disciplinary report from the medical board. Strong said the board absolved her after she made changes to her practice, including learning to use the database correctly and keeping clearer patient charts.
As a naturopathic doctor now working at the Cannabis Patient Evaluation Center in Tempe, Strong continues to write certifications.
"It doesn't always take away the pain completely, but it changes patients' response to the pain," Strong said. "But there's still a stigma. Patients are still feeling harassed."
This is from a continuing series from America's Weed Rush, an investigation of marijuana legalization in America, a 2015 project of the Carnegie-Knight News21 program produced by the nation's top journalism students and graduates.