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Washington, D.C. -- The tidy Takoma Wellness Center, one of the first medical marijuana dispensaries to open in the nation's capital, has a quaint reception area furnished with black leather chairs, plants and artwork. On the front desk are a pile of business cards and a sign-in sheet. In the back, shelves are stocked with the latest marijuana accessories: pipes, cookbooks, even a machine that mixes the drug into butter or oil for cooking. All that's missing are more patients. Since opening this summer, the three Washington, D.C.-based marijuana dispensaries have served a total of 111 patients in a district with about 600,000 residents. That's about 100 times fewer patients, on a per capita basis, than states such as California or Oregon, where the drug can also be legally used to alleviate illnesses. Not surprisingly, all three of the dispensaries say they are losing money. "I think there was a general expectation that the numbers would be higher," Jeffrey Kahn, owner of Takoma Wellness Center, said in an interview. The low numbers reflect a medical marijuana program that is considered the most restrictive in the nation. Patients can get prescriptions only from doctors with whom they have had an ongoing relationship, and only if they suffer from one of four conditions: HIV/AIDS, glaucoma, cancer or severe muscle spasms, such as those caused by multiple sclerosis. Although just three dispensaries have opened, the law allows up to five. To even visit one, patients must register with the health department, make an appointment and show a district-issued ID card before passing through security. That's a stark contrast from California, where patient registration is voluntary, doctors use their own judgment to determine whether medical pot can relieve an ailment, and some dispensaries are located just steps from the beach or deliver to a patient's door. In other states, the list of qualifying conditions is longer. A law passed in Illinois this year included 30 ailments. "They deliberately have the most buttoned-down laws in the country," said Mark Kleiman, a professor of public policy at UCLA. He said the district's strict rollout of medical marijuana reflected a desire by local officials "to keep the feds calm." For more than a decade, D.C. officials struggled to make medical marijuana available to their residents. In 1998, 69% of district voters approved a medical marijuana initiative. But such efforts were routinely overruled by conservative members of Congress, who wield unusual influence over the district's laws. After the 1998 ballot measure, then-Rep. Bob Barr, a Republican from Georgia, amended the district's budget to keep money from being spent on the program, effectively blocking it. But changing attitudes from Congress, as well as from the Justice Department, have opened the door for the district to quietly begin its medical marijuana program. Even Barr, who left office in 2003, reversed his position after aligning with libertarians. His newfound opposition to government intrusion led him to lobby Congress in 2007 on behalf of the Marijuana Policy Project, a nonprofit advocacy group that supports legalization, to remove his own amendment. (He is now running for Congress again as a Republican in Georgia's 11th District.) The Barr amendment was removed in 2009, and medical marijuana became legal in the district in 2010, drawing little notice from Congress. By that time, medical cannabis was legal in 14 states. Even when Colorado and Washington state passed laws legalizing recreational marijuana use last year, Congress said "nothing. Not a whisper," said Kleiman, who advised Washington state officials on how to set up their legal marijuana program. The Justice Department subsequently said it would not challenge the legalization programs as long as they were well-regulated. That move paved the way for dispensaries in Washington, D.C., to operate with little fear of federal intervention. "We're part of a robust regulatory system that the Justice Department called for," said Takoma's Kahn. Many patients and doctors praised the district's program, saying marijuana has been shown to relieve pain and improve appetites. Michelle Hill, a patient at another dispensary, Metropolitan Wellness Center, said the drug helped with the severe spasms she suffered because of a spinal cord ailment. "When I smoked cannabis, I had none of those issues," she said at a D.C. Council hearing in October. The district is looking into increasing availability by expanding the list of qualifying ailments. "We'd love to be able to help those patients," Scott Morgan, a spokesman for the dispensary Capital City Care, said of allowing more ailments to be treated. "We're looking forward to that. We think that's going to be a big help to the program." The changed landscape also has advocates confident that Congress will not object to a proposed local law that would decriminalize the possession of small amounts of pot. "Congress is unlikely to step in," said D.C. Councilmember Tommy Wells, who has proposed making possession of 1 ounce or less of pot a civil offense, subject to a fine that may be as low as $25. The measure, aimed at curbing a disproportionate number of arrests of African Americans for marijuana possession, has support from 10 of 13 council members, as well as Mayor Vincent Gray. Seventeen states have similar laws. Councilmember Yvette Alexander opposes decriminalization, warning it could exacerbate the district's drug problem. "I think it's going to encourage the drug market even more, if there's no fear of a crime or criminal record," she said. But Wells predicted that it would be law by early next spring. "I was excited about the response — or rather lack of response — by Congress," said Dan Riffle, lobbyist for the Marijuana Policy Project, adding that he had not heard opposition from any legislators about the decriminalization bill. "Everyone gets the message that marijuana is going to be legal sooner rather than later."