Marijuana Legalization in California: Rational Implementation of the Adult Use of Marijuana Act (AUMA)

One or more marijuana legalization initiatives will be on the California ballot in November 2016. The most carefully crafted and best funded is 15–0103, The Control, Regulate and Tax Cannabis Act of 2016, informally known as the Adult Use of Marijuana Act (AUMA) (State of California Department of Justice 2015a). AUMA incorporates most, but not all, of the recommendations of Lt. Governor Gavin Newsom’s 2015 Blue Ribbon Commission (BRC) on Marijuana Policy’s Youth Education & Prevention Work Group Report (BRC 2015). If passed, recreational marijuana possession will remain illegal only for minors under age 21. This editorial reviews core issues related to young marijuana users and makes independent recommendations for rational implementation of AUMA. Although the authors are members of the BRC, the following recommendations do not necessarily represent BRC consensus.

Medical marijuana as a base for recreational marijuana

The influence of the Medical Marijuana industry in California (authorized by a voters’ initiative in 1996) is evident in AUMA’s concatenation of medical and recreational marijuana, essentially promoting vertical integration for existing stakeholders and a business expansion of pre-existing medical marijuana dispensaries. AUMA prohibits large-scale cultivation licenses for the first five years in order to promote small and medium businesses. Research studies are authorized to evaluate the need for additional regulations to control anti-competitive and monopolistic practices. AUMA bans advertising of “untrue” health claims.

Recommendations

1. Bifurcation of Marijuana Dispensaries: The state should bifurcate medical and recreational marijuana dispensaries into physically separate facilities. The future of cannabinoid pharmaceuticals lies in highly purified, pharma-grade products with FDA-approved indications that should, in the next decade, be distributed from standard pharmacies. Separating patients from recreational users in dispensary settings will help clarify today’s blurry boundaries between two kinds of uses and two kinds of users.

2. Medical Marijuana Regulations: All medical marijuana recommendations/prescriptions should be tracked in the California’s confidential CURES database (already tracking opioids, stimulants, and sedatives) (State of California Department of Justice 2015b). Medical marijuana recommendations/prescriptions for youth under 18 should only be permitted following a second opinion from a board-certified, treating pediatrician and parental notification and approval.

3. Health Benefits Advertising: No health claims of any kind should be permitted. First, this initiative is not primarily a medical marijuana regulatory document. Second, on the recreational side, there is no reason to promote marketing by permitting spurious health claims for products that actually have some health risks. Third, science takes years to reach expert consensus on benefits, side-effects, and health costs. In the present environment, corporate interests will produce health advertising backed up by scant evidence or single studies.

Community controls

AUMA allows zoning controls, outright local bans and local taxation of the recreational marijuana industry. AUMA indirectly opens the door to consumption cafes (often called “Brown Cafes” in the Netherlands). AUMA permits on-site smoking, vaporizing, and ingesting in retail or microbusiness outlets. Such legal-use sites could also legally sell coffee, baked goods, and cannabis products, but not tobacco or alcohol.

Recommendations

1. Retail Outlets: On-site consumption should be banned in all medical dispensaries and recreational retail outlets. Liquor stores cannot permit drinking on premises; consumption is restricted to duly licensed bars and restaurants. Legal use venues for marijuana should require similar specialized licensing.

2. Consumption Cafes: It is prudent to delay licensing of consumption cafes for five years in order to first develop reliable protocols for assessment of marijuana-related driving impairment.

Protection of youth and effective sanctions

AUMA has a number of well-crafted provisions for protecting youth, including maintaining illegality of possession by minors, dedicating 60% of marijuana tax revenue (after regulatory expenses) for youth prevention and remediation, designating funding for Student Assistance Programs (SAPs), and specifying educational and supportive sanctions for underage marijuana use. AUMA is in concert with many Western countries that have defined 1 oz. (28.3 g) of marijuana as the upper limit in possession for personal use. Semi-annual reports of youth infractions, misdemeanors, and felonies will help to assess the efficacy of legal sanctions.

Recommendations

1. Labeling and Advertising: Although AUMA prohibits packaging and advertising that is attractive to youth, the public needs to be given a pathway to request a Bureau of Marijuana Control review of packaging, labels, marijuana products, advertising, and marketing that appear to be excessively attractive to young people.

2. Prevention Frameworks: The Institute of Medicine and SAMHSA frameworks for preventive care should be incorporated into all prevention and intervention services for youth, especially Student Assistance Programs (SAMHSA 2015; Springer and Phillips 2007). Supported school and community programs should emphasize evidence-based education, effective prevention, early intervention, school retention, and timely treatment services for youth and their families. School retention is a particularly important goal and one metric of long-term outcomes.

3. Community-Based Treatment Programs: Legislators need to specify stable funding support for the development of new public-sector clinical programs for affected youth and provide stable salary funding for the required counselors, clinicians, and learning disorder experts. Funded providers must be professionally credentialed and must document advanced training in adolescent psychology, substance use, and learning disorders.

4. Proportional Sanctions: It makes better common sense to define at least three tiers of possession with proportional sanctions: (1) personal use amount < 1 oz; (2) excessive personal use possession (perhaps 1–8 oz); and (3) trafficable amount in possession (perhaps >8 oz). Youthful, peer-based sharing or group purchases should not be legally conflated with criminal intent to distribute or trafficking.

5. Juvenile Justice Evaluations: The general efficacy of probation-based treatments and the specific practice of up-charging possession to “intent to sell or distribute” to qualify arrestees for probation will require independent evaluations by the Attorney General.

6. Anonymization of Youth Databases: Expunging of arrest/conviction data after two years and at one’s eighteenth birthday is provided, but privacy protections remain incompletely spelled out. Youth arrest and adjudication databases must be anonymized, but data must be granular enough to support the above studies.

Evaluations and research

The Director of the new Bureau of Marijuana Control will appoint an Advisory Board, including representatives from industry, labor, state agencies, and public health. AUMA supports only a decade of research and evaluation with an annual $10 M. In addition, it pipelines $2 M per year to a UCSD medical marijuana research center and $3 M to the California Highway Patrol (CHP) for five years to develop DUI protocols.

Recommendations

1. Director’s Advisory Board: The Director’s Advisory Board appears overly weighted towards industry and labor representation with insufficient clinical and evaluation inputs. The membership should be balanced among industry interests, regulatory agencies, secondary education, and public health experts.

2. Clinical Advisory Board: AUMA reserves 60% of marijuana tax revenues for the Youth Education, Prevention, Early Intervention and Treatment Account, to be managed by the Department of Health Care Services. We recommend an outside Clinical Advisory Board for the Department, consisting of expert representatives from addiction medicine, adolescent medicine, secondary education, and research/outcomes science. They are needed to advise on funds disbursement, long-term outcomes evaluation strategies, and evidence-based public education.

3. Long-Term Research Funding: Long-term studies beyond a decade are needed to understand the impact of AUMA on youth. Research funding should include annual COLA’s and be extended (at least) to a second decade. There should be no pipelining of research grants. The CHP is not organized to conduct research. Both medical marijuana and DUI studies would be more transparently managed through a competitive Request for Proposals (RFP) process.

4. Research Foci: AUMA responsibly calls for research on diverse marijuana-related concerns. However, many of the issues related to youth use (cognitive impact, educational progress, addiction risks, and psychiatric comorbidity) require long-term studies. Additional foci should include:

   • Long-term evaluation of Student Assistance Programs, including drug use and school retention;

   • Long-term evaluations of new community-based treatment programs for juvenile addictions;

   • Long-term evaluations of medical marijuana recommendations/prescriptions for juveniles;

   • Evaluation of medical risks of high-potency extract products, including analyses of emergency room presentations; and

   • Intoxication and DUI studies.

Conclusion

Three of the most important recommendations remain unmet in the AUMA initiative filed for the November 2016 California ballot: (1) implementation of medical and recreational marijuana dispensaries in entirely separate physical sites; (2) second medical opinion support and parental notification for juvenile medical marijuana recommendations/prescriptions; and (3) funding for long-term research and outcomes studies beyond the initial decade of support. Implementation of any will require additional legislative action following AUMA’s passage (which seems likely according to current polls). All new programs supported by marijuana tax revenues would benefit from sustained studies to assess the long-term impact of legalization on adults, and sanctions on California youth, the only sub-population for whom marijuana possession will remain illegal.