Issued October 12, 2015

As physicians dedicated to improving the treatment of substance use disorders, the California Society of Addiction Medicine (CSAM) provides the voice of addiction medicine specialists on clinical issues and public policy in California. CSAM’s recommendations for cannabis policy in California support the public’s health along a broad range of issues consistent with good scientific evidence and social justice.

The CSAM Executive Council formed a task force to address the following question: In the advent of policy changes that may increase availability of cannabis, an addictive drug, what are credible and evidenced based positions that prevent addiction, prevent harm to vulnerable populations, and promote access to quality treatment? It is not necessary to support an initiative to work toward ensuring that whatever initiative is presented or eventually adopted takes measures to mitigate public health harms associated with expanded access to and use of cannabis.

The Task Force has established the following recommendations for cannabis policy in the prospect of possible ballot initiatives legalizing cannabis in California:

WHEREAS:

1. Cannabis contains potentially addictive substances; regular or heavy cannabis use at an early age may lead to Cannabis Use Disorder (CUD). 
2. Current policies in California regarding the use of cannabis have failed to effectively protect California youth from potential medical, social, economic and psychological harm.
3. Current policies in California regarding the use of cannabis have failed to effectively protect Californians with psychotic disorders, or other distinct vulnerabilities, from cannabis related harms.
4. Criminal justice interventions have not been shown to be effective in preventing cannabis related harms.

THEREFORE: 

1. CSAM opposes criminal sanctions for use or personal possession of cannabis by adults and youth.
2. CSAM supports access to evidence-based treatment for all individuals who suffer from Cannabis Use Disorder, and a public health approach to prevent or reduce cannabis related harms among at-risk populations, particularly youth, persons with psychotic disorders, and pregnant women.
3. Policy changes that increase access to cannabis should establish adequate regulations to protect the public health.
4. Any policy change that generates tax revenues from use of an addictive substance such as cannabis should also ensure that sufficient tax revenue is committed upfront to fully fund prevention, intervention and treatment programs for vulnerable populations such as youth.

RECOMMENDATIONS:

1. Prevent or reduce use of cannabis by youth and mitigate harm to youth from cannabis use by the following:

A. Decriminalization for all ages
Since 2011, the possession of less than one ounce of cannabis (considered a personal use amount) has been reduced from a misdemeanor to a civil infraction, with a $100 fine for possession.

i. If cannabis is legalized for adults, California should set the age for legal possession and use at 21 and over, with strict enforcement of the age limit.

B. Sanctions for Youth Possession
Mere cannabis possession should not be conflated with a clinical diagnosis of cannabis use disorder (“addiction”).

i. Eliminate the practice of “up-charging” small-amount possession to “intent to distribute” in order to qualify youth for juvenile court probation-based treatments.

ii. Develop a graded series of civil sanctions for minors, taking into account concepts such as the following:

a. Fix-it tickets requiring enrollment in structured school-based Student Assistance Programs (SAPs), appropriate drug education programs for youth under 21 who are not in school, or (when indicated) clinical care

b. Waiver of fine after completion of sanctioned requirements

c. Parental notification and engagement whenever possible

d. Privacy protections for individual names in infraction databases

C. Structured Student Assistance Programs (SAP) in all high schools

i. Develop and fund highly structured programs in all high schools with the staff capacity to conduct behavioral assessments, offer basic counseling and peer support services, and referrals for professional evaluations and follow-up care when appropriate.

a. Reserve 20% of cannabis tax revenues to be earmarked for SAPs

b. For program designs utilize the Institute of Medicine (IOM) three-level structure of prevention services

c. Elimination of zero-tolerance suspension and expulsion policies in favor of SAPs

d. Parental engagement an essential component

ii. Goals of SAPs include retention in school, reduced drug use, and improved academic performance. Create a database with anonymized data to permit analyses of longer-term outcomes including drug use, school retention and academic performance.

D. Analysis of Juvenile Justice Treatment Outcomes
For youth who are adjudicated and treated within the Juvenile Justice System, we recommend annual analysis and publication of outcomes results from the probation and in-custody treatment systems.

i. We recommend that such data be analyzed by an agency outside of the criminal justice system itself, such as the Legislative Analyst’s Office (LAO) or a California-based research institute.

2. If cannabis is legalized for adults, a regulatory structure overseeing sales and distribution should be established to include:

A. The California Department of Public Health participating in establishing the regulations

B. Strict enforcement laws against distribution of cannabis to individuals under 21

C. Strictly limiting the number, type and location of outlets

D. Bifurcate sales outlets for medical and recreational cannabis. Sales from medical cannabis should be separate from recreational cannabis

E. Strictly limiting sales promotions and practices of cannabis retail outlets

F. Forbid the distribution of free samples

G. Limit sale of all products that are particularly attractive to young people, such as edibles that look like candy

H. Restrict all marketing and advertising practices that appeal to youth

I. Prohibit additives, such as nicotine, flavoring and menthol that can promote increased use and reduce awareness of cannabis dose

3. Measures to prevent or reduce accidental ingestions and overdoses, particularly among vulnerable populations to include:

A. Prohibit products and packaging likely to be attractive to youth or easily accessible by young children (e.g. use childproof packaging)

B. Limit concentration of THC, CBD and other cannabinoids in cannabis products

C. Establish uniform labeling requirements for all cannabis products, including seed to sale lot tracking, and certification of purity from pesticides, mold, and other contaminants as well as quantified content of THC and CBD in mg per unit

D. Clearly display warnings on all cannabis products

E. Display signage at all cannabis outlets warning vulnerable populations of potential harmful effects: youth, pregnant women, and individuals with mental health issues

4. The California Department of Public Health should take a prominent role in establishing and overseeing regulations and resources to reduce public health harms related to cannabis use, including:

A. Continued research into measuring and preventing impaired driving

B. Mandatory testing for product purity (pesticides, molds, etc.)

C. Prevent exposure to second hand smoke and THC vapors by adopting restrictions on public use similar to tobacco, and permit localities to set restrictions that exceed state requirements

D. Provide Science-based Public Education

i. Universal media based public education programs are more effective than those narrowly targeting youth. Media campaigns should be science-based and:

ii. Provide science-based information on the effects of cannabinoids and effects of smoking of any drug

iii. Provide data in support of delay of initiation of cannabis use

iv. Encourage moderation, self-regulation, and harm reduction when abstinence is not practiced

v. Include special educational focus on:

a. Driving Under the Influence of Drugs

b. The risk of overdose intoxication by use of edibles

c. Portrayal of cannabis use as “normal”

E. Establish dedicated sustainable funding of universal availability of drug treatment for individuals with Cannabis Use Disorders consistent with laws which mandate that there be parity in health insurance benefits for substance use disorders and for general medical disorders.

F. Support the establishment and maintenance of a collaborative evidence-based continuum of drug and alcohol treatment for teens and young adults with Cannabis Use Disorder. The network should serve as a resource for referral to ambulatory treatment, day treatment and residential treatment. It should collaborate closely with the SAPs to provide bi-directional referral resources when out of school programs are necessary. The effectiveness of this network should be evaluated on a regular basis.

5. If cannabis is legalized for adults, provide $10 million in stable funding with annual COLAs to California-based academic and research institutes for public health outcomes research to guide revisions to the law focusing on the following:

A. Outcome Studies: Initial priorities include assessment of structured Student Assistance Programs, juvenile justice interventions, emergency room presentations of cannabis-related urgencies/emergencies, rates of use, and the public’s perception of risk associated with cannabis use.

B. Professional Research: What constitutes treatment and who gets it; complete separation of medical and recreational cannabis.

C. Technical Research: Assessment of cannabis intoxication and driving risks, clinical effects of high-potency extracts and edible products

Above Statement Issued October 12, 2015

CSAM Task Force on Cannabis:

Itai Danovitch, MD, MBA (co-chair)
Monika Koch, MD (co-chair)
Seth Ammerman, MD
Peter Banys, MD, MSc
Angella Barr, MD
Timmen Cermak, MD
Ihor Galarnyk, MD
Randolph Holmes, MD
Brian Hurley, MD, MBA
Cathy McDonald, MD
Mario San Bartolomé, Jr., MD, MBA