For Jakki Hernandez, taking 1,000 milligrams of cannabis a day is about survival.

The 37-year-old Anaheim resident was born with a genetic disorder that causes benign tumors to grow throughout her nervous system, from her organs to her skin. Recently, she broke her foot and learned she has another rare neurological condition, one that means the pain from her injury will continue to worsen, even after it’s healed.

“It’s one of the worst pain conditions you can be diagnosed with,” she said.

Hernandez was only 13 when doctors first prescribed opioids. At 23, they wanted to put a morphine drip in her spine. But her stomach was already wrecked from the painkillers, so she decided to quit opioid use cold turkey.

Cannabis became the substitute.

Today, Hernandez starts each morning by swallowing cannabis capsules and liquid extracts. She sprays a marijuana-infused oil on her injured foot, then slathers on a medicated lotion, and follows that with microdoses of cannabis throughout the day. The regimen, she insists, keeps her pain under control with no debilitating side effects.

“Without cannabis, I don’t know what I would do,” she said.

Jakki Hernandez uses more wide of variety of cannabis brands. She is a patient who uses up to 1,000 milligrams of cannabis a day — in tinctures, pills, topicals, edibles and more — to ease pain from two neurological conditions. (Photo by Bill Alkofer, Contributing Photographer)

California has had an unregulated medical marijuana market since 1996, a law that turned out to make cannabis easily accessible to both serious medical patients and thinly disguised recreational consumers. But new state regulations, and the explosion of the more-profitable recreational cannabis market that started on Jan. 1, is starting a path that is supposed to lead to a wider range of products, lower prices, safety testing and clear dosing labels.

That’s helping patients like Hernandez better manage complex medical conditions. It’s also chipping away at stigmas, increasing awareness and adding legal protections for all consumers.

“As the prices come down, and the variety continues to blossom, it’s nothing but good for patients,” said William Britt, founder of the Association of Patient Advocates in Long Beach, who uses marijuana to manage pain from polio and to control epilepsy seizures.

But some of those changes are in the future. And, for now, many medical marijuana patients say the challenges created for them by California’s new cannabis climate outweigh the benefits. Taxes are high, potency of products is restricted and some once-trusted providers — from doctors to manufacturers to dispensaries — are shutting down.

“It has not been better for me,” Hernandez said. “It definitely has not been easy.”

Patients say they feel left behind in the rush to capitalize on the recreational cannabis market. And they worry things are going to get worse before they get better, with tougher rules set to kick in by the end of the year.

An advantage, but at a cost

State law offers medical marijuana patients one major perk, though it’s not free.

If residents pay for both a doctor’s recommendation and a state medical marijuana ID card, they can avoid paying sales tax that would add an average of 8 percent to their bill.

Prop. 64 capped annual fees to get ID cards at $100, significantly less than the $150 to $175 that most counties previously charged for the cards.

Still, those optional medical marijuana I.D. cards aren’t particularly popular. State records show county health departments issued 6,051 cards in the 2016-17 fiscal year, a 10-year-low and just a sliver of the people who might be eligible in a state with 39 million residents. The number of I.D. cards issued has ticked up this year, with counties reporting a spike in January as new state taxes kicked in, but customer surveys show only about 2 percent of patients who’ve received doctor’s recommendations for cannabis via have gone on to get county ID cards, according to Alex Milligan, cofounder of the San Francisco-based company.

Milligan chalks it up to a lack of awareness. Hernandez has another theory.

Though state law requires patient information to be kept confidential, she believes many cannabis patients fear retribution for joining a government registry. Some cite a court ruling that says marijuana consumers forfeit their Second Amendment right to own a gun, plus other possible complications from cannabis remaining federally illegal.

“Who knows what comes next?” asks patient advocate Britt.

More benefits for patients

Patients who don’t opt to get county ID cards still have slightly better access to legal retailers — many of whom offer price breaks for medical clients. There are 107 cities in California that allow sales to adults with a doctor’s recommendation, compared with just 70 cities that allow recreational shops, according to a database of local marijuana policies compiled by the Southern California News Group.

Another perk is that medical patients only need to be 18 to buy cannabis in a licensed shop, while recreational customers must be 21. Medical users also can legally possess eight times more cannabis than other adults — more if a doctor says its necessary — and they can smoke cannabis in most places where cigarettes are legal, even as Prop. 64 bans public consumption for casual consumers. Cannabis patients can even access cannabis concentrates and topicals that are more potent than what is typical in recreational cannabis.

Jakki Hernandez uses a PeaceMaker Bong in her Anaheim home. She is patient who uses up to 1,000 milligrams of cannabis a day — in tinctures, pills, topicals, edibles and more — to ease pain from two neurological conditions. (Photo by Bill Alkofer, Contributing Photographer)

A proposed law could, if passed, give medical users one more advantage over recreational users — their jobs.

Though Prop 64 legalized recreational use of cannabis, it also allows employers to fire, or not hire, people who test positive for the drug — including people who use cannabis medically. A bill introduced in February by Assemblyman Rob Bonta, D-Oakland, would protect those medical marijuana patients. To date, AB 2069 has made it through one assembly committee and is waiting for another hearing.

Now for the negatives

The biggest complaint most medical marijuana patients have about California’s new system is the impact on prices.

While they get a break on sales tax, since Jan. 1, all patients still pay a 15 percent excise tax imposed by Prop. 64. And they may face additional city or county taxes that can be as high as 20 percent.

That’s why many medical marijuana patients opposed Prop. 64.

Even before taxes, shops have raised prices as they try to cover costs to comply with new regulations that are also limiting what products they can sell.

Some patients, for example, might have spent $15 to buy a candy bar that had 1,000 milligrams of THC under the old system. But since state rules now say edibles can only have 100 milligrams of THC per package, medical patients may pay as much as $28 for a candy bar with just 100 milligrams of THC, said Kandice Hawes, executive director of the Orange County chapter of the marijuana advocacy group NORML. That means they’d need to spend $265 more (plus eat lots of additional calories) to get the same amount of THC they could buy on the gray market just five months ago.

Meanwhile, black market prices are tumbling. The street price for a pound of high-grade marijuana was about $6,000 five years ago, according to Britt. Now, he said, growers would be lucky to get $1,500 for that same batch.

“It makes it hard for patients who want to do it the right way and support this new system,” NORML’s Hawes said. “Money-wise, it just doesn’t make sense.”

Patients also have far fewer options for licensed shops. There were an estimated 12,500 retailers in California last year, according to the Cannabis Growers Association. But only around 400 shops are licensed to sell medical cannabis. And since most cities still ban all kinds of cannnabis shops, some patients in California are 150 miles or more from the nearest legal dispensary.

A major concern for Hernandez is the lack of licensed delivery services, with only about 100 authorized to deliver medicinal cannabis in California. And even then, cities can block those services from legally stopping in their borders. She said serious patients who aren’t mobile may be forced to go without their medicine or use black market delivery services, which may sell untested products.

Doctors forced to shut down

Before Prop 64 kicked in, there were an estimated 20 physicians in the Orange County area who specifically catered to medical cannabis patients, according to Hawes. Since recreational sales started in January, she said at least six have gone out of business.

Dr. Aury Lor Holtzman had a practice in Huntington Beach for seven years that offered $30 medical marijuana recommendations. Often, he said, patients who came to him said they wanted legal protection if they got stopped by police with marijuana in their possession.

But the day after voters passed Prop. 64 in November 2016, all adults could begin carrying an ounce of cannabis and growing six plants at home.

“It was a downward trend since then,” Holtzman said, forcing him to close his practice in March., which offered patients online consultations with doctors, also went dark in mid-January.

Jakki Hernandez uses up to 1,000 milligrams of cannabis a day — in tinctures, pills, topicals, edibles and more — to ease pain from two neurological conditions. (Photo by Bill Alkofer, Contributing Photographer)

But Dr. Allan Frankel, who’s focused on marijuana treatment for 12 years at his GreenBridge Medical practice in Santa Monica, said his business has actually increased in the past few months. Many new patients tell him they feel more comfortable trying marijuana as medicine now that cannabis is legal for all adults.

Frankel said he doesn’t just issue “permission slips” for marijuana and send patients on their way. He reviews their family history, conducts a medical exam, creates a detailed treatment plan and follows up to see if the suggested marijuana products are working. That’s why Frankel said he’s fine with new guidelines issued in April by the Medical Board of California for doctors recommending cannabis.

California’s 1996 medical marijuana law simply said cannabis had to be recommended by “a physician,” with doctors throughout the state taking advantage of that loophole to churn out dozens of referrals a day for patients they’d never see again. The Medical Board now says that doctors who don’t get to know their patients and create treatment plans before recommending cannabis, then monitor their progress, could be at risk for disciplinary action.

There hasn’t been any stepped-up enforcement of doctors so far, according to Medical Board spokesman Carlos Villatoro. The board investigates medical marijuana providers if it receives a complaint and, since 2016, the number of complaints, statewide, generally runs between 15 and 35 a year.

But the industry expects closer attention soon, Frankel said, with talk of the state auditing doctors who recommend cannabis the way regulators are investigating opioid providers to ensure they’re not over prescribing.

More changes coming

Patients are anxious about what the coming months will bring.

State law says all marijuana collectives, which have long sold cannabis to patients under protection of loose medical laws, will be forced to dissolve by the end of the year or get a license like any other retailer.

That’s a problem for the Laguna Woods Medical Cannabis Collective, which for nearly a decade has provided hundreds of seniors in the community with marijuana for medical use. Since the city of Laguna Woods has banned dispensaries, there doesn’t seem to be a legal route for the collective to continue past Dec. 31.

The state gave businesses until July 1 to comply with many other new rules, including THC limits. But medical marijuana businesses caught two breaks under updated emergency rules the state announced Friday.

Earlier regulations required businesses to apply separately for medical and recreational licenses. They also said businesses with licenses to work in the medical marijuana sector could only work with other medical businesses after July 1.

New rules remove that restriction, allowing operators to get one license for both sectors and for recreational cannabis growers, for example, to sell products to medical cannabis manufacturers. That eases one concern shared by Hernandez and others that, once new limits kicked in, the supply chain for medical cannabis would be strangled.

Frankel insists only the “fake” medical marijuana market is evaporating. And he’s optimistic that, once the dust settles, patients will be left with a better system.

“I’m hoping that ultimately medical cannabis will mean something,” he said.

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