Cannabis is a plant that has been used for its intoxicating effects for at least a century in the United States and for longer in other cultures. It also has a long history of use around the world for purported medical benefits. More than 100 different cannabinoids have been identified in cannabis. The primary intoxicating cannabinoid in cannabis is delta-9-tetrahydrocannabinol (THC). The cannabinoid cannabidiol (CBD) has received increasing public attention in recent years; preliminary findings suggest that CBD may be a useful treatment for several medical conditions and it is not reported to be associated with intoxication or addiction, unlike THC. In this document, the term “cannabis” is used to describe the plant-based products. When the document refers specifically to individual cannabinoids, they are identified as such.

Between 2001-2002 and 2012-2013, the prevalence of past-year cannabis use by U.S. adults increased from 4.1% to 9.5%, respectively, and the prevalence of cannabis use disorder (CUD) nearly doubled. Adults and adolescents increasingly view cannabis use as harmless. A 2019 Pew Research Center survey revealed two-thirds of American adults support cannabis legalization, which reflects a steady increase over the past decade. However, between 9.3% and 30.6% of American adults who use cannabis have CUD as measured in the largest recent national surveys. Specifically, 9.3% of past-year adult cannabis users met DSM-IV criteria for CUD based on the 2017 National Survey on Drug Use and Health (NSDUH).4 2012-2013 data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) showed that 30.6% of past-year cannabis users had DSM-IV CUD.2 Among U.S. lifetime cannabis users (current or past users), 19.5% met criteria for DSM-5 CUD, of whom 23% were symptomatically severe (with ⩾6 criteria). Thus, CUD in cannabis users is not rare and can be serious....

Recommendations (October 2020)

The American Society of Addiction Medicine (ASAM) recommends:

A. Cannabis and Related Products Used for Medical Purposes

1. Cannabis used for medical purposes should be rescheduled from Schedule 1 of the Controlled Substances Act (CSA) to promote more clinical research and FDA oversight typical of other medications.
2. Cannabis and cannabis-derived products recommended for medical indications should be subject to FDA review and approval to ensure their safety and effectiveness.
3. Healthcare professionals who recommend non-FDA-approved cannabis products under the authority of state-level medical cannabis programs should be required to complete specific training with an emphasis on risk mitigation and the prevention, diagnosis, and management of cannabis use disorder and other substance use disorders. Such training should be evidence-based and be informed by high standards of medical professionalism.
4. Healthcare professionals who recommend or write permits for non-FDA approved cannabis should do so only within the context of a bona fide patient-clinician relationship that includes appropriate patient evaluation, creation of a medical record and follow-up visits to assess the results of use and amend the treatment plan as needed. The same amount of caution exercised when any other controlled substance is prescribed should be applied when cannabis is recommended by a healthcare professional for a medical use. Clinicians should be prepared to discontinue treatment with cannabis if it is not effective or causes harm.
5. Healthcare professionals should only recommend non-FDA-approved cannabis if there is evidence that the potential benefits outweigh the potential harms. Healthcare professionals should avoid recommending cannabis to pregnant persons, and should recommend cannabis with great caution, if at all, to those with substance use disorders or psychiatric disorders, or to children and adolescents. Healthcare professionals should screen all patients for cannabis and other substance use disorders and refer to treatment as appropriate before recommending cannabis to be used for medical purposes.
6. Healthcare professionals should not recommend cannabis use for the treatment of OUD.
7. Regulation of cannabis use for medical purposes should be overseen by departments of health. Indications for cannabis used to treat medical or mental health conditions should not be specified by legislatures or public referenda.
8. Non-FDA-approved cannabis recommended by clinicians should be reported to Prescription Drug Monitoring Programs (PDMPs). Healthcare professionals who recommend cannabis should check the PDMP prior to making a recommendation.
9. Potency of non-FDA approved cannabis should be determined and clearly displayed on the label. Healthcare professionals should consider the ratio of CBD to THC with respect to the indication and minimize potential adverse effects.
10. Healthcare professionals should discourage combustion or vaporization of cannabis as a drug delivery method.
11. Federal legislation and regulation should encourage scientific and clinical research on cannabis and its compounds, expand sources of research-grade cannabis, and facilitate the development of FDA-approved medications derived from cannabis such as CBD or other cannabis compounds. Research needs for cannabis to be used for medical purposes include basic outcomes studies.

B. Cannabis and Related Products Used for Non-Medical Purposes

1. Public health efforts through evidence-based prevention programs should be strengthened to discourage people from using cannabis products due to their known potential harms. Given the particular risks to children and adolescents, cannabis products should not be distributed to anyone under the age of 21.
2. Cannabis use and possession should be decriminalized, and civil fines and fees should be eliminated whenever possible. A range of non-mandatory civil penalties to enforce restrictions such as age, place of use, quantity limits and others may be needed, however. Contingencies such as referral for clinical assessment or educational activities are preferred as alternatives to civil penalties. There should be no mandatory minimum penalties, which disproportionately punish people of limited means.
3. States should not use cannabis laws with criminal or civil penalties for possession or use to disproportionately penalize certain members of the population who use cannabis (e.g., people with limited means). States should offer automatic expungement for past minor cannabis-related convictions, so that hundreds of thousands of people — disproportionately people of color — do not remain marginalized for prior offenses.
4. The CSA should be amended so that – as long as states and tribes comply with substantial public health protections – its provisions no longer apply to any person acting in compliance with state or tribal laws relating to the manufacture, production, possession, distribution, dispensation, administration, or delivery of cannabis for non-medical purposes.
5. States or jurisdictions that decide to legalize cannabis production, distribution and sale should use models other than commercialization, such as limiting production, marketing and sale to nonprofits, benefit corporations, small co-ops, buyers’ clubs, home cultivation or a public authority.
6. States or jurisdictions that decide to legalize cannabis production, distribution or sale should only do so within a strong public health-based regulatory framework that minimizes the harms related to legalization. These should include best public health practices established for tobacco control, and components which have been identified as important for minimizing harmful use of tobacco or alcohol. Among these are:  Departments of health as lead agencies with a mandate to protect the public by minimizing all use,
   b. Restrict advertising in print and digital media with a youth audience,
   c. An independent advisory board with a strict conflict of interest policy,
   d. Mandatory merchant education and unannounced compliance checks,
   e. Protected local control over smoking and vaping restrictions, with local ability to prohibit cannabis licenses,
   f. Licensee liability with escalating fines and the possibility of permanent license revocation for violations,
   g. Prohibition of combustible or vaporized cannabis use wherever tobacco smoking or vaping is prohibited,
   h. Prohibition of mail order or electronic sales,
   i. Prohibition of product placement and misleading marketing with government health authority approval of packaging and warning labels,
   j. Prohibition of additives or residual chemicals that are toxic or injurious to health, that impart flavor, or create the impression of a health or energy benefit (e.g. vitamins, caffeine),
   k. Standardized plain packaging,
   l. Messaging on health risks that are aimed at the general public, with health warnings on advertising, promotion, and sponsorship covering a significant portion of the principle display area,
   m. Health warnings against use by persons under age 21 or pregnant persons,
   n. Regularly updated pricing and taxation policies effective to deter consumption,
   o. Quality standards determined by governmental health departments with testing by independent labs.
7. Health messages should warn against cannabis use by persons with a history of mental illness or substance use disorder, as well as persons who are pregnant, and should warn about the risk of impaired driving.
8. Given the correlation between cannabis potency and adverse reactions, particularly cannabis-induced psychosis, potency should be limited.
9. A substantial proportion of cannabis tax revenue should be earmarked to fund prevention and mitigation of cannabis-related harm, and substance use disorder prevention and treatment programs, including public awareness campaigns about the risks of cannabis use, including cannabis use disorder. Cannabis-generated revenue should also be used for enforcement of laws and regulations. Use of cannabis tax revenue for other purposes may create inappropriate incentives to maximize cannabis sales and revenue, despite negative public health consequences.
10. Healthcare professionals should be trained to identify unhealthy cannabis use and use disorder, raise awareness in patients to motivate change, and refer for treatment when cannabis use disorder is identified.
11. Women who are pregnant or contemplating pregnancy should be encouraged to avoid or discontinue cannabis use. Cannabis use during lactation and breastfeeding should also be discouraged as there are insufficient data to evaluate its effect on infants.
12. Excluding emergency circumstances, pregnant women should have a choice whether or not to provide consent for cannabis testing including during labor and delivery. Clinicians should explain state statute and local child welfare reporting requirements as part of the consent process.
13. Future research should include studies on the potential relative harms of various drug delivery systems and potency levels, patterns of cannabis use, prevalence of cannabis-related harm, impairment and motor vehicle crashes, and the effectiveness of prevention and control programs.