Physicians Should Make Harm Reduction Part of the Discussion About Cannabis

A patient comes to you who is interested in using cannabis or CBD (cannabidiol extracts). How should you respond?

“It is important that we first listen to the patient and defer judgment,” Henry Levine, M.D., a clinical professor of psychiatry at the University of Washington, said in a session today. Then, the psychiatrist can dispassionately provide the evidence and risks related to the patient’s history and reason for the patient’s interest—Is the patient trying to lower anxiety? Reduce pain? Stimulate appetite?

During a comprehensive two-part session on the evidence and harms of medical and recreational cannabis, Levine laid out a lot of data on why people with psychiatric issues should be steered away from these substances: one reason is that 25% people with a psychiatric illness who use cannabis go on to develop cannabis use disorder, compared with 9% of the general population; another reason is that cannabis can be a potent immunosuppressant.

However, given that deterred patients may try it anyway, as it is getting easier to acquire cannabis and CBD legally, Levine suggested that psychiatrists should do their best to encourage safe consumption.

One opportunity for intervention is to encourage patients to use cannabis only when they have nothing important planned; for example, don’t take it before going to work or school. Psychiatrists should also encourage patients to take breaks from use to avoid becoming recreational users and make them aware of potential legal consequences, such as loss of employment despite having a cannabis authorization card if they fail a drug screen.

Other harm reduction points to tell patients include the following:

• Avoid synthetic cannabinoids.


• Use high CBD/low THC marijuana strains.


• Store all cannabis under lock and key so kids and pets cannot access.


• Use of water pipes does not reduce the amount of smoke intake, only the temperature.


• Do not share joints, pipes, or other vaping devices.

Steering patients to CBD—which are legal, available over the counter, and reportedly safe—may not be the answer to discouraging patients from using cannabis. As Levine pointed out, patients also have countless options for a mode of delivery. They can shower with CBD soap, eat CBD-fortified foods, freshen up with CBD lotions, and even sleep on CBD-infused pillows. But Levine stressed that CBD products are poorly regulated and pose numerous health risks. In particular, some laboratory analyses have found that 21% of the time, the basic requirements of legal CBD supplements—that THC levels must be below 0.3%—are not met. This could pose problems for some people who have to take drug tests, as their samples will turn up positive. Other purity factors are that hemp (the term for low THC cannabis plants) readily absorbs heavy metals from the soil, and many companies don’t adequately remove these toxic metals.

Levine offered some steps to help patients choose safer CBD products:

• Look for something sourced in the European Union if possible, since the European Union has stronger CBD regulations than the United States.


• Look for products where CBD was extracted using carbon dioxide and not organic solvents.


• Choose organic CBD products since those presumably were not exposed to pesticides.

For psychiatrists who are willing to go one step further, Levine suggested visiting local cannabis dispensaries with good reputations and ask the staff to teach them about their products, so they can offer more specific guidance on strains to avoid and safer alternatives.

“Remember that our patients are more susceptible to the harms of this product,” Levine concluded. “And one part of our job is to reduce that harm as best we can.” ■