Position on Cannabis 

approved by NCPA Executive Council January 30, 2022

Decriminalization of Cannabis
The North Carolina Psychiatric Association (NCPA) Addiction Psychiatry Committee is in favor of decriminalization of cannabis. There is evidence that the potential for harm due to criminalization significantly outweighs the number of individuals who have been harmed by its use. That said, the use of this product--and in particular, daily use-- is associated with significant harms to the individual.

No Evidence Supporting Use of Cannabis to Treat Psychiatric Illnesses
Following a review of the current literature, we see no clear evidence supporting the use of cannabis products in the treatment of psychiatric illness. There is no evidence it is helpful in the treatment of PTSD. In fact, for some individuals, it puts them at greater risk of worsening problems including suicidality. This is not a treatment for their disease. We understand some individuals use this product to relieve their symptoms through intoxication and in that way find some benefit.

There is evidence that cannabis will worsen bipolar disorder exacerbating depression and hastening the emergence of psychotic episodes. This has been shown to be particularly troubling in adolescence.

We along with the American Psychiatric Association recognize there is inadequate information for the effects of non-pharmaceutical cannabinoids use in treating psychiatric conditions to establish it as such. We recognize some of this may be the result of the difficulties the federal government has put in place surrounding the ability to establish clinical research on the use of cannabinoids in the treatment of psychiatric conditions. However, there is now adequate evidence that establishing the legality of “medical marijuana” has not resulted in significant improvement in psychiatric illness in states where it has been established.

Impact on Adolescents
It is clear the regular use of cannabis by adolescents may result in an earlier onset of psychotic symptoms and more commonly a worsening of psychosocial functioning. There are neurotoxic effects from regular use of this product resulting in cognitive impairments most prominent in those under 25 years of age. These problems may extend into adulthood depending on the age of onset and regularity of use. Early onset of cannabis is also associated with the subsequent use of nicotine, alcohol, and other drugs, worsening the young person’s long-term health and social wellbeing. There can be confounding reasons for this evidence, but a consistent factor is the regular use of cannabis at a younger age.

We are concerned the poor evidence for medicalization of cannabis may result in a reduction in perceived risk of use, barriers to access, both potentially resulting in the increased incidence of associated cannabis use disorders. Therefore, we strongly recommend, in the event medical cannabis were to be made legal in North Carolina, significant safeguards be put in place helping to prevent initiation and safeguard adolescents from greater availability of this drug.

Evidence of Health Effects Are Modest
The National Academies of Sciences, Engineering, and Medicine summarized the evidence regarding health effects of cannabis and cannabis-derived products, establishing only modest improvements in pain symptoms among adults with chronic pain and patient-reported spasticity in adults with multiple sclerosis. The contribution cannabis may have to chronic neuropathic pain reduction has been found to be helpful only in short term management of sleep initiation.

Importance of THC/CBD Concentration/Dosing, Provider/Patient Education
These recommendations were also associated with specific THC/CBD concentrations. The concentration of THC found to be most effective for pain is well below that sold on the street and in cannabis medical dispensaries around the country. There has often been a lack of consistent product regulations with evidence of harmful pesticide content and microbial contamination. Any consideration to establish medical cannabis dispensaries in North Carolina should include clear product certification and dosing that is available to providers to properly inform patients on the use of cannabis in their attempt to relieve their symptoms. To do this, it would be important for the provider to be well educated in understanding the effective concentrations and dosing in keeping with the limited evidence available. A universal standard of medicine is to do no harm. It is also important to warn patients against self-diagnosis and the initiation of these products by friends or family. Considering this, a medical treatment should not recommend the inhaling a combusted substance including cannabis. The only exception we make to these considerations would be the use of any form of cannabis use by an individual currently in palliative care.

NCPA Recommendations if Cannabis Legislation Is Passed
The following recommendations are made in the event North Carolina were to establish a law allowing for the distribution of “medical cannabis.”

1) Given the need for control over the quality and the availability of this product, we strongly recommend the State of North Carolina maintain control over the retail outlets for the sale of cannabis. This would allow for store personnel to be educated and the maintenance of their education be monitored, including their understanding of the importance of controlling the sales and the particularities of the products sold.

2) We also recommend these outlets input this medical information into the NCCSRC registry. This would include the dosing recommendations, quantity, and percentage of THC/CBD sold, allowing the patient’s health care providers registered with the NCCSRC to have ready access to this information housed in the same profile in which they see other controlled substance medication information associated with their patient. Those submitting this information at the point of distribution would not have access to other medical information associated with the patient.

3) Tax revenues made available to the State of North Carolina through the sale of these products should be in part used for treatment, research, and collection of population data, including public health impact in general and, most importantly, the impact on adolescent use initiation.

In Summary
1) NCPA supports decriminalization of cannabis.

2) NCPA does not see general health or psychiatric benefits established in the medical literature identifying cannabis as a therapeutic substance important enough to add to the current pharmacopoeia.

3) Cannabis disorder is a growing problem in North Carolina and there is real concern that establishing cannabis as a medical therapy may, as it has in other states, result in the public’s and in particular adolescents’ reduction in their understanding the potential for harm associated with the use of cannabis, thus increasing its use.