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Cannabis and cannabinoid-based therapies are increasingly encountered in clinical practice for symptom management, particularly in pain, nausea, appetite stimulation, and spasticity, yet their use remains clinically complex because of variable product formulations, inconsistent evidence, and evolving regulatory frameworks. This activity provides clinicians with a focused review of cannabis pharmacology, including distinctions among cannabis, marijuana, hemp, delta-9-tetrahydrocannabinol, and cannabidiol, as well as Food and Drug Administration–approved cannabinoid products such as cannabidiol, dronabinol, and nabilone. This activity also covers approved and off-label clinical indications, pharmacokinetics, adverse effects, contraindications, drug interactions, toxicity, and considerations in special populations, including pregnant patients, children, and older adults. Particular emphasis is placed on safe prescribing, patient counseling, recognition of intoxication and withdrawal, and interprofessional management strategies. Participants are expected to gain the knowledge and clinical judgment necessary to evaluate therapeutic appropriateness, identify risks and precautions, counsel patients effectively, and integrate cannabinoid-related care into evidence-based clinical decision-making. Objectives: Identify the differences among cannabis, marijuana, hemp, and approved cannabinoid pharmaceuticals that are relevant to clinical decision-making. Assess patient-specific risks related to cannabinoid therapy, including psychiatric, cardiovascular, hepatic, pregnancy-related, and substance use concerns. Evaluate when cannabinoid use may contribute to acute or chronic complications that require treatment modification, supportive care, or specialty referral. Collaborate with pharmacists, nurses, specialists, and other members of the interprofessional healthcare team to improve communication, monitoring, and patient-centered management for individuals using cannabis or cannabinoid products. Access free multiple choice questions on this topic.

Clinical Features Data on cannabinoid toxicities remain limited in the literature. The lethal dose has not been established, and studies on dog and monkey models have shown that doses up to 3000 mg/kg do not lead to fatality.[70] Findings from a recent study suggest that electroencephalography can detect acute cannabis consumption. Electroencephalography displays alterations in θ-band oscillatory activity (4-7 Hz); it is not a validated clinical tool for diagnosing cannabis intoxication.[71] Cannabinoid overdose has no known antidote; only supportive therapy is available to help manage the symptoms. Chronic, prolonged, high-volume use of cannabinoids can lead to neuropsychiatric effects, with intelligence quotient and cognition being most impacted.[72] The estimated toxic dose for dronabinol is 30 mg/kg. Illicit synthetic cannabinoids are known to lead to toxicity at much lower doses. Overdose with dronabinol or nabilone can lead to a range of symptoms affecting the CNS, cardiovascular system, gastrointestinal tract, and autonomic functions. These symptoms may include drowsiness, euphoria, heightened sensory perception, altered time awareness, memory impairment, mood alteration, depersonalization, lethargy, slurred speech, and impaired motor coordination. Autonomic features include dry mouth, reddened conjunctiva, urinary retention, and reduced bowel motility. Tachycardia and postural hypotension are also observed. Individuals with a history of anxiety or nervousness may experience panic reactions, and seizures can occur in patients with known seizure disorders. Psychotic features such as hallucinations, delusions, or paranoia are observed at very high doses. Marijuana toxicity may manifest with clinical features such as tachycardia, postural hypotension, tachypnea, nystagmus, ataxia, euphoria or dysphoria, conjunctival injection, hypotonia, seizures associated with the coingestion of cocaine, impaired cognition, respiratory depression, and coma.[73] Diagnosis Following guidance from the Substance Abuse and Mental Health Services Administration, the recommended detection threshold is 50 ng/mL.[23][74] Management An anecdote for overdose is not available; only supportive therapy to help manage the symptoms. Discontinuation of the drug is essential. The management of conditions related to marijuana toxicity involves the following actions:

Following guidance from the Substance Abuse and Mental Health Services Administration, the recommended detection threshold is 50 ng/mL.[23][74] Management An anecdote for overdose is not available; only supportive therapy to help manage the symptoms. Discontinuation of the drug is essential. The management of conditions related to marijuana toxicity involves the following actions: Maintain airway, breathing, and circulation. In patients with respiratory depression or significantly altered mental status, airway protection and ventilatory support are essential. Hypotension should be managed with intravenous fluids and, if necessary, vasopressors or inotropes. Activated charcoal is preferred for gastrointestinal tract decontamination and may be administered in repeated doses to enhance elimination. Gastric emptying should only be considered if the airway is protected. Administer benzodiazepines, such as lorazepam or midazolam, for seizures. Treat cannabis hyperemesis syndrome with intravenous fluids and antiemetics, such as ondansetron, and consider haloperidol in refractory cases.[75] Consult a psychiatrist following stabilization for patients with cannabis use disorder. Reassurance and verbal support may be sufficient for managing mild-to-moderate psychiatric symptoms. In more severe cases, antipsychotic medications may be used with caution.[76]

A substantial body of literature exists on marijuana and its potential health benefits. However, this evidence consists of observational studies, small trials, or anecdotal reports, depending on the indication. Due to the absence of clinical trials and a lack of a universal formula for marijuana, significant controversies persist regarding the clinical benefits of marijuana. All clinicians, including nurse practitioners and pharmacists, should educate patients that marijuana may not be a panacea for all medical disorders. Marijuana has demonstrated appetite-stimulating and antiemetic effects in specific clinical settings. Until data from randomized clinical trials are available, the recommendation of marijuana use should be approached cautiously, as more evidence seems to indicate that this product may not be entirely safe for long-term consumption.[77][78][79] Opinions and values regarding the use of cannabinoids in medicine vary widely. Some individuals see cannabinoids as having significant potential to reduce pain, whereas others believe cannabis-derived compounds have no place in modern clinical practice. Regardless of personal values, clinicians should recognize the existence and use of cannabinoids among their patient population when deciding treatment options. Patients should feel comfortable discussing their cannabinoid use, including the type, dose, and CBD-to-THC ratio.[80] Dronabinol and nabilone are both legal and are available by prescription throughout all 50 states of the United States.[81] The legal status of formulas containing only CBD is more variable. Laws concerning the restriction of products containing THC vary widely across states.[82] If a patient informs the medical staff about using a cannabinoid, this information should be communicated to the primary clinician overseeing their care.

Dronabinol and nabilone are both legal and are available by prescription throughout all 50 states of the United States.[81] The legal status of formulas containing only CBD is more variable. Laws concerning the restriction of products containing THC vary widely across states.[82] If a patient informs the medical staff about using a cannabinoid, this information should be communicated to the primary clinician overseeing their care. The effective use of cannabinoids for emetic control is best achieved through an interprofessional healthcare team approach. Dronabinol and nabilone are most commonly prescribed by oncologists, palliative care specialists, and infectious disease specialists. Oncologists frequently prescribe cannabinoids alongside chemotherapy regimens.[83] Palliative care and infectious disease specialists often prescribe cannabinoids to provide comfort in the setting of nausea or to benefit from their orexigenic components. In states where medical marijuana is legal, a team of healthcare professionals, including clinicians, nurse practitioners, and physician assistants, can authorize the use of CBD- and THC-containing formulations for patients with various conditions, including nausea and vomiting. Pharmacists play a crucial role in verifying dosing, checking for potential drug interactions, and providing additional counseling to patients as needed.[84]

The effective use of cannabinoids for emetic control is best achieved through an interprofessional healthcare team approach. Dronabinol and nabilone are most commonly prescribed by oncologists, palliative care specialists, and infectious disease specialists. Oncologists frequently prescribe cannabinoids alongside chemotherapy regimens.[83] Palliative care and infectious disease specialists often prescribe cannabinoids to provide comfort in the setting of nausea or to benefit from their orexigenic components. In states where medical marijuana is legal, a team of healthcare professionals, including clinicians, nurse practitioners, and physician assistants, can authorize the use of CBD- and THC-containing formulations for patients with various conditions, including nausea and vomiting. Pharmacists play a crucial role in verifying dosing, checking for potential drug interactions, and providing additional counseling to patients as needed.[84] Findings from a 2019 survey of 178 community-based pharmacists and medical marijuana dispensing pharmacists revealed that both pharmacist groups highly valued opioid use information within the Connecticut Prescription Monitoring and Reporting System. Although approximately 90% of healthcare professionals in both groups checked opioid use, 81.2% of medical marijuana dispensing pharmacists and 38.4% of community-based pharmacists monitored medical marijuana use. Medical marijuana dispensing pharmacists highlighted the need for marijuana-related data for effective counseling. The study underscores the potential benefits of integrating marijuana data into prescription drug monitoring programs, enhancing pharmacist recommendations by addressing drug interactions and workflow issues.[85] The entire clinical picture must be considered when deciding whether to initiate cannabinoid therapy. Triage nurses and clinicians in the emergency department should assess and maintain airway, breathing, and circulation in acute intoxication. Psychiatrists should evaluate for signs of psychosis and administer proper treatment. Critical care clinicians should care for the patient in the intensive care unit. Additionally, clinicians should refer patients with cannabis dependency to social workers. Clinicians, pharmacists, specialists, nurses, and other healthcare professionals are involved in patient care, and an interprofessional approach helps minimize the risk associated with the use of marijuana and its analogs.