The landscape surrounding cannabidiol (CBD) use within healthcare systems is rapidly changing across the United States. As legal frameworks evolve and public attitudes shift towards acceptance, health professionals—including pharmacists—must stay informed about the complex legal, medical, and ethical issues involved. Ensuring safe and effective patient care requires a thorough understanding of current regulations, scientific evidence, and institutional policies related to CBD products. This guide aims to clarify these considerations, helping healthcare providers navigate CBD’s integration into clinical practice responsibly.
Medical and Pharmacological Aspects of CBD
CBD is a significant chemical constituent of the cannabis plant, commonly known as marijuana. Unlike tetrahydrocannabinol (THC), CBD does not produce intoxicating effects, making it an attractive option for various therapeutic applications. Its versatility allows administration through inhalation, oral ingestion, buccal absorption, or topical application. Over recent years, CBD has been marketed extensively for a multitude of uses, including as a treatment for conditions like chronic pain, epilepsy, and spasticity associated with multiple sclerosis. These claims, however, are often supported by limited conclusive evidence.
In 2017, a comprehensive review by the National Academies of Sciences, Engineering, and Medicine (NASEM) identified only three therapeutic uses with “conclusive” or “substantial” evidence supporting efficacy: antiemetic effects in chemotherapy-induced nausea and vomiting, chronic pain management in adults, and symptom relief of spasticity in multiple sclerosis patients. Although these findings are promising, the overall safety profile and efficacy of many CBD products remain under investigation. For a detailed understanding of the current evidence base, clinicians can consult the full NASEM report available at nationalacademies.org/CannabisHealthEffects.
Legal Landscape and Regulatory Challenges
Understanding and complying with the legal environment is paramount when considering CBD use within healthcare facilities. Federal laws provide a foundational framework, but state-specific regulations often create additional layers of complexity.
Under federal law, cannabis and marijuana have been classified as Schedule I substances under the Controlled Substance Act (CSA) since 1970, reflecting their high potential for abuse and lack of accepted medical use. This classification prohibits prescribing or dispensing cannabis products. However, the 2018 Farm Bill significantly altered this landscape by removing hemp—defined as cannabis containing less than 0.3% THC—from the CSA list. As a result, hemp-derived CBD products are no longer controlled substances federally. Nevertheless, the Food and Drug Administration (FDA) retains authority over their regulation, especially regarding marketing and safety standards. The FDA’s position is that CBD products cannot be marketed as dietary supplements if they contain active ingredients approved as drugs, such as Epidiolex. The agency has expressed uncertainty about how it will regulate these products moving forward, highlighted during a public hearing on May 31, 2019, which sought stakeholder input on regulatory strategies.
State laws further influence the legality of CBD products. For instance, Kansas recently descheduled CBD from its controlled substances list, provided it contains no THC. Legislators are considering bills that would permit CBD products with up to 5% THC—verified through third-party testing—for patients with serious conditions. If such legislation passes, it could surpass federal THC limits, potentially affecting how healthcare providers manage CBD use in clinical settings. The variability in state regulations complicates compliance, especially for health systems operating across multiple jurisdictions, and may necessitate tailored policies for different locations.
Institutional Policies and Patient Use Considerations
While it is unlikely that CBD products will be incorporated into hospital formularies or actively dispensed by healthcare institutions, many facilities may choose to permit patients to bring their own CBD products under a “Patient’s Own Medication” (POM) policy. A recent internal survey indicated support among providers for allowing POM use of CBD when deemed appropriate by a healthcare professional, treating these products similarly to herbal supplements or dietary aids.
The Joint Commission mandates that any patient-supplied products be identified and inspected for integrity prior to administration. However, accurately verifying CBD content is challenging because labeling can be unreliable, with documented cases of discrepancies in CBD and THC levels. Furthermore, contaminants such as pesticides and heavy metals have been detected in some products, posing safety risks and potential regulatory violations.
To operationalize POM policies safely, healthcare institutions should develop clear procedures, including secure storage, proper disposal, and documentation protocols. Placing CBD products in the electronic medical record as if prescribing them, such as entering them on the Medication Administration Record (MAR), may inadvertently constitute prescribing activity, which could violate federal laws depending on THC content. Therefore, establishing a specific CBD policy, separate from prescribing protocols, can help clarify handling procedures and mitigate legal risks.
Pharmacists are expected to play a central role in developing these policies, given their expertise in medication safety and regulation. Collaboration with risk management and regulatory departments is essential to address product safety, storage, and disposal, especially considering that many CBD products are consumer-grade and not FDA-approved.
FDA-Approved CBD Products and Therapeutic Use
In 2018, the FDA approved Epidiolex®, a purified CBD formulation, for treating seizures associated with Dravet syndrome and Lennox-Gastaut syndrome in children over 2 years old. This approval marked the first time an active cannabis-derived ingredient received FDA endorsement as a pharmaceutical treatment. Epidiolex is classified as Schedule V under the CSA, indicating low potential for abuse. Importantly, it contains only trace amounts of THC (≤0.1%) and is subject to strict monitoring guidelines, including regular liver function tests.
This approval underscores the importance of distinguishing FDA-approved medications from unregulated CBD products. Non–FDA approved products can contain variable amounts of CBD and impurities, such as pesticides or heavy metals, increasing potential health risks. Pharmacists and clinicians must be vigilant and base recommendations on evidence-based data, especially considering possible drug interactions and adverse effects. For instance, Epidiolex’s labeling recommends monitoring liver enzymes and bilirubin levels, particularly when used concomitantly with other hepatotoxic drugs like valproate or clobazam.
The Role of Pharmacists in CBD Integration
As CBD use becomes more prevalent, pharmacists will be essential in evaluating emerging scientific literature, managing drug interactions, and counseling patients about risks and benefits. They must stay current with ongoing research and regulatory developments, applying their expertise to guide safe patient practices. Addressing misconceptions and marketing claims that portray CBD as a risk-free cure-all is critical in providing balanced, evidence-based advice.
In addition, pharmacists should be involved in policy development related to non–FDA approved CBD products, ensuring operational procedures are clear and compliant with legal standards. This includes establishing protocols for product storage, disposal, and documentation to mitigate the risk of inadvertent exposure or legal violations.
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