Purpose of This Guideline

Date of current publication: October 30, 2025 Lead authors: Deepika Slawek, MD, MS, MPH; Julia H. Arnsten, MD, MPH Writing group: Susan D. Whitley, MD; Timothy J. Wiegand, MD, FACMT, FAACT, DFASAM, DFSAM; Sharon L. Stancliff, MD; Narelle Ellendon, RN; Christopher J. Hoffmann, MD, MPH, MSc, FACP; Brianna L. Norton, DO, MPH; Charles J. Gonzalez, MD Committee: Substance Use Guidelines Committee Date of original publication: January 24, 2022

This guideline on the therapeutic use of medical cannabis in New York State was developed by the New York State Department of Health AIDS Institute (NYSDOH AI) to:

• Provide clinicians with a framework for implementing the therapeutic use of medical cannabis in their outpatient settings in New York State.
• Increase access to evidence-based medical cannabis treatment for ambulatory patients in New York State by increasing the number of clinicians who can provide that care in outpatient settings (see Increasing Access to Safe Medical Cannabis).

Definition of Terms

Table 1, below, explains terms used throughout this guideline.

Cannabis Pharmacology and the Endocannabinoid System

“Cannabis” describes a family of plants including Cannabis sativa, Cannabis indica, and hemp. The cannabis plant produces more than 100 cannabinoids and a similar number of terpenes and flavonoids. The most widely studied cannabinoids are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). The other cannabinoids may contribute to the therapeutic effect of cannabis [Huestis 2007]; terpenes (e.g., limonene, myrcene) produce the smell, taste, and appearance of the plant; and flavonoids contribute to the color and pigmentation of the leaves and flowers of the plant [Tomko, et al. 2020]. Cannabinoids can be endogenous (endocannabinoid), plant-derived (phytocannabinoid), or synthetic and act as neurotransmitters within the human endocannabinoid system. Cannabinoid receptors in the endocannabinoid system are called CB1 and CB2 [Munro, et al. 1993; Matsuda, et al. 1990].

CB1 receptors exist primarily in areas of the brain that regulate appetite, memory, fear, and motor responses. Stimulation of CB1 receptors in the brain produces psychotropic effects. CB1 receptors are also found outside the brain in the gastrointestinal tract, adipocytes, liver, and skeletal muscle [Mackie 2005; Matsuda, et al. 1990]. CB2 is primarily expressed in macrophages and other macrophage-derived cells that are part of the immune system [Munro, et al. 1993].

Current understanding of cannabis pharmacology is incomplete and much remains under investigation. Both THC and CBD act on CB1 and CB2 receptors but in different ways. THC is a partial agonist of CB1 and CB2 receptors. Stimulation of these receptors by THC leads to analgesic, anti-inflammatory, and muscle-relaxant effects [Pertwee 2006]. The binding of THC to CB1 receptors is associated with psychoactive features, including reduced or enhanced anxiety, memory suppression, euphoria, and intoxication. Stimulation of CB2 receptors leads to anti-inflammatory effects [Russo and Guy 2006]. CBD binds weakly to CB1 and CB2 receptors [Russo and Guy 2006], producing anti-inflammatory [Ben-Shabat, et al. 2006], antispasmodic [Wade, et al. 2006], and analgesic effects [Maione, et al. 2011]. When THC and CBD are used together, several other receptors are activated to regulate pain perception [Russo and Guy 2006]. Other compounds in the cannabis plant, including minor cannabinoids and terpenes, have been hypothesized to affect the clinical effects of THC and CBD, which is often referred to as the “entourage effect” [André, et al. 2024]. The details of how this works are not completely known and have not been studied in a rigorous way.

Therapeutic Uses of Cannabis

Evidence supporting the most common current uses of medical cannabis is summarized below. Patients may be eligible for the use of medical cannabis if deemed clinically appropriate by a certifying healthcare provider (see Box 2, below). In the clinician’s professional opinion and review of past treatments, the patient is likely to receive therapeutic or palliative benefit from the primary or adjunctive treatment with medical cannabis for the condition.

Previously, the New York State Medical Cannabis Program (NYSMCP) listed associated conditions required for patient certification in addition to the qualifying conditions (including seizures, severe nausea, severe or persistent muscle spasms, severe or chronic pain resulting in substantial limitation of function, and cachexia or wasting syndrome). Associated conditions are no longer required under the Marihuana Regulation and Taxation Act. Certifying practitioners are authorized to evaluate and certify patients for medical cannabis based on their independent clinical judgement. There is no statutory requirement to reference a predetermined list of qualifying conditions. Instead, a practitioner may issue a certification for any condition deemed appropriate, consistent with their scope of practice and standards of care. Conditions with the most evidence for using medical cannabis are described below. Medical cannabis use requires caution for some conditions.

Chronic or severe pain: The most common condition for which patients are certified to receive medical cannabis in New York State is chronic or severe pain [NYS Office of Cannabis Management(b) 2023]. Chronic and severe pain are also the most well-researched indications for the use of medical cannabis [AHRQ 2024; McDonagh, et al. 2022; Whiting, et al. 2015]. A systematic review of randomized controlled trials (RCTs) found that, compared with placebo, the use of cannabinoids is more likely to result in a 30% or more reduction in pain scores, specifically among individuals with acute pain [Whiting, et al. 2015]. Of the 28 RCTs reviewed, 22 evaluated plant-derived cannabinoids and most used a placebo control. Most studies used a plant-derived medical cannabis product developed for medical use outside of the United States. The remainder evaluated cannabis in flower form, which can be obtained for research studies from the National Institute on Drug Abuse [National Academies 2017]. Specific to chronic pain, defined as pain lasting longer than 3 to 6 months or beyond the usual period of tissue healing [Treede, et al. 2015], several meta-analyses have found evidence that equal parts THC and CBD improve chronic pain. These meta-analyses were limited by low-quality evidence and a limited number of studies that met the criteria for inclusion in analyses [AHRQ 2024; McDonagh, et al. 2022]. These meta-analyses also found that several formulations of cannabis remain understudied in the context of reducing chronic pain, including high-THC whole-plant extract, whole-plant cannabis, and topical formulations [AHRQ 2024].

In an analysis of New York State Prescription Management Program Registry data from 2017 to 2019 that examined medical cannabis and opioid dispensing data of more than 8,000 patients receiving long-term opioid therapy who were certified for medical cannabis, receipt of medical cannabis for more than 30 days in the observation period (vs. <30 days) was associated with a significant reduction in opioid dose over time [Nguyen, et al. 2023]. Because the studies in this analysis were retrospective and observational, it is impossible to eliminate confounding factors and determine causality.

Severe or persistent muscle spasms: Cannabinoid use for the management of spasticity has been studied primarily in people with multiple sclerosis (MS). One systematic review identified 27 studies (8 RCTs) examining spasticity in adults [Nielsen, et al. 2019]; 21 of these studies included adults with MS. Spasticity improved in participants in the 8 RCTs, although improvement was based on participant- rather than clinician-rated measures, and the few RCTs that used clinician-rated measures for spasticity used the now outdated Modified Ashworth Scale [Nielsen, et al. 2019; Ansari, et al. 2006]. In another meta-analysis, investigators conducted a pooled analysis of data from 3 studies that used numerical rating scales in investigating the efficacy of cannabinoids for spasticity in MS [Whiting, et al. 2015]. Compared with placebo, formulations of cannabis with delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) were associated with improved spasticity on a participant-reported rating scale, and greater improvements in symptoms were reported by participants who received a formulation consisting of both THC and CBD (compared with those who received THC alone).

As with the research on chronic pain, these studies were all conducted with forms of medical cannabis that are not the same as those provided to medical cannabis patients in New York State. However, the cannabis studied contained the same primary active ingredients (THC and CBD) as the medical cannabis currently available in New York State.

Posttraumatic stress disorder (PTSD): PTSD was added as a qualifying condition for the NYSMCP in November 2017. The efficacy of cannabis for managing PTSD has not been well studied [Lowe, et al. 2019]. Several small studies examined THC for the treatment of nightmares, insomnia, and other PTSD symptoms, mostly in combat veterans [Nacasch, et al. 2022; Jetly, et al. 2015; Cameron, et al. 2014; Roitman, et al. 2014; Fraser 2009]. In all of these studies, participants experienced improved sleep, measured by a reduction in the number or intensity of nightmares or improvements in overall sleep quality. Concern remains that cannabis use in people with PTSD may result in adverse outcomes; however, this has also not been well studied [Lowe, et al. 2019].

Severe nausea: Few studies have examined medical cannabis use to treat severe nausea [National Academies 2017]. Oral synthetic THC (nabilone or dronabinol) has been used to treat chemotherapy-induced nausea for decades. It is superior to placebo and equally efficacious to comparator antiemetics [Grotenhermen and Müller-Vahl 2012]. CBD has been less well studied in humans for the management of nausea than THC. In animal studies, CBD alone was an effective antiemetic [Whiting, et al. 2015; Rock, et al. 2012].

Cachexia or wasting: There is very limited evidence that cannabis is effective in the management of cachexia or wasting. The use of cannabis for cachexia or wasting has been studied primarily in either AIDS wasting syndrome or cancer-associated cachexia. In an article summarizing 4 RCTs that investigated the effect of cannabis in individuals with AIDS wasting syndrome, the author concluded that these trials had a high risk of bias but there is some evidence that cannabis is effective for weight gain in individuals with HIV [Whiting, et al. 2015]. All 4 of these studies compared dronabinol (synthetic THC) with placebo or megestrol acetate. For cancer-associated cachexia, a phase 3 multicenter RCT compared treatment with cannabis extract (THC and CBD), THC alone, and placebo for 6 weeks. Participants (164 total) were monitored for appetite, mood, and nausea, with no significant differences between the 3 groups. Recruitment was terminated early because the data review board determined differences between groups were unlikely to emerge [Strasser, et al. 2006]. In a more recent pilot study, 17 individuals with cancer-associated cachexia were enrolled and received high THC:low CBD cannabis capsules for 6 months. Only 6 participants completed the study, 3 of whom had a weight gain of at least 10% from baseline; weight remained stable in the other participants [Bar-Sela, et al. 2019].

Seizures: In June 2018, CBD was approved by the U.S. Food and Drug Administration to treat rare forms of childhood epilepsy: Dravet syndrome, Lennox-Gastaut syndrome, and tuberous sclerosis complex [FDA 2018]. Dravet syndrome is a complex childhood epilepsy disorder associated with treatment-resistant seizures and a high mortality rate. In a double-blind RCT, daily oral CBD was associated with a statistically significant reduction in the frequency of convulsive seizures [Devinsky, et al. 2017]. In Lennox-Gastaut syndrome, another childhood epilepsy disorder with treatment-resistant seizures, CBD use resulted in a 41% reduction in seizure frequency. Reduction in seizure frequency was dose-dependent [Devinsky, et al. 2018].

The use of cannabinoids to manage seizures in adults and children with more common forms of epilepsy has not been as well studied. In an open-label study of CBD use in 70 pediatric and 62 adult participants with treatment-resistant epilepsy, 64% of participants experienced at least a 50% reduction in seizure frequency. Participants also experienced reduced severity of seizures and fewer adverse events [Szaflarski, et al. 2018]. In a small study of 21 adult participants with treatment-resistant seizures, CBD use was associated with a 71% reduction in seizure frequency, an 80% reduction in seizure severity, and improved mood [Allendorfer, et al. 2019]. These outcomes are encouraging but were achieved with doses of CBD alone that exceed the doses approved for sale by the NYSMCP. There is little evidence to support taking other cannabinoids than CBD to manage seizures [Perucca 2017].

Opioid use disorder: Medical cannabis treatment has emerged as a strategy to address the opioid epidemic. New York State Medical Use of Marijuana regulations include substance use disorder as a condition that may be considered for medical cannabis use [NYS Office of Cannabis Management 2022].

In several ecological studies, medical cannabis use was associated with reduced opioid-related deaths, opioid prescribing, and opioid use [Bradford, et al. 2018; Powell, et al. 2018; Bradford and Bradford 2017; Boehnke, et al. 2016; Bachhuber, et al. 2014]. However, follow-up studies found that opioid overdose mortality increased in U.S. states where medical cannabis was available [Shover, et al. 2019; Caputi and Humphreys 2018]. Evidence to support taking medical cannabis to treat opioid use disorder (OUD) is scant. Randomized controlled clinical trials are needed to understand the relationship between medical cannabis use and opioid-related outcomes.

There are well-established OUD treatments based on a strong evidence base. Buprenorphine and methadone are the standard of care for OUD and effectively retain patients in treatment and reduce illicit opioid use [Mancher and Leshner 2019; Hser, et al. 2016; Timko, et al. 2016; Mattick, et al. 2014; Fiellin, et al. 2011; Kakko, et al. 2003]. If there is a role for medical cannabis in OUD management, it will be to augment rather than replace evidence-based pharmacologic treatment. Currently, there is insufficient evidence to advocate for the use of medical cannabis to manage OUD.

Medical Cannabis Formulations and Administration Methods Available in New York State

All medical cannabis products sold in dispensing sites in New York State must meet specific manufacturing requirements regulated by the New York State Office of Cannabis Management. These requirements address methods for extracting cannabinoids from cannabis plants, the cannabinoid profile, the presence of additives, and labeling. All cannabis manufacturers must provide medical cannabis products that are equal parts delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) and low THC:high CBD (e.g., a 1:20 ratio of THC to CBD). All medical cannabis dispensaries also sell high THC:low CBD products, currently the most frequently used products by individuals in New York State. All products are tested by a laboratory located in New York State and permitted by the Cannabis Control Board to confirm cannabinoid content and identify contaminants [NYS Office of Cannabis Management 2025; NYS Office of Cannabis Management(a) 2023].

Table 2, below, describes the medical cannabis administration methods available to individuals in New York State, along with the advantages and disadvantages of each. The potential harms vary by administration method. Smoking ground flower through combustion confers the highest risk of harm because of the high temperature of inhaled smoke and potential for chronic damage to bronchioles and airways [Ribeiro and Ind 2018]. Risk is lower when cannabis is vaporized rather than smoked via combustion.

Hemp-based CBD versus medical cannabis: The 2018 U.S. Farm Bill Act made it legal to develop, distribute, sell, and market CBD products derived from hemp plants, which contain less than 0.3% THC on a dry weight basis. The Farm Bill Act removed hemp-based CBD regulation from the purview of the U.S. Food and Drug Administration and Schedule I status (Schedule I drugs, substances, or chemicals are defined as drugs with no medical purpose and a high potential for abuse). Hemp-based CBD has subsequently become available for purchase in retail settings, such as grocery and convenience stores, and with many different product types, including foods and beverages. Unregulated hemp-based CBD is often inaccurately labeled [Vandrey, et al. 2008]. One study found that almost half of products contained less CBD than the label described, and an additional quarter contained more CBD. In one-fifth of products sampled, THC was detected [Bonn-Miller, et al. 2017]. Additionally, while hemp plants are low THC at harvest, hemp-derived products can be processed to have intoxicating levels of THC and other cannabinoids and sold outside the regulated market. Consumers are often unaware of whether the products they are consuming are regulated versus illicit products.

Assessment

When assessing patients for medical cannabis use, clinicians should obtain information from patient interviews, medical records, and, when possible, the patient’s other clinicians (e.g., primary care, psychiatry, neurology, pain management, oncology, infectious disease).

Current amount and method of cannabis use: If patients are currently using medical, regulated adult-use, or unregulated cannabis, clinicians should ask patients to describe their use in detail, including the amount and frequency of cannabis used, estimated delta-9-tetrahydrocannabinol (THC) level, other cannabinoids (e.g., delta-8-tetrahydrocannabinol) in consumed cannabis (if known), and the type and method of use. Details about a patient’s current pattern of cannabis use inform the recommended dose and type of medical cannabis and the recommended method for use.

If patients smoke cannabis, clinicians should ask about the method used, such as rolling papers, water pipe (bong), pipe, or vaporizer. Other methods include using cigar papers to roll a large “blunt” and smoking a combination of cannabis and tobacco, which may result in nicotine dependence and require nicotine replacement therapy if switching to a form of cannabis that does not include nicotine.

Regulated cannabis versus unregulated cannabis: Medical and regulated adult-use cannabis may be less harmful than unregulated cannabis because they have known THC and cannabidiol (CBD) content, are tested for potential contaminants, and are required to be in child-resistant packaging that does not appeal to minors [NYS Office of Cannabis Management(a) 2023]. Regulated THC and CBD levels and ratios and doses in milligrams allow patients to titrate the dose of cannabis more precisely than is possible with unregulated cannabis. If a patient uses unregulated cannabis for a qualifying condition, a primary harm reduction goal may be to switch to medical cannabis. Clinicians can work with patients on limiting THC content and potentially harmful psychoactive effects while addressing symptoms of the qualifying condition.

By acquiring medical cannabis at medical cannabis dispensaries, individuals can limit interactions with the street market and the criminal justice system. The criminalization of cannabis has a disproportionately negative effect on Black and Hispanic people; in New York State, in 2018, the arrest rate for cannabis possession was 2.6 times higher among Black people than White people, with rates ranging widely among counties [ACLU 2020]. To help patients determine whether a dispensary is regulated or unregulated, the New York State Office of Cannabis Management created signage that all regulated dispensaries must display in their windows. A list of medical cannabis dispensaries is also available.

Conditions that require caution: Safety concerns are based on limited evidence that acute THC exposure is associated with tachycardia and developing or worsening psychosis [Di Forti, et al. 2014; Bryson and Frost 2011; Khiabani, et al. 2008; Sewell, et al. 2008]. Before initiation, clinicians should determine whether the patient seeking medical cannabis has a history of arrhythmia or CAD. Risk factors for cardiac disease may affect the safety of medical cannabis treatment and should be carefully evaluated [Skipina, et al. 2021; Yahud, et al. 2020; Goyal, et al. 2017]. Clinicians should also obtain a psychiatric history, including diagnoses, history of psychosis, previous treatment(s), hospitalization(s), signs and symptoms (e.g., auditory or visual hallucinations), history of suicide attempts or suicidal ideation, and family history of schizophrenia or other psychosis [Skipina, et al. 2021; Yahud, et al. 2020; Goyal, et al. 2017]. Personal history of hallucinations and family history of schizophrenia are also risk factors that may affect the safety of medical cannabis treatment and warrant careful evaluation [Athanassiou, et al. 2021; Shrivastava, et al. 2014]. Cannabis use may precipitate symptoms of schizophrenia, especially in patients younger than 26 years [Helle, et al. 2016].

Personal history of SUD is considered a relative contraindication to medical cannabis. Individuals who use medical cannabis may be at increased risk of cannabis use disorder, which has been found to be comorbid with other SUDs [Hasin, et al. 2016; Stinson, et al. 2006]. Clinicians should obtain and document a detailed history of current and prior substance use, SUD, including family history of SUD, and SUD treatment. DSM-5-TR diagnostic criteria should be used to diagnose SUD and determine its severity. For more information on monitoring cannabis use or diagnosing cannabis use disorder, see guideline section Monitoring and NYSDOH guideline Substance Use Screening, Risk Assessment, and Use Disorder Diagnosis in Adults > Diagnosis of Substance Use Disorder.

If any of the above conditions are identified during evaluation for medical cannabis use and the patient is not being treated, refer for treatment as appropriate prior to medical cannabis initiation. If the patient is already being treated for the condition, consult with the treating clinician. For patients with these conditions who are using unregulated cannabis, switching to medical cannabis could reduce THC intake and support harm reduction.

Cannabis use during pregnancy also warrants careful evaluation. See the guideline section Medical Cannabis Initiation > Cannabis use during pregnancy.

Potential drug-drug interactions: Along with obtaining a patient’s medical history, clinicians should conduct a full medication reconciliation. This should include checking the New York State Prescription Monitoring Program Registry to identify any controlled substances or medical cannabis taken by the patient. There is a paucity of evidence on potential drug-drug interactions with medical cannabis. THC and CBD are metabolized in the cytochrome P450 (CYP450) system and may inhibit the metabolism of other strong CYP450 inhibitors, such as warfarin [Damkier, et al. 2019; Alsherbiny and Li 2018]. Cannabis can also have additive sedative effects when used with other sedating agents [Echeverria-Villalobos, et al. 2019; Russo 2016]. Cannabis and alcohol used in combination are associated with increased impairment of complex task performance, such as driving, compared with cannabis or alcohol use alone [Miller, et al. 2020]. For information on potential drug-drug interactions with medical cannabis, see Table 3, below.

Assess for qualifying conditions with standardized tools: Clinicians should obtain a thorough history of the condition for which the patient seeks medical cannabis, including onset, duration, and characteristics as well as previous treatment attempts and their success. Standardized instruments, such as the PEG Scale [Krebs, et al. 2009] and DSM-5 PTSD Checklist [Lang, et al. 2005], should be used at baseline and follow-up visits to assess the qualifying condition and other conditions that may be affected by cannabis treatment. Changes in scores can indicate response to medical cannabis treatment and whether it is advisable to change dosage or formulation.

Cost of medical cannabis: The typical cost of a 30-day supply of a starting dose of medical cannabis from a dispensary ranges from $70 to $150. Medical cannabis is not covered by insurance and must be paid for with cash or a debit card, which may pose significant barriers to access. Clinicians should ensure that patients seeking medical cannabis certification are informed about cost and payment requirements.

Medical cannabis certification: For medical cannabis certification in New York State, patients must have a government-issued photo identification, email address, and current physical address that matches their state identification. If they do not have a government-issued photo identification, they must submit a different proof of New York State residence. The health care provider will print and sign the certification or, if using a certifying provider via telehealth, transmit a signed certification electronically for the patient to download or print.

The certification document contains the patient’s name, date of birth, address, and a unique barcode with their registration identification number, as well as specific clinician recommendations. Once patients receive certification (either a paper copy of the signed patient certification or an electronic copy displayed on a smart device), they are immediately able to visit a medical dispensary and purchase medical cannabis products. The certification document and identification that matches the information on the certification are required.

Medical Cannabis Initiation

Clinicians do not prescribe medical cannabis; they recommend it. Clinicians can choose to manage all aspects of medical cannabis treatment or limit their practice to assessment and certification and refer patients to dispensary pharmacists for all other related services (formulation, initial dosing, and dosing adjustments based on individual symptoms). Because clinicians have knowledge of or access to a patient’s medical history, comorbidities, and history of cannabis use, it is preferable for clinicians to direct formulation, initial dosing, and dosing adjustments for patients’ medical cannabis use and collaborate with the medical cannabis dispensary pharmacist as needed. If clinicians make specific recommendations in their certifications, dispensary pharmacists are bound by law to follow those instructions (see New York State Office of Cannabis Management Practitioner Guide to Patient Certification).

Administration method and dose: Clinicians should counsel patients on the risks and benefits of available medical cannabis administration methods (see Table 2: Medical Cannabis Administration Methods Currently Available in New York State) and engage in shared decision-making with the patient on the appropriate method. Because of potential short- and long-term adverse effects, clinicians should advise patients against using vaped, smoked, or dab/wax cannabis products [Rossi and Beck 2020; Stephens, et al. 2020; Raber, et al. 2015].

Because of a lack of high-quality evidence, specific dosing regimens for the therapeutic use of medical cannabis are lacking. The authors have been managing medical cannabis use in patients since 2016 when the Montefiore Medical Center Medical Cannabis Program was implemented. Boxes 3 and 4, below, outline basic strategies for implementing medical cannabis treatment based on the authors’ clinical experiences.

For cannabis-naive patients, a dose of 2.5 mg THC daily or lower is recommended. For cannabis-experienced patients, including patients who are currently using nonmedical cannabis, clinicians should recommend an initial dose equivalent to 50% of the patient’s current amount of THC and titrate to an effective daily dose (see Box 3, below). The overall goal is to reduce THC use, limit intoxication, and minimize withdrawal symptoms such as irritability, sleeplessness, and decreased appetite [Vandrey, et al. 2008].

After initiating the lowest possible dose, advise patients to slowly titrate up. Patients should take their initial dose at night and maintain that dose for 2 to 3 days. After that period, the dose can be increased by 2.5 to 5 mg THC daily. Patients can continue to increase the dose every 2 to 3 days until a therapeutic level is reached. If symptoms are experienced during the day, a midday or morning dose can be added. Advise patients to maintain direct contact with pharmacists at the dispensary or with their certifying medical cannabis clinician during the induction period to report any adverse events and address any dosing concerns.

Potential adverse effects: Clinicians should use caution when initiating medical cannabis for patients with a known history of arrhythmia, CAD, SUD, or psychosis or a family history of schizophrenia (see guideline section Assessment > Conditions that require caution). As with all patients initiating medical cannabis, clinicians should advise patients with these conditions to start at a low dose and increase their dose cautiously every 2 to 3 days, maintain contact with their clinicians, and seek emergency medical evaluation if they experience any serious adverse effects, including hallucinations, psychosis, severe anxiety, paranoia, pulmonary or cardiac symptoms, or hyperemesis.

Clinicians should advise patients initiating medical cannabis to take the first dose at night to limit potential adverse effects, such as feeling high, dizzy, or unable to concentrate. Severe adverse effects usually present as anxiety, paranoia, or panic attacks. Other neurologic symptoms include euphoria, lightheadedness, dizziness, or vertigo. In most cases, these symptoms require no intervention and are managed through observation. Rarely, cannabis can cause immediate nausea, vomiting, or abdominal pain, which can be managed with symptomatic treatment such as antiemetics [Noble, et al. 2019]. To date, there are no known cases of fatal overdose from cannabis use [Hasin 2018], but heavy cannabis use has been linked to increased healthcare utilization in states with legalized cannabis use, particularly among individuals using cannabis through oral rather than inhaled routes [Monte, et al. 2019].

New York regulations require registered organizations and certifying practitioners to report adverse events using the Office of Cannabis Management Incident Reporting Form.

There is concern that cannabis intoxication will contribute to motor vehicle accidents [Brady and Li 2014]. Cannabis use impairs driving in a dose-response manner [Hartman and Huestis 2013]. However, population-level studies have shown a mixed relationship between medical cannabis laws and increased motor vehicle accidents or traffic fatalities [Rogeberg 2019; Santaella-Tenorio, et al. 2017; Dubois, et al. 2015; Pollini, et al. 2015; Masten and Guenzburger 2014; Blows, et al. 2005]. Clinicians should caution patients about the potential for impaired driving while using cannabis and advise them to avoid driving or operating heavy machinery if physical or mental control is diminished by cannabis use. Emphasize that combining cannabis with alcohol can impair complex task performance, such as driving [Miller, et al. 2020]. Advise patients to store cannabis locked up, out of sight, and out of reach from children and pets.

Cannabis use during pregnancy: In patients who are or may become pregnant, clinicians should discuss the risks, to the patient and the fetus associated with prenatal cannabis use and encourage them to discontinue or minimize use during pregnancy. In a population-based retrospective cohort study from January 2011 to December 2019, prenatal cannabis use was associated with an increased risk of gestational hypertension, preeclampsia, gestational weight gain outside of recommendations, and placental abruption [Young-Wolff, et al. 2024]. Additionally, there is evidence indicating that prenatal cannabis use is associated with moderate increases in the risk of other adverse fetal and neonatal health outcomes, including low birthweight, preterm birth, and neonatal intensive care unit admission [Avalos, et al. 2024; Baía and Domingues 2024; Lo, et al. 2024; Young-Wolff, et al. 2024].

No evidence supports the use of medical cannabis to manage pregnancy-associated nausea and vomiting. In patients who are pregnant and who are not already using cannabis, clinicians should advise against initiating medical cannabis. In patients who are pregnant and using unregulated cannabis, clinicians and patients may find a harm reduction perspective useful. Patients may be using unregulated cannabis to treat specific symptoms such as posttraumatic stress disorder, and medical cannabis may be the safer choice if a patient plans to continue using cannabis. For individuals who could become pregnant, clinicians should recommend using contraception while using medical cannabis.

Patients younger than 25 years: Among adolescents and young adults, whose brains are still developing, cannabis use is associated with changes in cognitive processes that could affect mental health, propensity toward future SUDs, and cognition [Hurd, et al. 2019]. As with adults, cognitive performance improves in adolescents after at least 25 days of abstinence from cannabis use [Hurd, et al. 2019]. There remains much to be understood about cannabis use and the developing brain. For additional information about the effects of cannabis use in adolescents and young adults, see World Health Organization The Health and Social Effects of Nonmedical Cannabis Use and American Academy of Pediatrics Counseling Parents and Teens About Marijuana Use in the Era of Legalization of Marijuana.

Follow-up after medical cannabis initiation: Following up within 2 weeks of treatment initiation allows for adjustment of a patient’s treatment plan based on initial experience. As treatment continues, the frequency of follow-up can be tailored to a patient’s specific needs and in accordance with the clinic’s existing policies regarding treatment and follow-up for patients taking other controlled substances. In the absence of an existing policy, this committee suggests clinical follow-up every 3 to 6 months.

Monitoring

Clinicians should perform an annual assessment for CUD in all patients taking medical, regulated adult-use, and unregulated cannabis. If CUD is identified, clinicians should engage patients in shared decision-making to revise treatment goals as needed and update the treatment plan to meet the new goals. There are no U.S. Food and Drug Administration–approved pharmacotherapies for CUD, and referral to treatment will likely focus on behavioral therapy. The treatment plan should prioritize harm reduction and may include increased visits, using methods other than smoking, THC dose reduction, a modified dosing schedule, or linking patients to therapists or other mental health professionals [Fischer, et al. 2017].

At follow-up appointments, clinicians should ask patients about symptoms of potential adverse effects. Clinicians should collaborate with patients’ existing treatment teams, including primary care clinicians, mental health care clinicians, cardiologists, and other specialists, to monitor these signs and symptoms. The most common adverse effects are described below.

Psychiatric symptoms: Chronic cannabis use is associated with psychiatric symptoms, including anxiety, depression, and psychosis, and has been linked to worsening schizophrenia in individuals with a preexisting genetic vulnerability [Di Forti, et al. 2014; Caspi, et al. 2005; Patton, et al. 2002]. However, a direct causal relationship is difficult to establish because multiple confounding factors blur the relationship between cannabis use and psychiatric illness. For example, individuals with anxiety or stress may be more likely to use cannabis [Volkow, et al. 2014]. Clinicians should monitor patients for new or worsening psychiatric symptoms and discontinue medical cannabis if symptoms are identified. To decertify patients for medical cannabis use, see New York State Medical Cannabis Program: Patient Certification Instructions.

Cognition: Cannabis intoxication has an acute effect on memory and attention, but the effect of cannabis use on long-term cognition has not been well studied [Broyd, et al. 2016; Volkow, et al. 2016]. Some case-control studies found that neuropsychological function was worse in participants who used unregulated cannabis than in controls with no use; however, in similar studies of individuals with at least 1 month of abstinence from unregulated cannabis, neuropsychological measures were similar in both groups [Schreiner and Dunn 2012; Grant, et al. 2003]. These findings suggest that any cognitive impairment due to cannabis use may be inversely related to the length of abstinence. In addition, longitudinal data from a small cohort of adult patients who use medical cannabis indicate improved executive function after 3 months. Medical cannabis could affect cognition differently than unregulated cannabis [Gruber, et al. 2017]

Cannabis hyperemesis syndrome: One study reported that gastrointestinal symptoms were the most common cause for emergency room visits related to cannabis use [Monte, et al. 2019]. The most severe gastrointestinal effect of cannabis use, cannabis hyperemesis syndrome [Allen, et al. 2004], manifests as cyclical nausea and vomiting and abdominal pain in individuals with chronic cannabis use. Symptoms may improve with hot showers or baths and resolve after cessation of cannabis use [Schreck, et al. 2018]. Cannabis hyperemesis syndrome has been described primarily in case series as early as 2004 [Venkatesan, et al. 2019; Allen, et al. 2004]; however, the criteria for diagnosing cannabis hyperemesis syndrome have been inconsistent, making it difficult to define the epidemiology. The most recent diagnostic criteria include episodic vomiting at least 3 times in the past year, cannabis use for at least 1 year, cannabis use at least 4 times per week on average, and resolution of symptoms following a period of abstinence from cannabis use for at least 6 months or a period that spans at least 3 typical cyclical vomiting episodes for the individual [Venkatesan, et al. 2019]. Clinicians should monitor patients using medical cannabis for hyperemesis disorder symptoms; if symptoms are present, a trial of abstinence from cannabis may be appropriate.

Pulmonary effects: For patients who choose to vape or combust their cannabis, clinicians should recommend avoiding products purchased outside of registered facilities and, during follow-up visits, ask patients about any changes in breathing. Chronic inhaled cannabis use can lead to chronic bronchitis symptoms, including cough, sputum production, and wheezing [Ribeiro and Ind 2018; Tashkin 2018]. Cannabis use may result in pulmonary function test changes, but, unlike tobacco, cannabis has not been associated with chronic obstructive lung disease in observational studies [Ribeiro and Ind 2018; Tashkin 2018]. The mode of consumption could be related to specific types of respiratory syndromes.

A new lung disease associated with heavy vaping emerged in late 2019 [Layden, et al. 2020; Schier, et al. 2019]. To date, it remains unclear whether the risk is limited to specific types of vaping products or oils or associated with specific use patterns. Between 75% and 80% of cases of e-cigarette or vaping product use-associated lung injury (EVALI) occurred among individuals using delta-9-tetrahydrocannabinol (THC)-containing vaporized products, leaving a proportion of patients with EVALI who had no exposure to THC, suggesting other factors could contribute to its pathogenesis [Adkins, et al. 2020; FDA 2020]. Vitamin E acetate was often used as a thickening agent in THC-containing liquid for vaping devices and was found in 48 of 51 bronchoalveolar lavage samples of patients with EVALI and is suspected to be linked to its pathogenesis [Blount, et al. 2020]; after its ban from vaporized products by the U.S. Food and Drug Administration in 2020, continued cases of EVALI have occurred though the number has declined [Soerianto and Jaspers 2025]. No cases of vaping lung injury have been attributed to New York State medical cannabis vaped products.

Cannabis smoking may predispose individuals to pneumonia through damage of central airways and local immune response changes [Shay, et al. 2003; Baldwin, et al. 1997; Fligiel, et al. 1997].

Smoked cannabis contains carcinogens, raising concerns about lung cancer risk. Observational studies show mixed findings: increased risk of lung cancer in all users of smoked cannabis [Zhang, et al. 2015], only among heavy users [Aldington, et al. 2008], and not at all [Aldington, et al. 2008]. These studies included potential confounders (e.g., tobacco use, environmental exposures) that may have skewed the results. Further research is needed to understand how individuals using cannabis should be monitored for cancer.

Cessation of medical cannabis: In patients with chronic cannabis use, abrupt cessation may lead to symptoms of cannabis withdrawal, which include but are not limited to irritability, anxiety, insomnia, depressed mood, strange dreams, headaches, and stomach pain [Bonnet and Preuss 2017]. Clinicians should inform patients who want to stop using cannabis about the risk of cannabis withdrawal symptoms. Treatment of cannabis withdrawal symptoms has not been well studied, but short-term symptoms may be managed (e.g., zolpidem for insomnia or benzodiazepines for anxiety) [Brezing and Levin 2018]. Few data exist on the effects of tapering cannabis, but individuals may experience fewer withdrawal symptoms with a gradual reduction in dose rather than an abrupt stop. Clinicians should discuss these factors with the patient and, if requested, help develop a tapering plan. To decertify patients for medical cannabis use, see New York State Medical Cannabis Program: Patient Certification Instructions.

Urine toxicology testing: In patients using controlled substances, urine toxicology testing is commonly used to confirm compliance with agreed-upon treatment plans and identify signs of diversion, misuse, or substance use disorder. However, there is a paucity of evidence on the utility of urine toxicology testing for patients using medical cannabis. Urine toxicology testing for cannabis use cannot specify timeline, source (regulated versus unregulated), route of administration, or amount of use [Miller, et al. 2024; Sazegar 2021; Smith, et al. 2009], and only tests for metabolites of THC, not cannabidiol (CBD) or delta-8-tetrahydrocannabinol. Urine toxicology results may remain positive for up to 4 to 5 days after a single use of cannabis or for a month or more after chronic daily use. Urine toxicology testing, specifically for medical cannabis but also for other substances, should only be performed to answer a specific clinical question and only after shared decision-making and patient agreement.

Appendix: Office of Cannabis Management (OCM) Dear Colleague Letter

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Supplementary Material

Supplement: Guideline Development and Recommendation Ratings