ADVANCED CANNABINOID MEDICINE

Core Competencies & Medical Necessity

Terel Newton, M.D.

I. INTRODUCTION & DISCLOSURES

1. Interventional Pain Physician

2. Consultant and Medical Advisor on Opioid Alternatives

3. State Medical Director at Trulieve Florida

4. Research interests in chronic pain and mental health

5. No remuneration for presentation

6. Federal law updates and THC Schedule III discussion

7. Many cannabis medicines remain non-FDA approved

II. GOALS OF ADVANCED CANNABINOID CARE

1. Understand JAMA Network core cannabis competencies

2. Identify medical specialties certifying cannabis patients

3. Define medical necessity and medical complexity

4. Learn personalized cannabis care planning strategies

III. RECENT NEWS & REGULATORY DEVELOPMENTS

A. DEA & Federal Rescheduling

1. HHS recommended Schedule I → Schedule III transition

2. JAMA Psychiatry critique questioned adequacy of evidence

3. Concerns: psychosis risk, cannabis use disorder, youth exposure

4. FDA has not approved dispensary cannabis as medicine

5. Public comments favored descheduling over rescheduling

6. State dispensary THC discussed as Schedule III

7. Documentation standards remain unchanged regardless of scheduling

B. Landmark Publications 2025–2026

1. ACP 2025: balanced THC-CBD modestly improves chronic pain

2. Cochrane 2026: low-certainty neuropathic pain benefit

3. CanPan Trial 2026: improved pain, appetite, insomnia in pancreatic cancer

4. JAMA Network Open 2025: six foundational competencies identified

IV. SIX FOUNDATIONAL CANNABIS COMPETENCIES

1. Plant Components

• Cannabinoids, terpenes, flavonoids, sterols

• Biological and pharmacologic effects

2. Endocannabinoid System

• ECS physiology and receptor function

• CB1 and CB2 receptor mechanisms

3. Evidence Base

• Conditions commonly managed with cannabis

• Strengths and limitations of current evidence

4. Legal & Regulatory Landscape

• State vs federal law differences

• Documentation and compliance standards

5. Potential Risks

• Adverse effects and dependency concerns

• Drug interactions and psychiatric risk

6. Clinical Management

• Initiation, titration, monitoring, maintenance

V. CANNABIS PLANT SCIENCE

A. Cannabis Plant Anatomy

1. Female flowering plant anatomy

2. Trichomes and cannabinoid production

3. Roots, stems, internodes, leaves, buds

4. Male vs female plant characteristics

B. Cannabis Biochemistry

1. CBGA as precursor cannabinoid

2. THCA, CBDA, CBCA synthesis pathways

3. Monoterpenes and sesquiterpenes

4. Flavonoids and sterol compounds

5. Entourage effect concepts

VI. ENDOCANNABINOID SYSTEM & CLINICAL RELEVANCE

A. Receptors

1. CB1 receptors

• CNS predominant

• Psychoactivity, analgesia, memory modulation

2. CB2 receptors

• Immune system and microglia

• Anti-inflammatory effects

B. Endogenous Cannabinoids

1. Anandamide

2. 2-AG

C. THC & CBD

1. THC

• Partial agonist

• Biphasic dose response

• Analgesia vs hyperalgesia

2. CBD

• Non-intoxicating

• 60 molecular targets
  
  
  

VII. FORMULATIONS & DELIVERY SYSTEMS

A. Historical Formulations

1. Cannabis Americana extracts

2. Cannabis Indica tinctures

3. Early medicinal preparations

B. Modern Products

1. Epidiolex

2. Dronabinol

3. Cesamet (Nabilone)

4. Distillates and RSO syringes

5. Tinctures and topical products

VIII. THC PHARMACOLOGY & CYP450 INTERACTIONS

A. THC Metabolism

1. Primarily CYP2C9 metabolism

2. CYP3A4 and CYP2C19 involvement

3. Active metabolite: 11-OH-THC

4. Oral bioavailability 6–8%

B. Drug Interaction Principles

1. THC weak CYP inhibition at standard doses

2. CBD significantly increases THC exposure

3. Smoked cannabis induces CYP1A2

4. Strong CYP3A4 inhibitors increase THC levels

5. CYP3A4 inducers decrease THC levels

C. High-Risk Interactions

1. Warfarin → INR monitoring

2. Tacrolimus → trough monitoring

3. Benzodiazepines/opioids → additive CNS depression

4. CBD + valproate → hepatotoxicity risk

IX. SCREENING TOOLS & SAFETY MONITORING

A. Cannabis Use Disorder Screening

1. CUDIT-R ≥8 = problematic use

2. CAGE-AID ≥2 positive responses

3. DSM-5 CUD severity grading

B. Withdrawal Monitoring

1. Irritability

2. Insomnia

3. Anorexia

4. Peak symptoms days 2–6

C. Cannabinoid Hyperemesis Syndrome

1. Cyclic vomiting

2. Hot shower relief

3. Heavy chronic cannabis exposure

X. EVIDENCE BASE & RESEARCH

A. Literature Volume

1. Cannabis research exceeds 40,000 studies

2. Marijuana research exceeds 55,000 studies

3. Broad cannabinoid evidence base

B. AI & Evidence Tools

1. OpenEvidence

2. Cannabase

3. ChatGPT

4. Claude AI systems

C. FDA-Approved Cannabinoid Products

1. Epidiolex → epilepsy syndromes

2. Dronabinol → HIV anorexia, CINV

3. Nabilone → refractory CINV

4. Nabiximols → MS spasticity evidence

XI. ROUTES OF ADMINISTRATION

A. Inhaled

• Onset 1–5 minutes

• Duration 2–4 hours

B. Oral

• Onset 30–90 minutes

• Duration 6–8 hours

• Significant first-pass metabolism

C. Sublingual

• Faster onset than oral

• Partial first-pass bypass

D. Topical / Transdermal

• Limited systemic absorption

• Minimal RCT evidence

XII. TYPES OF MEDICAL CANNABIS EVIDENCE

1. FDA-approved Phase III RCT evidence

2. High-quality randomized controlled trials

3. Meta-analyses and systematic reviews

4. Registry and observational studies

5. Surveys and patient-reported outcomes

Teaching Points

• Product heterogeneity

• Placebo response challenges

• Evidence vs availability gap

XIII. OUTCOME MEASUREMENT & HARM REDUCTION

A. Validated Tools

1. PEG, VAS, Oswestry → pain

2. PCL-5 → PTSD

3. PHQ-9, GAD-7 → mood disorders

4. ISI → insomnia

5. MoCA → cognition

6. ECOG/Karnofsky → cancer function

B. Harm Reduction

1. Prefer oral/sublingual routes

2. Avoid >10 mg THC/day in high-risk patients

3. Monitor driving impairment

4. Avoid benzodiazepine-opioid combinations

5. Avoid cannabis in neurodevelopment (<25 years)

6. Start ≤2.5 mg THC in elderly

7. Avoid pregnancy/breastfeeding exposure

XIV. CERTIFYING SPECIALTIES & EDUCATION GAP

A. National Trends

1. ~29,500 US certifying clinicians

2. 4.1 million patients enrolled

3. 33% enrollment growth

B. Top Specialties

1. Internal/Family Medicine

2. Physical Medicine/Rehabilitation

3. Pain Medicine/Anesthesiology

C. Education Crisis

1. Limited cannabis curriculum exposure

2. Graduates poorly prepared for certification responsibilities

XV. SPECIALTY-SPECIFIC PERSPECTIVES

A. Neurology

1. Epidiolex for seizure disorders

2. Parkinson’s disease mixed evidence

3. Cognitive monitoring with MoCA

B. Oncology/Palliative Care

1. ASCO antiemesis guidance

2. Pancreatic cancer symptom improvement

3. Palliative care integration

C. Psychiatry/Addiction Medicine

1. Mixed psychiatric evidence

2. THC cautioned in serious mental illness

3. Addiction screening importance

D. Gastroenterology

1. Symptomatic Crohn’s improvement

2. No consistent endoscopic benefit

3. CHS management considerations

E. Geriatrics

1. Polypharmacy challenges

2. Fall and cognition monitoring

3. Conservative dosing strategies

F. Perioperative Medicine

1. Tapering strategies

2. Postoperative pain management

3. Withdrawal prevention

XVI. EVIDENCE FOR CHRONIC PAIN

1. ACP 2025 modest pain improvement

2. BMJ 2021: NNT = 11 for 30% pain reduction

3. Cochrane neuropathic pain evidence low-certainty

4. Cannabis may rival opioids for chronic pain efficacy

5. Observational opioid-sparing evidence remains inconsistent

XVII. EVIDENCE-INFORMED TREATMENT SELECTION

1. Confirm qualifying condition and ICD-10

2. Assess medical complexity tier

3. Select formulation

• CBD dominant

• Balanced THC/CBD

• THC dominant

4. Select administration route

5. Start low and titrate slowly

6. Monitor outcomes and safety

7. Document using five-pillar framework

XVIII. MEDICAL NECESSITY

Definition

Clinical justification that cannabis treatment is:

1. Reasonable

2. Appropriate

3. Evidence-based

4. Expected to improve or stabilize condition

Key Requirements

1. Appropriate for diagnosis

2. Meets accepted standards of care

3. Not for convenience

4. Safest effective treatment level

XIX. DOCUMENTATION REQUIREMENTS

Why Documentation Matters

1. Legal protection

2. Standard-of-care compliance

3. Continuity of care

4. Outcome tracking

5. Audit defensibility

Strong Documentation Examples

1. Specific diagnosis and ICD-10

2. Functional impairment details

3. Failed treatment history

4. Risk discussions

5. Explicit medical necessity rationale

XX. PATIENT EDUCATION PRIOR TO CERTIFICATION

1. Risks: CUD, cardiovascular, psychiatric, CHS

2. Benefits: realistic symptom improvement

3. Alternatives: conventional therapies

4. Expectations: symptom control, not cure

5. Driving impairment counseling

6. Withdrawal and tapering education

XXI. FIVE PILLARS OF EVERY CANNABIS ENCOUNTER

1. Diagnosis

2. Dysfunction

3. Failed Drugs/Therapies

4. Discuss & Document

5. Goal Monitoring

XXII. CODING & BILLING

A. ICD-10 Coding

1. F12.90 → cannabis use uncomplicated

2. Z79.899 → long-term drug therapy

3. Z51.81 → therapeutic drug monitoring

B. Florida Qualifying Conditions

1. Chronic pain

2. PTSD

3. MS

4. Epilepsy

5. Crohn’s disease

6. Parkinson’s disease

7. HIV/AIDS

8. ALS

9. Glaucoma

10. Fibromyalgia

C. E/M Billing

1. Tier 1–4 complexity structure

2. 99213–99215 coding

3. 99417 prolonged services

4. 96127 behavioral screening

5. Drug testing codes

XXIII. MEDICAL COMPLEXITY

Definition

Dynamic interaction of:

1. Medical illness

2. Psychiatric illness

3. Social factors

4. Treatment burden

5. Functional capacity

Complexity Drivers

1. Polypharmacy

2. Psychiatric comorbidity

3. Cardiovascular disease

4. Age extremes

5. Perioperative status

6. Substance use disorders

XXIV. COMPLEXITY TIERS

Tier 1 – Low

• Single stable condition

• Minimal risk

Tier 2 – Moderate

• Multiple comorbidities

• Moderate impairment

Tier 3 – High

• Polypharmacy

• Active psychiatric disease

• Opioid/benzodiazepine use

Tier 4 – Very High

• Cancer

• Organ failure

• Pregnancy

• Psychosis history

• CHS history

• Frailty/perioperative risk

XXV. PERSONALIZED CARE PROCESS

Five-Step Process

1. Identify diagnosis and severity

2. Screen for risk and evaluate evidence

3. Match formulation and route

4. Discuss/document medical necessity

5. Establish monitoring plan

XXVI. MATCHING PRODUCTS TO PATIENT NEEDS

1. Sleep → THC dominant or balanced

2. Neuropathic pain → balanced 1:1

3. Spasticity → nabiximols model

4. Opioid reduction → balanced oral

5. Anxiety/PTSD → CBD dominant

6. Appetite/nausea → THC dominant

7. Daytime function → CBD dominant

XXVII. FMCCE CLINICAL CASES

Case 1 – Perioperative Spine Surgery

• Chronic pain, PTSD, opioids, OSA

• Tier 4 complexity

• Requires perioperative taper and monitoring

Case 2 – Pancreatic Cancer / Whipple

• Cancer pain, cachexia, hepatic impairment

• CanPan trial evidence

• Extensive monitoring and coordination

Case 3 – Young Adult Psychiatric Complexity

• Fibromyalgia, anxiety, depression

• CBD-dominant strategy

• Addiction and psychiatric monitoring

Case 4 – GI Disease + CHS History

• Crohn’s disease, neuropathy, CHS

• CBD-dominant approach preferred

• Avoid THC escalation

XXVIII. CROSS-CASE SUMMARY

Harm Reduction

1. Prefer oral/sublingual routes

2. Low-dose THC initiation

3. Avoid high-risk combinations

4. Protect neurodevelopment

Evidence Benchmarks

1. Chronic pain modest improvement

2. Cancer symptom benefit

3. Crohn’s symptomatic benefit only

4. Mixed psychiatric evidence

CYP450 Essentials

1. THC: CYP2C9 dominant

2. CBD: CYP2C19 inhibitor

3. Cannabis smoke induces CYP1A2

Coding Reminders

1. Use therapeutic-use codes appropriately

2. Avoid labeling therapeutic use as abuse/dependence unless documented

XXIX. CASE-SPECIFIC MEDICAL NECESSITY SUMMARY

1. Chronic pain supported by BMJ and ACP evidence

2. Pancreatic cancer supported by CanPan and ASCO guidance

3. Fibromyalgia/anxiety supported by ACP and Cochrane reviews

4. Crohn’s/neuropathy supported by neuropathic pain evidence and CHS precautions

XXX. REFERENCES

1. BMJ 2021 systematic review and meta-analysis

2. Cochrane neuropathic pain review 2026

3. ACP chronic pain guidelines 2025

4. ASCO cannabinoid oncology guideline 2024

5. National Academies cannabis report

6. JAMA Network Open competency consensus

7. CanPan Trial 2026

8. ASRA/SPAQI perioperative guidance

9. APA and ASAM cannabis position statements

X. EVIDENCE BASE & RESEARCH

A. Literature Volume

1. Cannabis research exceeds 40,000 studies

2. Marijuana research exceeds 55,000 studies

3. Broad cannabinoid evidence base

B. AI & Evidence Tools

1. OpenEvidence

2. Cannabase

3. ChatGPT

4. Claude AI systems

C. FDA-Approved Cannabinoid Products

1. Epidiolex → epilepsy syndromes

2. Dronabinol → HIV anorexia, CINV

3. Nabilone → refractory CINV

4. Nabiximols → MS spasticity evidence

XI. ROUTES OF ADMINISTRATION

A. Inhaled

• Onset 1–5 minutes

• Duration 2–4 hours

B. Oral

• Onset 30–90 minutes

• Duration 6–8 hours

• Significant first-pass metabolism

C. Sublingual

• Faster onset than oral

• Partial first-pass bypass

D. Topical / Transdermal

• Limited systemic absorption

• Minimal RCT evidence

XII. TYPES OF MEDICAL CANNABIS EVIDENCE

1. FDA-approved Phase III RCT evidence

2. High-quality randomized controlled trials

3. Meta-analyses and systematic reviews

4. Registry and observational studies

5. Surveys and patient-reported outcomes

Teaching Points

• Product heterogeneity

• Placebo response challenges

• Evidence vs availability gap

XIII. OUTCOME MEASUREMENT & HARM REDUCTION

A. Validated Tools

1. PEG, VAS, Oswestry → pain

2. PCL-5 → PTSD

3. PHQ-9, GAD-7 → mood disorders

4. ISI → insomnia

5. MoCA → cognition

6. ECOG/Karnofsky → cancer function

B. Harm Reduction

1. Prefer oral/sublingual routes

2. Avoid >10 mg THC/day in high-risk patients

3. Monitor driving impairment

4. Avoid benzodiazepine-opioid combinations

5. Avoid cannabis in neurodevelopment (<25 years)

6. Start ≤2.5 mg THC in elderly

7. Avoid pregnancy/breastfeeding exposure

XIV. CERTIFYING SPECIALTIES & EDUCATION GAP

A. National Trends

1. ~29,500 US certifying clinicians

2. 4.1 million patients enrolled

3. 33% enrollment growth

B. Top Specialties

1. Internal/Family Medicine

2. Physical Medicine/Rehabilitation

3. Pain Medicine/Anesthesiology

C. Education Crisis

1. Limited cannabis curriculum exposure

2. Graduates poorly prepared for certification responsibilities

XV. SPECIALTY-SPECIFIC PERSPECTIVES

A. Neurology

1. Epidiolex for seizure disorders

2. Parkinson’s disease mixed evidence

3. Cognitive monitoring with MoCA

B. Oncology/Palliative Care

1. ASCO antiemesis guidance

2. Pancreatic cancer symptom improvement

3. Palliative care integration

C. Psychiatry/Addiction Medicine

1. Mixed psychiatric evidence

2. THC cautioned in serious mental illness

3. Addiction screening importance

D. Gastroenterology

1. Symptomatic Crohn’s improvement

2. No consistent endoscopic benefit

3. CHS management considerations

E. Geriatrics

1. Polypharmacy challenges

2. Fall and cognition monitoring

3. Conservative dosing strategies

F. Perioperative Medicine

1. Tapering strategies

2. Postoperative pain management

3. Withdrawal prevention

XVI. EVIDENCE FOR CHRONIC PAIN

1. ACP 2025 modest pain improvement

2. BMJ 2021: NNT = 11 for 30% pain reduction

3. Cochrane neuropathic pain evidence low-certainty

4. Cannabis may rival opioids for chronic pain efficacy

5. Observational opioid-sparing evidence remains inconsistent

XVII. EVIDENCE-INFORMED TREATMENT SELECTION

1. Confirm qualifying condition and ICD-10

2. Assess medical complexity tier

3. Select formulation

• CBD dominant

• Balanced THC/CBD

• THC dominant

4. Select administration route

5. Start low and titrate slowly

6. Monitor outcomes and safety

7. Document using five-pillar framework

XVIII. MEDICAL NECESSITY

Definition

Clinical justification that cannabis treatment is:

1. Reasonable

2. Appropriate

3. Evidence-based

4. Expected to improve or stabilize condition

Key Requirements

1. Appropriate for diagnosis

2. Meets accepted standards of care

3. Not for convenience

4. Safest effective treatment level

XIX. DOCUMENTATION REQUIREMENTS

Why Documentation Matters

1. Legal protection

2. Standard-of-care compliance

3. Continuity of care

4. Outcome tracking

5. Audit defensibility

Strong Documentation Examples

1. Specific diagnosis and ICD-10

2. Functional impairment details

3. Failed treatment history

4. Risk discussions

5. Explicit medical necessity rationale

XX. PATIENT EDUCATION PRIOR TO CERTIFICATION

1. Risks: CUD, cardiovascular, psychiatric, CHS

2. Benefits: realistic symptom improvement

3. Alternatives: conventional therapies

4. Expectations: symptom control, not cure

5. Driving impairment counseling

6. Withdrawal and tapering education

XXI. FIVE PILLARS OF EVERY CANNABIS ENCOUNTER

1. Diagnosis

2. Dysfunction

3. Failed Drugs/Therapies

4. Discuss & Document

5. Goal Monitoring

XXII. CODING & BILLING

A. ICD-10 Coding

1. F12.90 → cannabis use uncomplicated

2. Z79.899 → long-term drug therapy

3. Z51.81 → therapeutic drug monitoring

B. Florida Qualifying Conditions

1. Chronic pain

2. PTSD

3. MS

4. Epilepsy

5. Crohn’s disease

6. Parkinson’s disease

7. HIV/AIDS

8. ALS

9. Glaucoma

10. Fibromyalgia

C. E/M Billing

1. Tier 1–4 complexity structure

2. 99213–99215 coding

3. 99417 prolonged services

4. 96127 behavioral screening

5. Drug testing codes

XXIII. MEDICAL COMPLEXITY

Definition

Dynamic interaction of:

1. Medical illness

2. Psychiatric illness

3. Social factors

4. Treatment burden

5. Functional capacity

Complexity Drivers

1. Polypharmacy

2. Psychiatric comorbidity

3. Cardiovascular disease

4. Age extremes

5. Perioperative status

6. Substance use disorders

XXIV. COMPLEXITY TIERS

Tier 1 – Low

• Single stable condition

• Minimal risk

Tier 2 – Moderate

• Multiple comorbidities

• Moderate impairment

Tier 3 – High

• Polypharmacy

• Active psychiatric disease

• Opioid/benzodiazepine use

Tier 4 – Very High

• Cancer

• Organ failure

• Pregnancy

• Psychosis history

• CHS history

• Frailty/perioperative risk

XXV. PERSONALIZED CARE PROCESS

Five-Step Process

1. Identify diagnosis and severity

2. Screen for risk and evaluate evidence

3. Match formulation and route

4. Discuss/document medical necessity

5. Establish monitoring plan

XXVI. MATCHING PRODUCTS TO PATIENT NEEDS

1. Sleep → THC dominant or balanced

2. Neuropathic pain → balanced 1:1

3. Spasticity → nabiximols model

4. Opioid reduction → balanced oral

5. Anxiety/PTSD → CBD dominant

6. Appetite/nausea → THC dominant

7. Daytime function → CBD dominant

XXVII. FMCCE CLINICAL CASES

Case 1 – Perioperative Spine Surgery

• Chronic pain, PTSD, opioids, OSA

• Tier 4 complexity

• Requires perioperative taper and monitoring

Case 2 – Pancreatic Cancer / Whipple

• Cancer pain, cachexia, hepatic impairment

• CanPan trial evidence

• Extensive monitoring and coordination

Case 3 – Young Adult Psychiatric Complexity

• Fibromyalgia, anxiety, depression

• CBD-dominant strategy

• Addiction and psychiatric monitoring

Case 4 – GI Disease + CHS History

• Crohn’s disease, neuropathy, CHS

• CBD-dominant approach preferred

• Avoid THC escalation

XXVIII. CROSS-CASE SUMMARY

Harm Reduction

1. Prefer oral/sublingual routes

2. Low-dose THC initiation

3. Avoid high-risk combinations

4. Protect neurodevelopment

Evidence Benchmarks

1. Chronic pain modest improvement

2. Cancer symptom benefit

3. Crohn’s symptomatic benefit only

4. Mixed psychiatric evidence

CYP450 Essentials

1. THC: CYP2C9 dominant

2. CBD: CYP2C19 inhibitor

3. Cannabis smoke induces CYP1A2

Coding Reminders

1. Use therapeutic-use codes appropriately

2. Avoid labeling therapeutic use as abuse/dependence unless documented

XXIX. CASE-SPECIFIC MEDICAL NECESSITY SUMMARY

1. Chronic pain supported by BMJ and ACP evidence

2. Pancreatic cancer supported by CanPan and ASCO guidance

3. Fibromyalgia/anxiety supported by ACP and Cochrane reviews

4. Crohn’s/neuropathy supported by neuropathic pain evidence and CHS precautions

XXX. REFERENCES

1. BMJ 2021 systematic review and meta-analysis

2. Cochrane neuropathic pain review 2026

3. ACP chronic pain guidelines 2025

4. ASCO cannabinoid oncology guideline 2024

5. National Academies cannabis report

6. JAMA Network Open competency consensus

7. CanPan Trial 2026

8. ASRA/SPAQI perioperative guidance

9. APA and ASAM cannabis position statements

I. CONTROLLED SUBSTANCE DRUG SCHEDULING

A. Schedule I

• Meaning: High abuse potential, no federally accepted medical use, lack of accepted safety under medical supervision

• Restrictions: Most federally restricted category

• Examples: Cannabis/Marijuana THC, Heroin, LSD, MDMA/Ecstasy, Psilocybin

B. Schedule II

• Meaning: High abuse potential with accepted medical use, severe psychological or physical dependence risk

• Restrictions: Strict prescribing and refill limitations

• Examples: Morphine, Oxycodone, Hydromorphone, Fentanyl, Cocaine, Methamphetamine

C. Schedule III

• Meaning: Moderate to low physical dependence risk, accepted medical use

• Restrictions: Less restrictive than Schedule II

• Examples: Ketamine, Testosterone, Marinol/Dronabinol, Tylenol with Codeine, Anabolic steroids

D. Schedule IV

• Meaning: Lower abuse potential relative to Schedule III

• Restrictions: Standard controlled prescribing regulations

• Examples: Alprazolam/Xanax, Diazepam/Valium, Lorazepam/Ativan, Tramadol, Zolpidem/Ambien

E. Schedule V

• Meaning: Lowest abuse potential among controlled substances, accepted medical use

• Restrictions: Least restrictive controlled category

• Examples: Pregabalin/Lyrica, low-dose Codeine cough syrup, Lomotil

F. Non-Scheduled Medications

• Meaning: Not federally controlled substances

• Restrictions: Standard prescription or OTC regulations only

• Examples: Epidiolex/CBD, Acetaminophen, NSAIDs, Antibiotics

II. CANNABIS-SPECIFIC SCHEDULING

A. Cannabis/Marijuana THC

• Federal Status: Schedule I

• Meaning: Federally illegal despite state medical programs

• Examples: Medical cannabis flower, concentrates, vape products

B. Hemp-Derived CBD (<0.3% THC)

• Federal Status: Non-Scheduled

• Meaning: Federally legal under Farm Bill if compliant

• Examples: OTC CBD oils, hemp CBD gummies

C. Epidiolex (Cannabidiol/CBD)

• Federal Status: Non-Scheduled

• FDA Approved Uses: Lennox-Gastaut syndrome, Dravet syndrome, Tuberous sclerosis complex

• Meaning: FDA-approved purified CBD product

D. Marinol (Dronabinol)

• Federal Status: Schedule III

• Meaning: Synthetic THC capsule medication

• Uses: Chemotherapy-induced nausea/vomiting, HIV/AIDS cachexia

E. Cesamet (Nabilone)

• Federal Status: Schedule II

• Meaning: Synthetic cannabinoid medication

• Uses: Refractory chemotherapy nausea/vomiting

III. DEA SCHEDULING DEFINITIONS SUMMARY

A. Schedule I

• No federally accepted medical use

• Highest abuse potential

• Highest federal restrictions

B. Schedule II

• Accepted medical use

• High addiction/dependence potential

• Strict monitoring required

C. Schedule III

• Moderate abuse/dependence risk

• Accepted medical use

• Moderate prescribing controls

D. Schedule IV

• Lower abuse risk

• Common outpatient controlled medications

E. Schedule V

• Lowest abuse/dependence risk among controlled substances

F. Non-Scheduled

• No federal controlled substance classification

• Minimal abuse/dependence concerns

Below are sample weaning schedules for both opioid and benzodiazepine tapering when introducing medical cannabis as adjunctive therapy. These are drawn from the best available consensus-based recommendations and clinical practice guidelines. No RCT has validated a specific cannabis-assisted tapering protocol for either drug class, so these schedules represent expert consensus and should be individualized.

OPIOID TAPERING WITH CONCURRENT CANNABIS INITIATION

The most detailed published protocol comes from a modified Delphi consensus (Sihota et al., 2021) and the MacCallum Canadian Clinical Tool (2021), which together outline a three-phase approach. 

[1-2]

Phase 1: Cannabis Initiation (Weeks 1–4) — Do NOT taper opioids yet

• Start with a CBD-predominant oral extract during the daytime (e.g., 5–20 mg CBD BID, titrate up as tolerated)

• After 1–2 weeks of stable CBD dosing, consider adding low-dose THC: start at 0.5–3 mg THC at bedtime

• Increase THC by 1–2 mg once or twice weekly, targeting a dose of up to 30–40 mg/day THC (most patients stabilize at much lower doses)

• Monitor for excessive sedation, dizziness, and cognitive effects — particularly given additive CNS depression with opioids

• Do not begin opioid taper until the patient reports functional improvement, reduced use of breakthrough/PRN pain medications, or the cannabis dose has been optimized 

• [1-2]

Phase 2: Opioid Taper (Weeks 4–6+)

The consensus recommendation is to reduce by 5%–10% of the current morphine equivalent dose (MED) every 1–4 weeks. 

Phase 3: Monitoring and Success Criteria

Clinical success is defined as achieving any of the following: 

[1]

• ≥30% reduction in pain intensity

• ≥25% reduction in opioid dose

• Reduction in opioid dose to <90 mg MED

• Improvement in function/quality of life

• Reduction in opioid-related adverse events (constipation, sedation, falls)

The MEMO Study (JAMA Internal Medicine, 2025) observed a mean 22% reduction in daily MME over 18 months with this slow, patient-directed approach — consistent with the emphasis on gradual reduction over months to years rather than rapid cessation. 

[3]

Key safety points: Monitor for opioid withdrawal symptoms at each step. If withdrawal symptoms emerge, pause the taper for 2–4 weeks before resuming. THC may alleviate some opioid withdrawal symptoms (anxiety, insomnia, pain), but this effect has a narrow therapeutic window and is not reliably demonstrated in RCTs. 

[4]

 Concurrent use of cannabis and opioids increases CNS depression risk — counsel patients about driving impairment and fall risk. 

[5]

BENZODIAZEPINE TAPERING WITH CONCURRENT CANNABIS INITIATION

No published consensus protocol exists specifically for cannabis-assisted benzodiazepine tapering. The schedule below integrates the 2025 ASAM Joint Clinical Practice Guideline on Benzodiazepine Tapering (endorsed by 10 medical societies) with the general cannabis initiation principles described above, adapted for the unique pharmacokinetic and safety considerations of benzodiazepine co-administration. 

[6-7]

Phase 1: Cannabis Initiation (Weeks 1–4) — Do NOT taper benzodiazepines yet

• Start with CBD-predominant oral product (5–10 mg CBD BID), targeting anxiolytic effect

• Critical pharmacokinetic warning: CBD inhibits CYP3A4 and UGT2B7, which can increase serum levels of clonazepam, diazepam, and lorazepam. THC also inhibits CYP3A4. Monitor closely for excessive sedation, ataxia, and respiratory depression when adding cannabinoids to benzodiazepines. 

• [5][8]

• If adding THC, start at 0.5–1 mg at bedtime only — lower starting dose than for opioid patients due to additive sedation risk

• Titrate THC slowly (1 mg increments weekly) — note that low-dose THC may reduce anxiety, but higher doses (>10 mg) may worsen anxiety 

• [5][8]

• Assess for symptom improvement (anxiety, insomnia, muscle tension) before initiating taper

Phase 2: Benzodiazepine Taper (Weeks 4+)

Per the ASAM guideline, the recommended approach is: 

[7][9-10]

• Initial reduction: 5%–10% of current dose (no more than 25%) during the first 2 weeks

• Subsequent reductions: 5%–10% every 2–4 weeks

• Slow further at lower doses — the final 25% of the taper is typically the most difficult and may require 5% reductions every 4 weeks

• Consider converting to diazepam (long half-life) for smoother taper, though evidence of superiority is limited 

• [10-11]

Phase 3: Monitoring

• Withdrawal symptoms to watch for: Rebound anxiety, insomnia, tremor, perceptual disturbances, seizures (rare, primarily with abrupt discontinuation of high doses) 

• [6][10]

• Pause the taper if withdrawal symptoms are moderate-to-severe; resume at a slower rate once symptoms resolve 

• [7]

• Adjunctive psychosocial interventions (particularly CBT) significantly improve taper success rates — NNT of 2 in one trial of older adults tapering benzodiazepines for insomnia 

• [11]

• Never discontinue benzodiazepines abruptly in patients with likely physical dependence — seizure risk is real 

• [6][10]

• The entire process may take 6 months to over a year for long-term users

OPIOID TAPER WITH MEDICAL CANNABIS

(Example: Patient on 60 mg morphine equivalent dose/day)

Phase 1 — Cannabis Initiation (Do NOT reduce opioids yet)

• Weeks 1–2: Start CBD-predominant oral extract (5–20 mg CBD twice daily), no opioid change

• Weeks 2–4: Add low-dose THC at bedtime (start 0.5–3 mg), increase by 1–2 mg weekly, no opioid change

• Week 4: Assess pain/function — proceed to taper only if patient reports improvement

Phase 2 — Opioid Taper (5–10% of current dose every 1–4 weeks)

• Weeks 5–6: Reduce to 54–57 mg MED (first 5–10% cut), titrate THC to effect

• Weeks 7–8: Reduce to 49–54 mg MED, maintain cannabis dose

• Weeks 9–10: Reduce to 44–51 mg MED, reassess pain and function

• Weeks 11–14: Reduce to 40–48 mg MED, continue monitoring

• Weeks 15–18: Reduce to 36–46 mg MED, slow taper further if tolerated

• Week 19+: Continue 5–10% reductions every 2–4 weeks toward goal

Phase 3 — Goals and Monitoring

• Success = any of: ≥30% pain reduction, ≥25% opioid dose reduction, dose below 90 MED, or improved function

• Pause taper 2–4 weeks if withdrawal symptoms emerge, then resume at slower rate

• Typical total duration: 3–12+ months

• Monitor for excessive sedation, dizziness, and driving impairment throughout

BENZODIAZEPINE TAPER WITH MEDICAL CANNABIS

(Example: Patient on alprazolam 2 mg/day)

Phase 1 — Cannabis Initiation (Do NOT reduce benzodiazepines yet)

• Weeks 1–2: Start CBD-predominant oral product (5–10 mg CBD twice daily), no benzodiazepine change

• Weeks 2–4: Add low-dose THC at bedtime only (start 0.5–1 mg), increase by 1 mg weekly, no benzodiazepine change

• Week 4: Assess anxiety/sleep — proceed to taper only if patient reports improvement

• SAFETY NOTE: CBD and THC increase benzodiazepine blood levels — watch closely for excess sedation

Phase 2 — Benzodiazepine Taper (5–10% of current dose every 2–4 weeks)

• Weeks 5–6: Reduce to 1.75–1.9 mg alprazolam (first 5–12.5% cut), maintain cannabis dose

• Weeks 7–8: Hold dose if any withdrawal symptoms appear, adjust cannabis if needed

• Weeks 9–10: Reduce to 1.5–1.7 mg, continue monitoring

• Weeks 11–14: Reduce to 1.25–1.5 mg (5–10% every 2–4 weeks), reassess anxiety and sleep

• Weeks 15–22: Reduce to 1.0–1.25 mg, optimize cannabis dose, add CBT if available

• Weeks 23–30: Reduce to 0.5–1.0 mg — slow to 5% every 4 weeks (this phase is hardest)

• Week 31+: Reduce from 0.25–0.5 mg toward discontinuation at 5% every 4 weeks or slower

Phase 3 — Goals and Monitoring

• Watch for: rebound anxiety, insomnia, tremor, perceptual disturbances, seizures (rare)

• NEVER stop benzodiazepines abruptly — seizure risk is real

• Pause taper if withdrawal symptoms are moderate-to-severe, resume slower once resolved

• CBT significantly improves taper success (NNT = 2 for insomnia indication)

• Typical total duration: 6–18+ months

IMPORTANT REMINDERS FOR BOTH TAPERS

• Always start cannabis FIRST and stabilize before beginning any taper

• THC doses above 10 mg may worsen anxiety — use lowest effective dose

• Check drug interactions at www.CANN-DIR.psu.edu before co-prescribing

• Schedule follow-up every 1–4 weeks during active taper

• These are sample schedules — individualize based on patient response

These schedules are derived from the modified Delphi consensus on cannabinoid titration and opioid tapering, the 2025 ASAM Joint Clinical Practice Guideline on benzodiazepine tapering, and general cannabis initiation principles from the ACP and Canadian clinical tools. 

[1-5]

 No RCT has validated a cannabis-specific tapering protocol for either drug class. The benzodiazepine schedule is adapted from standard deprescribing guidelines rather than a cannabis-specific protocol, as no such protocol exists. 

[6-7]

 The pharmacokinetic interaction warnings (CBD/THC inhibiting CYP3A4 and UGT2B7, raising benzodiazepine levels) are drawn from the JAMA 2025 and JAMA Internal Medicine 2026 reviews. 

https://www.youtube.com/watch?v=Gvn9xqTmKww

Advanced Cannabinoid Medicine Medical Necessity, Complexity Grading, Coding & Case-Based Treatment Planning

A Competency-Based Framework for the Medically Complex Cannabis Patient

PART 1 — FOUNDATIONS & PHARMACOLOGY

1 — Title, Disclosures & Course Map

Title, presenter credentials, specialty background, financial disclosures, CME accreditation, 5-part course map, 40-slide educational arc, EHR documentation gap (~33% documented), pre-test polling question, overview of evidence-based cannabinoid medicine for medically complex patients

2 — Learning Objectives & Competency Framework

Medical necessity documentation, ICD-10/DSM-5/CPT integration, ASA/complexity grading, evidence-informed treatment planning, perioperative cannabis medicine, harm reduction, multi-route cannabinoid decision-making, drug-interaction management, complex patient analysis, multidisciplinary coordination

3 — Endocannabinoid System: Clinical Pharmacology Primer

CB1 receptors = cortex/hippocampus/basal ganglia/cerebellum, CB2 receptors = immune cells/microglia/peripheral tissues, anandamide (AEA), 2-AG, THC partial CB1/CB2 agonist, CBD indirect ECS modulation, 5-HT1A agonism, GPR55 antagonism, pain signaling, mood regulation, appetite, sleep, inflammation, antiemetic pathways, CBD mitigation of THC-induced anxiety/tachycardia

4 — Cannabinoid Pharmacology & Adverse Effects

THC psychoactive effects, CBD anxiolytic/antiepileptic effects, terpenes, entourage effect, dose-response relationships, biphasic THC anxiety effects, tolerance, withdrawal, dependence, psychomotor slowing, memory impairment, dizziness, tachycardia, orthostasis, sedation, psychiatric destabilization, anti-inflammatory mechanisms

5 — Cannabinoid Formulations: FDA vs State-Regulated

Epidiolex, dronabinol, nabilone, nabiximols, oral oils, capsules, tinctures, flower, concentrates, RSO, THC:CBD ratios, FDA-approved vs dispensary products, labeling variability, contamination risk, evidence-to-product availability gap, state-specific regulation differences

6 — Routes of Administration & Pharmacokinetics

Oral, sublingual, inhaled, vaporized, topical/transdermal, onset/peak/duration, first-pass metabolism, 11-OH-THC formation, delayed edible onset, pulmonary exposure, bioavailability differences, oral overconsumption risk, topical localized therapy, route selection by age/comorbidity/psychiatric risk

7 — CYP450 Drug Interactions

CBD CYP2C19/CYP3A4 inhibition, THC CYP2C9/CYP3A4 effects, smoked cannabis CYP1A2 induction, warfarin, tacrolimus, clobazam, valproate, SSRIs, opioids, benzodiazepines, sedating antidepressants, additive CNS depression, hepatic metabolism, immunosuppressants, polypharmacy risk management, CANN-DIR interaction checker

8 — Screening Tools & DSM-5 Integration

CUDIT-R = Cannabis Use Disorders Identification Test-Revised, CAGE-AID = alcohol/drug risk screen, CAST = Cannabis Abuse Screening Test, DSM-5 Cannabis Use Disorder mild = 2–3 criteria/moderate = 4–5/severe ≥6, cannabis withdrawal syndrome, CHS screening, cyclic vomiting assessment, AGA recommendations, substance-use severity grading

9 — Functional Impairment Scales

PEG = Pain, Enjoyment, General Activity scale, Oswestry Disability Index = spinal disability grading, PCL-5 = PTSD Checklist for DSM-5, score ≥31–33 suggests PTSD, ISI = Insomnia Severity Index (0–28), PHQ-9 = depression severity questionnaire, GAD-7 = generalized anxiety severity, FIQ-R = Fibromyalgia Impact Questionnaire-Revised, ECOG/Karnofsky = oncology functional status, MoCA = Montreal Cognitive Assessment, Timed Up and Go = fall-risk assessment

10 — Harm Reduction & Evidence Hierarchy

Avoid >10% THC inhaled products, avoid >10 mg/day oral THC, oral/sublingual preferred, avoid smoking in pulmonary/CV disease, avoid cannabis + opioids/benzodiazepines/alcohol, driving precautions, age ≤25 THC caution, geriatric low-dose approach, pregnancy contraindication, FDA-approved RCTs vs observational studies, confounding bias, placebo effects, evidence-tier interpretation

PART 2 — MEDICAL NECESSITY, DOCUMENTATION & CODING

11 — 5-Pillar Medical Necessity Framework

Qualifying diagnosis, functional impairment, failed/inaccessible therapies, individualized risk-benefit analysis, monitoring/documentation, informed consent, treatment goals, multimodal care justification, symptom severity, quality-of-life impairment, cost/access barriers

12 — Informed Consent & Clinical Decision-Making

Risks/benefits/options, failed prior therapies, FDA-approved alternatives discussed, realistic treatment expectations, psychiatric/CV risks, cannabis use disorder risk, driving impairment, dependence potential, withdrawal planning, sedation counseling, route-specific risks, shared decision-making

13 — ICD-10 Coding: Qualifying Diagnoses

Chronic pain G89.29/G89.4, cancer pain G89.3, PTSD F43.10, fibromyalgia M79.7, multiple sclerosis G35, epilepsy G40.909, Crohn’s disease K50.90, Parkinson’s disease G20, insomnia G47.00, neuropathy G62.9, anxiety disorder F41.1, nausea/vomiting R11.2

14 — ICD-10 Coding: Cannabis-Related Complications

Therapeutic/uncomplicated cannabis use F12.90, cannabis abuse F12.10, dependence F12.20, withdrawal F12.23, CHS F12.188/F12.288 + R11.2, long-term therapy Z79.899, monitoring Z51.81, cannabis-induced anxiety, cannabis-induced psychosis, dehydration, AKI risk, DSM-5 linkage

15 — CPT Coding & Billing

99205 new high-complexity visit, 99214 moderate follow-up, 99215 high-complexity follow-up, 99417 prolonged services, G3002/G3003 chronic pain management, 90791/90792 psychiatric evaluation, 80305–80307 urine drug screening, SBIRT billing G0443/G2011, prolonged counseling, telehealth documentation, modifier 25

16 — Billing Optimization Pearls

Time-based billing, multimodal treatment plans, UDS justification, PDMP documentation, modifier 25, telehealth coding, cannabis counseling complexity, prolonged-service documentation, chronic pain management coding, psychiatric complexity documentation, risk stratification documentation

17 — Cannabis Patient Complexity Grading

Tier 1 low complexity, Tier 2 moderate complexity, Tier 3 high complexity, Tier 4 specialist-only complexity, ASA I healthy patient, ASA II mild systemic disease, ASA III severe systemic disease, ASA IV life-threatening disease, organ-system burden, psychiatric complexity, polypharmacy, perioperative risk

18 — Cardiovascular Risk Stratification

MI/stroke risk, CHF/CAD, tachycardia, orthostasis, exercise intolerance, angina, inhalation contraindications, AHA recommendations, young adult MI risk, arrhythmia concerns, cardiovascular mortality signal, perioperative cardiac considerations

19 — Psychiatric Risk Stratification

Psychosis risk, bipolar disorder, PTSD F43.10, anxiety F41.1, depression F32.A, suicidal ideation, THC biphasic anxiety effects, CBD anxiolytic evidence, age ≤25 THC vulnerability, dissociation, paranoia, psychiatry co-management, substance-use overlap

20 — Evidence-Informed Treatment Planning Algorithm

Indication assessment, route selection, formulation selection, CBD-dominant vs balanced THC:CBD, dosing initiation, “start low, go slow,” THC 1–2.5 mg initiation, CBD titration, harm reduction, follow-up intervals, UDS/PDMP monitoring, specialist referral criteria

PART 3 — EVIDENCE BY DIAGNOSIS & TREATMENT PLANNING

21 — Chronic Noncancer Pain

ICD-10: G89.29/G89.4/R52, prevalence: 24.3% U.S. adults chronic pain, 8.5% high-impact chronic pain, ACP guidance, BMJ meta-analysis, nabiximols, nabilone vs dronabinol, neuropathic pain evidence, opioid-sparing literature, sleep improvement, functional outcomes, CBD limitations, inhaled cannabis concerns

22 — Fibromyalgia

ICD-10: M79.7, prevalence: ~2–4% adults, widespread pain, fatigue, sleep dysfunction, anxiety/depression overlap, Mayo Clinic survey, UK Cannabis Registry, FIQ-R tracking, observational vs RCT limitations, adverse effects, quality-of-life outcomes

23 — Epilepsy Evidence: Epidiolex

ICD-10: G40.909, Dravet G40.83, Lennox-Gastaut G40.812, TSC Q85.1, prevalence: ~3.4M U.S. patients, seizure reduction, clobazam interaction, hepatotoxicity monitoring, LFT surveillance, somnolence, diarrhea, FDA-approved CBD evidence, AES/AAN guidance

24 — CINV & MS Spasticity

CINV ICD-10: R11.2 + T45.1X5A, MS ICD-10: G35, MS prevalence: ~1M U.S. patients, Grimison THC:CBD trial, ASCO guidance, refractory nausea/vomiting, appetite stimulation, palliative symptom control, breakthrough CINV, MS spasticity reduction, nabiximols evidence, NICE recommendations

25 — PTSD, Anxiety, Tourette Syndrome & Insomnia

PTSD F43.10, anxiety F41.1/F41.9, insomnia G47.00/F51.01, Tourette syndrome F95.2, anxiety prevalence ~19.1% U.S. adults annually, PTSD lifetime prevalence ~6–8%, insomnia symptoms ~30% adults, nightmare reduction, nabilone, CBD anxiety evidence, hypervigilance, psychiatric destabilization risk

26 — Cancer, Palliative Care & Survival Literature

Cancer C80.1, cancer pain G89.3, cachexia R64, palliative care Z51.5, U.S. cancer burden >2M new cases/year, appetite stimulation, nausea/vomiting, insomnia, existential distress, caregiver burden, palliative care integration, low-dose THC literature, observational survival studies, QOL improvement

27 — CHS & Cannabis-Related Complications

CHS F12.188/F12.288 + R11.2/E86.0, Rome IV criteria, concentrate exposure, cyclic vomiting, hot shower behavior, dehydration, electrolyte imbalance, AKI risk, recurrent ED visits, differential diagnosis, cessation counseling, supportive care, high-potency THC risk

28 — Neuropathy, Diabetes & Parkinson’s Disease

Neuropathy G62.9/E11.40, diabetes E11.9, Parkinson’s disease G20, diabetes prevalence >38M Americans, Parkinson’s prevalence >1.1M Americans, neuropathic pain, gait instability, insomnia overlap, fall risk, geriatric considerations, observational cannabinoid data

29 — Florida & Georgia Qualified Conditions

Florida: cancer, epilepsy, glaucoma, HIV/AIDS, PTSD, ALS, Crohn’s disease, Parkinson’s disease, MS, terminal illness, chronic nonmalignant pain
Georgia: cancer, ALS, epilepsy/TBI seizures, MS, Crohn’s disease, mitochondrial disease, Parkinson’s disease, sickle cell disease, Tourette syndrome, autism spectrum disorder, epidermolysis bullosa, Alzheimer’s disease, AIDS, neuropathy, hospice, intractable pain, PTSD

30 — Integrated Treatment Planning

Diagnosis + ICD-10, prevalence/context, qualifying condition status, severity grade, ASA status, failed therapies, access barriers, route selection, THC/CBD ratio, dose titration, monitoring tools, CPT/E&M level, follow-up interval, multidisciplinary referrals

PART 4 — COMPLEX PATIENT CASES & CLINICAL DECISION-MAKING

31 — Case 1: Chronic Pain & Polypharmacy

Chronic pain G89.4, lumbar pain M54.50, insomnia G47.00, anxiety F41.1, opioid therapy Z79.891, long-term medication use Z79.899, ASA III, PEG/PDI tracking, opioid reduction, temazepam taper, occupational impairment, failed PT/injections/gabapentin

32 — Case 2: Veteran With Crohn’s Disease, MS & PTSD

Crohn’s disease K50.90, MS G35, PTSD F43.10, insomnia G47.00, neuropathy G62.9, PCL-5/ISI monitoring, autoimmune overlap, bowel dysfunction, spasticity, gait instability, psychiatric risk, polypharmacy, fall-risk assessment

33 — Case 3: Cancer Surgery & Case 4: CHF/BKA

Cancer surgery: cancer C50.919/C80.1, cancer pain G89.3, nausea/vomiting R11.2, cachexia R64, anxiety F41.1, ASA III–IV, perioperative planning, appetite support, opioid minimization
CHF/BKA: diabetic neuropathy E11.40, CHF I50.9, PVD I73.9, chronic pain G89.29, depression F32.A, phantom limb pain risk, respiratory concerns, rehabilitation planning, ASA IV

34 — Case 5: ADHD, OSA, Prior CHS & Arthroscopy

ADHD F90.9, OSA G47.33, meniscus tear S83.209A, cannabis use F12.90, CHS history Z87.898, anxiety F41.1, substance use F19.90, CUDIT-R/ISI monitoring, concentrate exposure, kratom interactions, aspiration risk, insomnia, perioperative harm reduction

35 — Ethical Challenges & Multidisciplinary Care

Autonomy vs safety, THC benefit vs psychiatric risk, cannabis vs first-line therapies, documentation/legal concerns, psychiatry, pain management, oncology, surgery/anesthesia, addiction medicine, rehabilitation, sleep medicine, pharmacy collaboration

PART 5 — TRULIEVE PRODUCTS & CLINICAL APPLICATIONS

36 — Trulieve Product Categories

Momenta THC Cream, Momenta CBD tincture, 1:1 tinctures, RSO tincture, CBD capsules, THC capsules, CBN capsules, distillate syringes, RSO syringes, Sweet Talk gels, vape carts, TruPods, whole flower, all-in-one devices

37 — Product Selection by Clinical Goal

Pain/neuropathy = ratio tincture + topical, insomnia = low-dose THC/CBN, anxiety/PTSD = CBD-dominant or balanced low-dose ratio, appetite/nausea = THC/RSO caution, breakthrough pain = rapid-onset inhalation in low-risk patients, geriatric care = low-dose oral/topical

38 — Product Selection by Risk Profile

CHF/CAD/OSA/COPD = avoid inhalation, elderly/fall risk = low-dose oral/topical, psychiatric instability = avoid high-THC concentrates, CHS history = avoid concentrates/frequent THC, polypharmacy = prefer topical/CBD-dominant options, perioperative risk modification

39 — Pharmacokinetics & CHS Prevention

Oral = delayed onset/longer acting/11-OH-THC formation, sublingual = intermediate onset, inhaled = rapid onset/higher pulmonary-CV risk, topicals = minimal systemic exposure, concentrates/high-potency THC = highest CHS risk, safer alternatives = ratio/CBD-dominant formulations

40 — Final Clinical Pearls & Future Directions

Medical necessity requires diagnosis + impairment + risk-benefit analysis + monitoring, product selection should match clinical goal and ASA risk, ratio products often better tolerated, CBD may mitigate THC adverse effects, harm reduction is essential, evidence gaps remain, multidisciplinary care improves safety, future cannabinoid research directions, Q&A

Reference List

1. CDC/NCHS — Chronic Pain and High-Impact Chronic Pain in U.S. Adults, 2023

2. CDC — National Diabetes Statistics Report

3. National MS Society — U.S. MS Prevalence Data

4. Parkinson’s Foundation — Parkinson’s Disease Statistics

5. NIMH — Anxiety Disorder Statistics

6. NIMH — PTSD Statistics

7. American Cancer Society — Cancer Facts & Figures 2026

8. Hsu M, Shah A, Jordan A, Gold MS, Hill KP. Therapeutic Use of Cannabis and Cannabinoids. JAMA. 2025.

9. Kansagara D, Hill KP, Yost J, et al. Cannabis or Cannabinoids for Chronic Noncancer Pain. Ann Intern Med. 2025.

10. Wang L, Hong PJ, May C, et al. Medical Cannabis or Cannabinoids for Chronic Pain. BMJ. 2021.

11. Lam PM, Wang F, Shing CH, et al. Analgesic Effect of Cannabinoids for Fibromyalgia. Pain Physician. 2026.

12. Braun IM, Bohlke K, Abrams DI, et al. Cannabis and Cannabinoids in Adults With Cancer: ASCO Guideline. J Clin Oncol. 2024.

13. Han K, Wang JY, Wang PY, Peng YC. CBD in Anxiety Disorders: Systematic Review & Meta-analysis. Psychiatry Research. 2024.

14. Shah S, Schwenk ES, Sondekoppam RV, et al. ASRA Perioperative Cannabis Guidelines. Reg Anesth Pain Med. 2023.

15. Rubio-Tapia A, McCallum R, Camilleri M. AGA Clinical Practice Update on CHS. Gastroenterology. 2024.