Risk and reward: Cannabinoids and chiropractic

When considering cannabinoids as part of your treatment portfolio, you must stay within scope of practice, adhere to legal and ethical standards, and prioritize evidence-based recommendations while maintaining ongoing education and clear patient communication.

Over the past decade, cannabinoids have become interwoven into the fabric of American healthcare, but not just legacy cannabinoids such as CBD and THC. The completely unregulated hemp-derived cannabinoid market has exploded since the passing of the Farm Bill in 2018, and cannabinoids have become a multibillion-dollar industry that technically falls within the chiropractic scope of practice.¹ Understanding the legal landscape of CBD and other cannabinoids is the first step to compliance, followed by an evidence-based approach that supports their therapeutic use. Education will be the foundational building block required to legitimize a formerly illegal, plant-based therapeutic option, while operating legally within the chiropractic scope of practice.

Legal landscape of cannabinoids in chiropractic practice

Historically, cannabis and the cannabinoids contained within it have been considered a taboo topic within healthcare. The allopathic medical model implemented in the 1930s removed cannabis from the pharmacopeia and American healthcare was forcefully transitioned into the allopathic medical model, touting pharmaceuticals as the new face of healthcare. The 2018 Farm Bill was the first legislative act to bring cannabis back into healthcare, although that was not its intention when passed. Hemp plants containing less than 0.3% total THC (by dry weight) were considered federally legal, but not without significant legal restrictions tied to them. The intention of the hemp component of the Farm Bill was for industrial usage of the stalk and seeds, not necessarily the chemical components found within the “flowering portion” of the buds/leaves containing the cannabinoids. With this legislation, cannabidiol (CBD) was catapulted onto the healthcare scene after being designated as “federally legal” since it originated from the federally legal hemp plant. Piggybacking off of the newly created CBD industry was the spawning of the hemp-derived “alternate cannabinoid” market. Hemp-derived alternate cannabinoids start with federally legal CBD extracted from the federally legal hemp plant, which then gets synthetically manipulated into isomers of the intoxicating cannabinoid tetrahydrocannabinol (THC) found within the marijuana plant. The legal gray areas of both CBD and its hemp-derived alternate cannabinoids create an ethical dilemma for DCs interested in expanding therapeutic offerings within their practices.

While the Farm Bill may have legalized hemp after decades of prohibition, inadvertently creating and launching the new CBD industry, what it did not do was create any type of regulatory body to oversee it. The lack of regulatory oversight is especially problematic when choosing specific products to be used or sold in DC offices. To stay compliant within the legal framework in which physicians are required to maneuver, it is imperative that products chosen and endorsed are from reputable vendors supplying quality products that meet the federally legal THC threshold.

Additionally, the Farm Bill did not approve CBD to be used as a nutritional supplement, regardless of its new legal status. Yes, CBD is considered a federally legal product when derived from a federally compliant hemp plant, but recommending its ingestion for the purpose of treating a specific health condition can throw the DC into legal jeopardy from a regulatory standpoint. The risk also encompasses any advertising done, which is frequently monitored by the FDA for false medical claims of efficacy.

Maintain chiropractic scope of practice

In 2022, 20% of Americans reported CBD use in the past year.² Although patients are coming into the chiropractic office most likely knowing more about the endocannabinoid system, CBD and THC than the doctor, their information is not always accurate.

This introduces an ethical consideration: whether the physician has been adequately educated in cannabinoid therapeutics. Because of the allopathic medical model promoted in today’s healthcare curriculum, there has been a dearth of education on the endocannabinoid system (ECS) and how cannabinoids interact with it within the body.³ Without education from a qualified source, should the DC be discussing/promoting cannabinoid-related therapies in the office?

Another ethical consideration regarding the application of CBD or any other cannabinoids is promoting off-label use to patients. Currently, cannabinoids (except approved pharmaceuticals) lack FDA endorsement for treatment of musculoskeletal conditions, impacting claims chiropractors might make. Because of this, remaining evidence-based when recommending use is the best way to stay in compliance when it comes to CBD. Clinically, CBD has been extremely effective for reducing symptoms associated with musculoskeletal conditions seen in the chiropractic office, such as inflammation, with emerging evidence-based research to supports its use.⁴ Anecdotally patients are successfully using CBD most commonly for insomnia, chronic pain and anxiety,⁵ which would be considered off-label use. This creates an ethical gray area when DCs recommend CBD to their patients. It is the DC’s responsibility to develop a discerning eye when evaluating the robustness of the research studies, while staying abreast of current research studies supporting its recommended use in the chiropractic office.

The third ethical gray area involves the chiropractors’ position on intoxicating “alternate” cannabinoids made synthetically from CBD found in hemp. CBD is the main cannabinoid in federally legal hemp and is considered a “major cannabinoid” because it’s naturally abundant. Other cannabinoids in hemp exist only in lesser amounts and are known as “minor cannabinoids.” One popular intoxicating minor cannabinoid is Delta-8 THC, which is present in hemp but in very minute quantities. Since there is not enough naturally occurring Delta-8 THC to meet commercial demand, the industry creates these cannabinoids by converting CBD into chemical isomers similar to THC found in marijuana. This hemp-derived alternate cannabinoid market is completely unregulated with no accepted best practices for use. Some argue that because these intoxicating cannabinoids come from a legally allowed source (CBD) that recommending them falls within chiropractic scope of practice. However, due to the lack of regulation, safety standards and solid evidence supporting their therapeutic use, recommending them is harder to justify and could risk malpractice. Remember, just because something is legal does not automatically make it ethical to recommend.

Compliance and risk management strategies

• Documentation and risk management: Detailed clinical documentation of all cannabinoid-related discussions, including rationale and patient decisions, is advisable to mitigate liability.
• Keep current information on hand: Stay updated on evolving laws via professional associations and legal counsel; incorporate cannabinoid-related education to support clinical decisions.
• Monitor product quality and claims: Educate patients on risks of unregulated cannabinoid supplements and discourage off-label use unless supported by robust clinical evidence.
• Balance risk and reward in clinical application: Chiropractors should prioritize evidence-based interventions, cautiously considering cannabinoids within a multidisciplinary framework rather than as primary therapies.

Final thoughts

In summary, the integration of cannabinoids into chiropractic care requires a sophisticated balancing act, such as appreciating their promising therapeutic potential while rigorously adhering to the complex and variable legal environment and clearly defined professional boundaries. Ongoing education, judicious patient communication and staying current with cannabis research are vital to mitigating risk and responsibly harnessing cannabinoids’ emerging role in chiropractic care.

Misty Green, DC, MS-MCST, has served the Cape Coral, Florida, community as a chiropractic physician since graduating from Life University in 1999. With nearly three decades of clinical experience, she has become a dedicated advocate for cannabis education in healthcare. She earned her master of science in medical cannabis science and therapeutics from the University of Maryland School of Pharmacy in 2022, completing the nation’s first graduate level cannabis program. Blending her clinical background with advanced cannabis training, Green now focuses on educating healthcare professionals through continuing education courses and curriculum development, helping bridge the gap between clinical practice and evidence-based cannabis therapeutics. For more information, email drmistydc@hotmail.com.

References

1. Cannabis and Hemp Market Size and Growth. Regional Forecast 2025 to 2033. Global Growth Insights. https://www.globalgrowthinsights.com/market-reports/cannabis-and-hemp-market-100732. Accessed January 13, 2026.
2. Choi NG, et al. Prevalence of cannabidiol use and correlates in US adults. Drug Alcohol Depend. 2024;13:100289. https://doi.org/10.1016/j.dadr.2024.100289. Accessed January 13, 2026.
3. Evanoff AB, et al. Physicians-in-training are not prepared to prescribe medical marijuana. Drug Alcohol Depend. 2017;180:151-155. https://pubmed.ncbi.nlm.nih.gov/28892720/ . Accessed January 13, 2026.
4. Burstein S. Cannabidiol (CBD) and its analogs: A review of their effects on inflammation. Bioorg Med Chem. 2015;23(7):1377-1385. https://pubmed.ncbi.nlm.nih.gov/25703248/ . Accessed January 26, 2026.
5. Moltke J, Hindocha C. Reasons for cannabidiol use: A cross-sectional study of CBD users, focusing on self-perceived stress, anxiety and sleep problems. J Cannabis Res. 2021; 3(5). https://doi.org/10.1186/s42238-021-00061-5/. Accessed January 13, 2026.