The intersection of chiropractic care and cannabinoid use

As the use of cannabinoids, including cannabidiol (CBD) and medical marijuana, continues to rise across the US, DCs find themselves navigating a complex landscape.

While these substances are increasingly popular for managing pain and other conditions, their integration into a patient’s chiropractic care can present potential risks and ethical dilemmas. DCs must balance patient safety, regulatory compliance and ethical standards to provide the best care while managing these risks.

This article explores key risk management issues surrounding the use of cannabinoids in chiropractic care, including patient safety, informed consent, legal compliance and the ethical gray areas that can arise. It will also highlight best practices in documentation, communication and education that are crucial for minimizing risk and ensuring that chiropractic treatment remains safe and effective for all patients.

Patient safety and interaction

Potential drug interactions

Cannabinoids, particularly CBD and medical marijuana (THC), are frequently used for pain relief, anxiety and sleep disorders, conditions that DCs commonly treat. However, cannabinoids can interact with various medications and alter physiological functions, which may complicate treatment outcomes. For example, CBD has been shown to interact with medications that affect the liver’s cytochrome P450 enzyme system, which is responsible for metabolizing many drugs. This interaction can either enhance or reduce the efficacy of these medications, potentially leading to unintended side effects or treatment failures.¹

Additionally, cannabinoids can influence vital signs such as blood pressure and heart rate. CBD has been found to have hypotensive effects, a potential concern for patients who are already on antihypertensive medications.² This is particularly relevant in chiropractic care, as adjustments and manual therapies may impact blood pressure and cardiovascular responses. You must be aware of these interactions and how they might affect treatment plans and patient outcomes.

Impairment and cognitive function

Patients who use intoxicating cannabinoids, such as THC, may experience cognitive impairment, altered perception and decreased coordination.³ This is a significant concern in the chiropractic setting, where adjustments require a patient to be both physically stable and mentally aware of instructions for optimal safety. If a patient is impaired by cannabinoids, they may have difficulty following instructions, positioning their body appropriately during adjustments or responding quickly to physical manipulation, all of which can increase the risk of injury. Use of coordination-impairing cannabinoids could also contribute to at-home injuries that may complicate or negatively impact chiropractic outcomes. Determining clinical correlation between injury due to joint instability or vertigo symptomology vs. cannabinoid-induced discoordination should be explored and risks discussed with the patient.

For example, a patient who is using cannabis for pain management may be less aware of the risks associated with its use or may not fully disclose their usage. You must navigate this issue by providing clear, non-judgmental guidance and ensuring the patient is aware of the potential effects cannabinoids can have on their treatment.

Given these risks, you should assess a patient’s mental and physical state prior to treatment, especially if the patient is known to be using cannabinoids. Clear communication regarding the patient’s current state of impairment and how it might affect the treatment is essential.

Informed consent and documentation best practices

Complexity of treatment plans

Informed consent is one of the most crucial components of chiropractic practice, particularly when the patient’s cannabinoid use may impact their care. For patients using cannabinoids, you must ensure that they fully understand how the use of these substances may interact with their treatment plan. This includes explaining potential side effects, interactions with prescribed medications and the possible impact on the chiropractic adjustment process.

It is important to note that informed consent is not a one-time event but an ongoing process. As a patient’s condition evolves, so too may the risks associated with their cannabinoid use, and these changes must be reflected in updated treatment plans and consent forms. Additionally, you must be prepared to document these discussions comprehensively.

Documentation

Thorough documentation is critical in managing the risks associated with cannabinoid use in chiropractic care. Documenting each conversation with the patient about their use of cannabinoids, as well as the effects on treatment, is essential for legal protection. Make clear notes about the patient’s reported cannabinoid use, any potential side effects and any modifications made to the treatment plan as a result. This documentation not only provides legal protection but also ensures continuity of care by allowing other healthcare providers to be informed about the patient’s cannabinoid use.

Given the complexity of managing patients on cannabinoids, you should also keep detailed records of any adverse events, including changes in patient responses to adjustments or other treatments. This ensures that you can provide appropriate follow-up care and promptly address any complications.

Legal and regulatory compliance

State laws and federal considerations

One of the most challenging aspects of managing cannabinoids in a chiropractic practice is navigating the varying state laws regarding the legality of hemp-derived cannabinoids and their intoxicating/impairing derivatives. Additionally, some states have legalized medical and recreational cannabis, while others have not. You must remain informed about the legal status of cannabinoids in their specific jurisdiction. Failure to do so could equal noncompliance with state laws, as well as potential exposure to liability or regulatory action.

However, even in states where medical marijuana is legal, the federal government still classifies THC-dominant cannabis types as Schedule I controlled substances, which creates a unique dilemma for healthcare providers. The legality of recommending intoxicating/impairing cannabis products is generally outside the scope of chiropractic practice, as DCs are not licensed to prescribe medication. Yet, this does not prevent patients from using THC and other impairing cannabinoids independently, which means you must remain vigilant in documenting and discussing any potential risks with patients.

Product selection and compliance

You should also be cautious when it comes to recommending or offering cannabinoid-based products in your practice. While hemp-derived CBD products (containing less than 0.3% THC) are federally legal, the legal status of other cannabinoid products originating from CBD, such as THC or newer derivatives like delta-8-THC, can vary from state to state. It is crucial for you to ensure any cannabinoid-based products you sell or recommend are compliant with both state and federal regulations.⁴

Selling or promoting cannabinoid products that do not meet regulatory standards can expose a DC to legal risks, including malpractice suits or regulatory sanctions. Therefore, it is essential for you to engage in thorough due diligence regarding the sourcing, quality and legality of the products you recommend or sell to patients.

Ethical gray areas

Patient autonomy vs. professional guidance

One of the most challenging ethical considerations when treating patients who use cannabinoids is balancing patient autonomy with professional responsibility. While patients have the right to make informed choices about their health, DCs may feel compelled to advise against or limit certain treatments based on the potential impact of cannabinoid use. If you believe a patient’s cannabinoid use may compromise the safety or effectiveness of treatment, you may face an ethical dilemma. Another ethical consideration is off-label use of cannabinoids. As physicians, DCs should remain evidence-based in their recommendations and discussions with patients despite any therapeutic potential associated with individual cannabinoids.

Advertising and promotion

DCs must be cautious in how they advertise their services in relation to cannabinoid use. Misleading or exaggerated claims about the benefits of combining chiropractic care with cannabinoid use could lead to ethical breaches and also damage the practice’s reputation. Focus on evidence-based information and avoid making claims that imply cannabinoids can “cure” or “treat” specific conditions, especially when the scientific evidence for such claims is lacking.

Instead, your marketing efforts should emphasize your commitment to safe, comprehensive care and patient education. Clearly communicate that you are knowledgeable about cannabinoid use, but refrain from making any therapeutic claims that could be construed as false or misleading.

Overcoming challenges of cannabinoid use

Education and training

Ongoing education is essential for DCs who are navigating the complexities of cannabinoid use in healthcare. Actively seek out continuing education courses that address the science behind cannabinoids, their potential effects on musculoskeletal health and the legal considerations involved. Being well-informed allows you to make the best decisions for your patients and reduces the risk of litigation or noncompliance.

Open communication and collaborative care

Encouraging open communication with patients about their cannabinoid use is vital. Foster an environment where patients feel comfortable discussing their cannabinoid use with you without fear of judgment. Establishing trust will help ensure that patients are transparent about their health practices, which ultimately leads to better care.

Collaborating with other healthcare providers, such as physicians or pharmacists, who have expertise in cannabinoid therapy can also enhance patient safety and treatment outcomes. A team-based approach to care can ensure all aspects of a patient’s health are considered when developing a treatment plan.

Clear policies and procedures

Developing clear policies and procedures regarding cannabinoids in patient treatment is crucial for minimizing risk. These policies should include guidelines for assessing patient safety, obtaining informed consent and documenting treatment plans. Well-established protocols help protect you from legal action and provide consistency in care.

Final thoughts

The intersection of chiropractic care and cannabinoid use presents numerous challenges, but with thoughtful consideration and proactive risk management strategies, you can provide safe, effective care for your patients. By remaining informed about the legal, ethical and clinical aspects of cannabinoid use, you can navigate these complex issues while maintaining the highest standards of patient care.

Misty Green, DC, MS, is a cannabis educator for physicians. She completed the first graduate-level cannabis program in the US, obtaining her master’s degree in medical cannabis science and therapeutics through the University of Maryland, School of Pharmacy. She has combined her decades of clinical practice with her fascination with all things cannabis to pivot into the cannabis space, helping bridge the gap between healthcare workers and much-needed cannabis education through lectures and cannabis curriculum production. Contact her at drmistydc@hotmail.com.

References

1. Lopera V, et al. Clinical relevance of drug interactions with cannabis: A systematic review. J Clin Med. 2022;11(5):1154. PubMed. https://pubmed.ncbi.nlm.nih.gov/35268245/. Accessed February 26, 2025.

2. Dujic G, et al. Chronic effects of oral cannabidiol delivery on 24-h ambulatory blood pressure in patients with hypertension (HYPER-H21-4): A randomized, placebo-controlled, and crossover study. Cannabis Cannabinoid Res. 2024;9(4):979–989. PubMed. https://pubmed.ncbi.nlm.nih.gov/37093160/. Accessed February 26, 2025.

3. Moore CF, et al. Effects of oral Δ9-tetrahydrocannabinol and cannabidiol combinations on a sustained attention task in rats. Exp Clin Psychopharmacol. 2023;31(5):881–887. PubMed. https://pubmed.ncbi.nlm.nih.gov/36634015/. Accessed February 26, 2025.

4. Mead A. Legal and regulatory issues governing cannabis and cannabis-derived products in the United States. 2019;10:697. Front. Plant Sci. https://doi.org/10.3389/fpls.2019.00697/. Accessed February 27, 2025.