Cannabinoids and Pain Care: A Federal Shift That Needs Guardrails
/By Dr. Lynn Webster
On December 18, President Trump signed an executive order directing the Department of Justice to expedite completion of the process moving marijuana from an illegal Schedule I controlled substance to Schedule III, a less restrictive category that allows for medical use.
The order also directs federal health agencies to expand research, explicitly including real-world evidence, to better inform patients and clinicians about medical marijuana and hemp-derived cannabidiol (CBD).
For clinicians who treat chronic pain, the significance is simple. Federal policy is starting to align with clinical reality. Cannabinoids are already widely used for pain and related symptoms, yet clinical guidance and product standards have lagged.
What the Order Gets Right
It squarely names the research gap. The order cites FDA’s review finding scientific support for marijuana’s medical use in specific settings (including pain), and it connects the current rescheduling effort to the Department of Health and Human Service’s 2023 recommendation that marijuana be placed in Schedule III.
Whatever one thinks about cannabis politics, Schedule I status did not prevent use — it contributed to widespread use with limited standardization and weak clinical guidance.
It also highlights a practical safety problem that clinicians recognize immediately: non-disclosure by patients. The order cites survey data that only about 56% of older adults using marijuana have discussed it with a healthcare provider.
This is an avoidable risk in a population where polypharmacy is common, and adverse events can be consequential. Normalizing nonjudgmental conversations about cannabinoid use is low-tech harm reduction.
Another constructive element is that the order explicitly calls for a regulatory framework for hemp-derived cannabinoid products, including guidance on an upper limit of THC per serving and considerations such as per-container limits and CBD:THC ratio requirements.
Where the Risks Remain
Rescheduling is not the finish line. Moving marijuana to Schedule III may improve research, but it does not automatically create FDA-approved medications, standardized dosing, or clinically reliable formulations for the products most patients actually use. If the public interprets Schedule III as “safe and proven,” we may inadvertently widen the gap between perception and evidence.
CBD is the other major vulnerability. The order acknowledges that some commercially available CBD products are inaccurately labeled (for example, isolate vs. broad-spectrum vs. full-spectrum), leaving patients and clinicians without adequate safeguards. Independent testing supports this concern. A JAMA analysis of CBD products sold online found substantial labeling inaccuracies and detectable THC in a meaningful share of samples.
In pain care, that matters. Unintended THC exposure can impair cognition, contribute to sedation and increase fall risk, especially in older adults. It can also trigger unexpected positive drug tests with real-world consequences.
Safety signals also deserve more humility than the marketing suggests. FDA warns that CBD can cause liver injury and affect how other drugs work, potentially leading to serious side effects.
A randomized clinical trial in healthy adults reported liver enzyme elevations in a subset receiving CBD 5 mg/kg/day for 28 days, with some meeting protocol criteria for potential drug-induced liver injury.
The takeaway from this is not “CBD is dangerous.” It is that population-level use without dose clarity, interaction guidance, or monitoring invites harm, especially in older adults, medically complex patients, and in people taking anticoagulants, anti-epileptics, sedatives or other CNS-active medications.
Finally, the order hints at regulatory whiplash around “full-spectrum” products, noting that some could be treated as controlled substances — again, depending on statutory THC thresholds.
Shifting definitions and enforcement create confusion for patients, clinicians and legitimate manufacturers, and can favor market consolidation that raises prices and narrows choice.
A Clinician’s Checklist for Doing This Right
If this federal pivot is going to improve pain care, access must be paired with guardrails including:
Product integrity first. Batch testing, contaminant screening, and accurate labeling (including verified CBD and THC per serving, and spectrum classification) for any federally supported access or research model.
Pharmacovigilance at scale. If real-world evidence is the strategy, real-world safety reporting must be built in and transparent.
Routine medication reconciliation. Clinicians should ask about cannabinoid use the way we ask about supplements — calmly, consistently, and without stigma.
Honest messaging. Clear statements about what the evidence supports, what remains uncertain, and what warrants extra caution.
Bottom Line
The executive order is an important acknowledgement that Americans are using cannabinoids for pain while federal research, standards, and safeguards have lagged. If rescheduling accelerates rigorous research and CBD access is paired with product standards and safety monitoring, clinicians and patients could benefit.
But if access expands faster than quality control and pharmacovigilance, we risk repeating a familiar U.S. cycle: adoption first, guardrails later. Cannabinoids give us a chance to do it differently: evidence first, standards always, and patient safety at the center.
Lynn R. Webster, MD, is a physician specializing in pain and addiction medicine, a former president of the American Academy of Pain Medicine, Senior Fellow at the Center for U.S. Policy, and author of “The Painful Truth” and the forthcoming book “Deconstructing Toxic Narratives: Data, Disparities, and a New Path Forward in the Opioid Crisis.”
Lynn has written extensively on drug policy, the opioid crisis, and criminalization of medicine. Webster reports no relevant financial relationships related to cannabis or CBD products.
