Thank you for publishing the extensive and detailed article by Dr. Roneet Lev on cannabis and its potential for abuse (“Fifteen Things the Cannabis Industry Doesn’t Want You to Know,” April 4, 2023). Cannabis is a serious medicine, albeit now over the counter, and should only be used as such. Dr. Lev has compelling arguments why there is essentially no place for teen cannabis use, other than as prescribed by a qualified pediatrician for specific conditions. The teen brain is growing, and cannabis use surely does not augment that process. In addition, as the author mentions, it poses a risk for unmasking psychosis for a select few.

That said, as a geriatric hospitalist in the intensive care unit, I think Dr. Lev’s stark warning bordered on hyperbole.

Dr. Lev openly represents the approach of the federal government, which labels cannabis as having “no acceptable medical use,” or Schedule I. This is very far from the truth, as science both from the U.S. and Israel has shown clearly in many maladies, from inflammatory bowel disease to cancer to PTSD, to name a few. And while inducing psychosis remains a concern, studies at Tel Aviv University even show cannabis to serve as neuroprotective against oxidative injury, and Hebrew University has shown that cannabis may even reverse brain aging. Again, this is all at the right dose at the right time. Dr. Lev seems to be warning against wanton, unsupervised use, which is a concern as availability becomes more widespread.

And while cannabis hyperemesis syndrome (CHS) is a real phenomenon for those who over-ingest cannabis products, theoretically landing a patient in the ICU with low sodium or potassium, it is rare. That is in stark contrast to opioid and alcohol overdose, which hits our ICU weekly. In fact, there is greater than a 9/11-scale disaster occurring, with people dying daily from opioid overdose, in addition to the 1,000-plus Americans that die daily of alcohol abuse-related complications. This is far from the case with cannabis, whose deaths nearly always involved mixing other drugs.

Dr. Lev rightly warns that cannabis could be potentially tainted with fentanyl or other opioids, which is why it is so important for those over age 21 who do self-prescribe adult-use cannabis to obtain it from a licensed dispensary. Obtaining cannabis responsibly from a licensed dispensary is the only way to engage in self-prescription. Just like someone should not buy aspirin or acetaminophen off the street, the same applies to cannabis. It is a medicine. Dispensaries are charged with making sure their product is pure and its contents labeled.

The stories that Dr. Lev described rightfully apply to warn teens not to self-prescribe cannabis, and serve as a justified warning to adults who do have cannabis products at home to store them properly—out of the reach of children.

That all said, cannabis is a highly useful adjunct in the American pharmacopeia that needs to be applied with a responsible and moderating eye; it is not all or nothing, however.