Research Article Review:  Medical Cannabis for Addiction Treatment in a Residential SUD Setting

What was the study?

Imagine a study examining the benefits of patients using cannabis as a part of their residential addiction treatment. 

In this post I’ll share some of my thoughts about the following paper:  

Fehr, F. C., Lo, L. A., Nelson, C. N., Diehl, L. & Walsh, Z.  (2025).  Medical Cannabis Use Adjunct to Standard of Care in a Residential Substance Use Recovery Program: A Pilot Study.  Journal of Studies on Alcohol and Drugs.  86:6, 967-976.

In this study from Canada the research subjects were ten men and four women undergoing residential addiction treatment.  The outcomes being evaluated were subjective (emotions, physical feelings, etc.) and determined by the self-report of those in the study.  In terms of results, the participants reported they felt less bad and found other benefits as well. 

What are my concerns about the study?

I have a number of concerns about this study.  And I also have concerns about what this study signals. 

Below, I share my thoughts related to the context of the study, its rationale, some terminology in the paper, risks and benefits of this approach, related credentialing for clinical staff, the study’s method, the results, and stigma in the context of the study. 

At the end I’ll list the references and some related readings, and then provide the abstract from another paper as a bonus reading.

Context of the study

To help set the context, the authors note that “problematic substance use involves patterns of substance use that lead to significant harm or distress.” 

To me the word “harm” in that context seems to be doing a lot of work, especially reframing.  After all, the DSM definition of a mental disorder is one that causes significant “impairment or distress”, not “harm or distress”.  Of course, naturally, less harm in any context would normally be thought of as good.  But I would like to add that causing an impairment by adding a drug is not good.  While cannabis use might be less harmful than some other drugs, cannabis use all on its own is impairing.  We should “do no harm”, right?  Or do we think that it’s absolutely unavoidable that “do no harm” and harm reduction must be in tension?   

The authors go further in setting the context by stating we are in a “drug poisoning epidemic”.  Reading their paper, the reason for them making that statement is not explicitly clear to me.  I will say that to me the phrase “drug poisoning epidemic” seems to be making a wedge argument within which they can insert their rationale for this clinical approach.  We could, by contrast, call the epidemic a “potency” epidemic.  Is purity necessarily “safe”?  Here’s the conundrum:  both purity and potency may come at the price of toxicity.

Rationale for the study

The authors describe the method of their study and the rationale for their experiment.  In doing so they state that, “Some clients may prefer a harm reduction strategy that allows for the continued use of certain substances while eliminating more harmful ones…” 

Readers already know that a persistent desire to cut down or abstain counts as a diagnostic criterion for a substance use disorder.  My point is that one would assume this kind of thinking would be present among the patients and reflect the course of illness (as the DSM points out). 

It is also the case that the phenomenon of “serial recovery” is already in the clinical-applied addiction literature.  It describes a recovery pathway where someone stops use of some drugs, and later others.  One common example of “serial recovery” would be someone gladly stopping their IV heroin or IV cocaine use while planning to continue to drink alcohol or smoke cannabis from time to time.  An even more common example would be anyone in any routine residential addiction treatment program whose active addiction illness is retained throughout their stay via smoking cigarettes, while giving the lethality of that plan almost no thought, and reconsidering and stopping their use later. 

And so I ask, in clinical settings, should we allow someone to keep using drugs and alcohol, and prolong and/or worsen their disorder?

The authors go further and state that “…clients may wish to incorporate cannabis as part of their recovery process…” 

In response to that I ask if we are now to understand that using is part of recovery?  Does using while saying you’re in recovery meet the definition of recovery? And regardless, are we now to understand that using is part of residential addiction treatment? 

Further, many claim that the word “recovery” is narrow and stigmatizing.  Perhaps we could pick a different word, such as “healing” – which might accommodate continued substance use in this context more naturally and easily than the word “recovery” does. 

Now I’ll turn to some specific terminology found in the paper.

“Medical cannabis”?

In the paper the authors use the phrase “medical cannabis”.  And “cannabinoid medicines” is also a term the authors use. 

This causes me to ask if it is the case that cannabinoids are medicines?  And if so, for what diagnoses, problems, and clinical targets?  Subjective benefits are one thing, but medication approval for specific clinical indications is another.  The reader might wonder if cannabis or THC has been approved by the FDA for any indication?  The FDA has made a very few specific approvals (FDA:  Cannabis research and drug approval process).

Thus, I wonder if this study was subject to review by an Institutional Review Board (IRB) and approved as ethical?  I wonder because it is research with human subjects.  And it is a study giving psychotropic drugs with addiction potential to people with substance use disorders.  I also wonder what clinical practice guidelines were used within the study.  The authors don’t indicate that any practice guidelines were adopted and followed, or improved upon. 

Cannabis is a “substitute”?

You might be wondering what substances with addiction potential were most commonly used among those patients in the study.  Those substances were opioids, cocaine, alcohol, and methamphetamine. 

The authors use the word “substitute” to describe the role of cannabinoids in this study.  Normally, the word “substitute” would refer to a drug prescribed within the same drug class as the diagnosed substance use disorder, and being used to treat it.  An example would be methadone prescribed in the treatment of a heroin use disorder. 

In a plain sense, “substitute” seems to carry ambiguity in their paper, and therefore opens the door to misunderstanding and perhaps unwarranted stigma as well for their approach.  Or perhaps the word “substitute” works as a way to widen the wedge argument for their therapeutic rationale of this cannabinoid approach.

Risks and benefits of a study like this?

The authors state that the benefits and risks of cannabinoid therapies are important to identify. 

I also wonder about identifying the markers for who specifically is at the greatest risk for adverse reactions to this protocol.  And how exclusion criteria for participation in such studies should be developed.  The paper mentions exclusion criteria but none related to SUDs per se.

Further, the authors call their approach “novel”. 

Cannabinoids and our knowledge of their effects/benefits are not novel.  But it is the case that this approach to addiction treatment is novel.  My point is that I’m honestly not sure what the main benefits of doing such a study are, given the longstanding knowledge we already have about the effects and side-effects of cannabinoids. 

I’m also concerned that the study fails to mention if first-rank symptoms (using more than planned, difficulty staying stopped) of addiction in general, or cannabis use disorder in particular, were screened for as useful exclusion criteria (e.g Coon, 2025). 

Cannabinoid medicine vs Addiction medicine?

The paper states that the physician providing care in the study had over ten years of experience with cannabinoid medicine. 

I wonder if the physician had any experience in addiction medicine?  And I wonder if the physician was blind to the purpose and method of the study, like in a double-blind, randomized, controlled trial?  The paper makes no mention. 

But beyond credentials I also have concerns about the study’s method.

The study’s method

Do you have a guess about what cannabinoids were administered and how?  The paper describes “…a weekly supply of cannabis, consisting of oils, capsules for oral administration, and dried cannabis for inhalation…with diverse cannabinoid profiles, including high and low THC and CBD…a maximum of 2 g of cannabis flower per day for inhalation”. 

In my background I’m accustomed to cannabinoids being referred to in ounces and pounds, rather than metric measures.  I did some looking and found that on average, a joint = 0.3 grams.  So roughly speaking, it seems these patients received the equivalent of 6 joints a day, plus oils and capsules. 

Treatment and study phases

In terms of the research method itself, they describe a three-month introductory period in the treatment setting followed by Phase 2 and Phase 3.  A phased system like that reminds me of the treatment approach used in the Therapeutic Community model.  The cannabinoid was delivered during Phase 2 and Phase 3.  As they describe it, Phase 2 and 3 in their program focus on consolidation of initial gains and then exploring re-entry to the outside world. 

I’m a bit surprised that the patient’s abstinence, treatment program involvement, and personal recovery formation and development were interrupted in Phase 2 by introducing cannabis.  I would guess a strategy such as adding cannabis might be used to soften the patient’s initial arrival and adaptation to the program. 

The authors go on to say that those receiving medicinal cannabis also received five cannabis education sessions covering the risks, benefits, and so forth, during the study period. 

The paper does not say this education was completed before the cannabis was provided and I found that surprising.  From a research method perspective, one could argue that the education served as a confounding factor planting suggestions about the benefits of the cannabinoids for those receiving them. 

To examine results, the patients were followed for 3 months.

What about the results?

What results were found for giving cannabis to those in residential addiction treatment during Phases 2 and 3 of their care?  Pain relief was a prominent benefit.  The patients reported improvements in pain relief, mental health, sleep, drug substitution and craving, and medication use changes.  Looking closer, “medication use changes” meant that the study participants found that taking cannabinoids provided benefits such that they could stop taking their prescribed medications, or take less of their prescribed medications. 

For me, patients taking less of or stopping their prescribed medication raises questions and concerns.  The authors do not elaborate on this matter.

The study includes a table with verbatim journal entries from the study participants about the benefits of their use of cannabinoids during the study. 

Many of the benefits listed remind me of the broad range of benefits from a placebo.  And they also remind me of the claims made by purveyors of so-called medicines prior to our modern system of things like FDA, IRB, medical ethics, and related laws. 

Harms of this intervention were not mentioned or measured. 

We are left to wonder if any of the participants experienced their cannabis use in this context as iatrogenic, such as forming the onset of a cannabis use disorder during the study. We apparently have only their self-reported regular cannabis use prior to enrollment, used as inclusion criteria, to obviate part of that concern. 

It strikes me that we could reasonably predict that adding alcohol would also “help” in similar ways.  As would adding acetaminophen.  One might consider adding acetaminophen as preferable, given that it limits the initial raw neurological production of feelings, and does not merely blunt one’s awareness of the feelings their neurological system already manufactures. 

Predictably, the authors state that one unintended consequence of the study was stigma.

Stigma

The authors say that almost half of the participants experienced stigma during the study due to their use of cannabinoids while in treatment.  For example, they say that the patients “sometimes met resistance from staff who were not fully informed…” 

I’m concerned that staff in the program were not made aware or “fully informed” of these clinical methods.  One reason I’m concerned is that stigmatizing the use of cannabinoids while not being fully informed about the study and its rationale would be predictable – as stigmatizing any harmful practice would.

Skepticism

The authors note a “disparity between the participants’ positive experiences” with medicinal cannabis and “the ambivalence expressed by staff”.  And further note that several staff remained “skeptical”. 

Why should the ambivalence or skepticism of a clinical staff in an addiction treatment program who were not fully educated on this project be described as “striking” when compared to the endorsement of the plan by those smoking the cannabinoids?  Regardless, skepticism is the position of science.  And professional counselors are an example of a “scientist-practitioner”, using evidence-based methods. 

This skepticism of professional counselors seems natural, normal, a product of education, and ethical.  And it seems their skepticism should itself be well regarded, not stigmatized.  A 2023 paper I read titled “Stigmata That Are Desired:  Contradictions in Addiction” covers this larger topic in our field very well (Vanyukov, 2023).

Future studies?

In concluding the authors note that “Larger, longitudinal studies are needed…” 

That claim could be debated on many levels.  Rather than list arguments against doing so I’ll simply state one would hope such study proposals would include IRB approval and a clinical framework enveloped inside medical ethics, regardless of IRB approval. 

To me, anyone interested in this topic should read this open access paper by William White and John Kelly: 

My concluding comments

Back in 2023 I shared a post titled, “Recovery Oriented Systems of Care” and “Recovery Management” are slowly becoming “Using Oriented Systems of Care” and “Using Management”.  While some might find some of my comments in that work somewhat disorienting (given they come from a way of thinking that is outside many of the fundamentals we all take for granted), I would argue they are in no way hyperbolic.  

In that work I provided a list of considerations.  Hold the research study I discussed above in mind as you consider the items on that list, shown below: 

1. Using for the sake of recovery 
2. Abstinence for the sake of using 
3. Recovery for the sake of using 
4. Abstinence is relieved by using 
5. Abstinence for the sake of recovery is relieved by using
6. Recovery is relieved by using
7. Recovery for the sake of recovery is relieved by using 
8. Recurrence of abstinence is a prequel of using
9. Recurrence of use is relieved by using.
10. Recurrence of recovery is relieved by using. 

Should those be our standards of care in residential addiction treatment?

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References

Coon, B.  (2023).  “Recovery Oriented Systems of Care” and “Recovery Management” are slowly becoming “Using Oriented Systems of Care” and “Using Management”.

Coon, B.  (2025).  Proposing Two First-Rank Symptoms of Alcoholism.

FDA:  Cannabis research and drug approval process

Fehr, F. C., Lo, L. A., Nelson, C. N., Diehl, L. & Walsh, Z.  (2025).  Medical Cannabis Use Adjunct to Standard of Care in a Residential Substance Use Recovery Program: A Pilot Study.  Journal of Studies on Alcohol and Drugs.  86:6, 967-976.

Vanyukov, M. M. (2023): Stigmata That Are Desired: Contradictions in Addiction.  Addiction Research & Theory.  doi: 10.1080/16066359.2023.2238603

White WL and Kelly JF (2025) Toward a solution-focused addiction science. Front. Public Health. 13:1701524. doi: 10.3389/fpubh.2025.1701524 

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Related Readings

Coon, B.  (2022).  Addiction:  Understandings and enactments of the current era

Coon, B.  (2023).  Technique vs Empathy

Coon, B.  (2025).  A Fresh Look at the Topic of “Addiction Hospice”

Schwartz, J.  (2025).  The AI Mirror: “Take that small hit, and you’ll be fine”. 

Schwartz, J.  (2025).  How important are conceptual boundaries?

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Bonus Reading

Hsu M, Shah A, Jordan A, Gold MS, Hill KP. Therapeutic Use of Cannabis and Cannabinoids: A Review. JAMA. Published online November 26, 2025. doi:10.1001/jama.2025.19433

Abstract

Importance  Approximately 27% of adults in the US and Canada report having ever used cannabis for medical purposes. An estimated 10.5% of the US population reports using cannabidiol (CBD), a chemical compound extracted from cannabis that does not have psychoactive effects, for therapeutic purposes.

Observations  Conditions for which cannabinoids have approval from the US Food and Drug Administration include HIV/AIDS–related anorexia, chemotherapy-induced nausea and vomiting, and certain pediatric seizure disorders. A meta-analysis of randomized clinical trials reported a small but significant reduction in nausea and vomiting from various causes (eg, chemotherapy, cancer) when comparing prescribed cannabinoids (eg, dronabinol, nabilone) with placebo or active comparators (eg, alizapride, chlorpromazine; standardized mean difference [SMD], −0.29 [95% CI, −0.39 to −0.18]). A meta-analysis of randomized clinical trials among patients with HIV/AIDS reported that cannabinoids had a moderate effect on increasing body weight compared with placebo (SMD, 0.57 [95% CI, 0.22 to 0.92]). Evidence-based guidelines do not recommend the use of inhaled or high-potency cannabis (≥10% or 10 mg Δ9-tetrahydrocannabinol [Δ9-THC]) for medical purposes. High-potency cannabis compared with low-potency cannabis use is associated with increased risk of psychotic symptoms (12.4% vs 7.1%) and generalized anxiety disorder (19.1% vs 11.6%). A meta-analysis of observational studies reported that 29% of individuals who used cannabis for medical purposes met criteria for cannabis use disorder. Daily inhaled cannabis use compared with nondaily use was associated with an increased risk of coronary heart disease (2.0% vs 0.9%), myocardial infarction (1.7% vs 1.3%), and stroke (2.6% vs 1.0%). Evidence from randomized clinical trials does not support the use of cannabis or cannabinoids for most conditions for which it is promoted, such as acute pain and insomnia. Before considering cannabis or cannabinoids for medical use, clinicians should consult applicable institutional, state, and national regulations; evaluate for drug-drug interactions; and assess for contraindications (eg, pregnancy) or conditions in which risks likely outweigh benefits (eg, schizophrenia or ischemic heart disease). For patients using cannabis or cannabinoids for treatment of medical conditions, clinicians should discuss harm reduction strategies, including avoiding concurrent use with alcohol or other central nervous system depressants such as benzodiazepines, using the lowest effective dose, and avoiding use when driving or operating machinery.

Conclusions and Relevance  Evidence is insufficient for the use of cannabis or cannabinoids for most medical indications. Clear guidance from clinicians is essential to support safe, evidence-based decision-making. Clinicians should weigh benefits against risks when engaging patients in informed discussions about cannabis or cannabinoid use.