TALES FROM THE CLINIC
-Series Editor Nidal Moukaddam, MD, PhD
In this installment of Tales From the Clinic: The Art of Psychiatry, we examine how cannabis policy has evolved rapidly over the past 2 decades, producing a patchwork of regulatory environments across countries and even within the United States.1 While discussions often frame legalization as a simple yes-or-no issue, the clinical realities are far more intricate than that. The way cannabis is regulated, produced, labeled, accessed, and socially perceived, shapes not only patterns of use, but also how patients experience and interpret its effects.
From a psychiatric perspective, these differences are quite significant. They influence risk perception, exposure to high-potency cannabis products, and the level of uncertainty surrounding use. Consequently, cannabis policy becomes more than a legal framework, and becomes part of the clinical context in which psychiatric symptoms emerge.
Case Study
“Elijah” is an 18-year-old freshman college student with no prior psychiatric history who presented to student mental health services with escalating anxiety, insomnia, and intermittent paranoia over the past 5 months. He described racing thoughts happening during the night, difficulty concentrating in class, and a persistent sense that “something just feels off and out of the norm.”
Elijah grew up in Denver, Colorado, where recreational cannabis was legal and regulated. During high school, he reported occasional cannabis use, typically low-dose products purchased from licensed dispensaries with labeled tetrahydrocannabinol (THC) concentrations. He described his use as it being “very well controlled,” never viewing it as risky.
Earlier this year, Elijah relocated to Houston, Texas, for college. He assumed cannabis laws would not significantly impact his routine. However, he quickly learned that access was restricted and largely informal. The products were obtained through friends, without labeling or clear knowledge of potency. Elijah reported that the cannabis available to him “felt stronger than back home,” though he was unsure of its THC concentration or where it came from.
Over the following weeks, he began experiencing heightened anxiety, sleep disturbance (insomnia), and episodes of suspiciousness that alarmed both him and his roommates. He presented to the clinic after a panic episode in his residential building, stating, “Back home it was all going well, and everything felt normal. Here, however, it feels very different, like I don’t know what I’m taking or what could be happening.”
During evaluation, Elijah was confused about how the same substance could feel so different in another state. His distress appeared linked not only to cannabis use, but to uncertainty surrounding regulation, legality, and risk. He reported fearing legal consequences while simultaneously lacking access to regulated products or reliable education regarding potency. Following the intake, the treating psychiatrist reflected on how policy environments shape not only access to substances, but they shape the contexts in which young adults interpret and experience risk. Elijah’s case raised broader questions: How do varying cannabis policies influence mental health outcomes? Does legalization with regulation reduce psychiatric risk through transparency and quality control? Or does increased availability contribute to higher rates of anxiety and psychosis-related presentations?
Elijah’s experience highlights that cannabis policy is not only a legal framework, but it tends to also structures economic markets, risk perception, and clinical realities. As jurisdictions adopt varied models, such as Portugal’s public-health-oriented decriminalization approach to US state-level legalization and more restrictive settings, the psychiatric implications extend beyond ideology and deeply influence individuals’ lived experiences.
Discussion
This case illustrates a broader reality, which is that cannabis (or other substance) use does not occur in isolation from its regulatory context. The same substance can have very different clinical implications depending on how it is produced, distributed, and perceived within a given policy environment.2
Proponents of restricting and criminalizing substance use point to pervasive rates of substance use disorders in society, the current overdose epidemic, opioid epidemic, and risky mental health sequelae in users. For a fair discussion, decades of restriction have not helped rates of use disorders or protected youth, yet open use of cannabis has shown an elevated rate of anxiety, mood, and psychosis symptoms with sustained high dose usage. In regulated markets like Colorado, cannabis is subject to labeling requirements, potency disclosure, and quality control measures.3,4 These regulations provide a level of transparency that can help users make more informed decisions about dose and frequency. On the contrary, in more restrictive settings, access often relies on informal networks where potency is less predictable, product composition is uncertain, and harm-reduction information is limited. Drugs obtained in this fashion risking laced with other substances as well. For some people, this uncertainty may cause anxiety, mistrust, and worsening of symptoms.5
Beyond individual experiences, these differences reflect broader cannabis policy models. In this discussion, we briefly compare 2 distinct regulatory approaches: (1) Portugal’s decriminalization model, characterized by a public-health-oriented framework focused on treatment, harm reduction, and social reintegration; and (2) US state-level legalization models, such as Colorado’s, which regulate cannabis through commercial markets with licensed production and retail sales. As of date of writing of this manuscript, 24 US states, Washington DC, and 2 territories have legalized recreational cannabis, whereas medical cannabis is legal in 41 US states.
Key Takeaways
- Cannabis policy environments shape access, product regulation, potency transparency, and patient risk perception.
- Regulated markets may provide greater transparency and harm-reduction opportunities, whereas restrictive environments can shift use toward informal markets with unpredictable product potency.
- Comparative models, including Portugal’s decriminalization framework and US state-level legalization, highlight the complex interplay between economic policy and mental health outcomes.
- Economic impacts (tax revenue, healthcare utilization, and criminal justice costs) intersect with psychiatric morbidity, particularly among young adults navigating different regulatory systems.
- Incorporating policy context into psychiatric assessment may enhance understanding of substance-related presentations and inform more tailored care.
Decriminalization
Portugal’s decriminalization approach reframes substance use as a public health issue rather than a criminal one, emphasizing treatment, harm reduction, and social reintegration.6 Portugal implemented this policy in 2001 as part of a broader national response to rising rates of problematic substance use, overdose, and HIV transmission associated with drug injection. Decriminalization removes the illicit label from substance possession and use as long as they do not exceed the amount required for an average individual’s use for 10 days, and included all substances, not just those considered “softer,” like cannabis. Rather than treating personal drug possession as a criminal offense, the policy redirected individuals toward administrative review panels composed of health, legal, and social-service professionals. It is important to note that while decriminalization removes legal penalties, allowing legal sales and supply, it does not exempt the user from civil consequences, such as civil fines or referral to treatment. The model emphasized treatment access, harm reduction strategies, and social reintegration measures such as employment support and community-based recovery services. Although the policy initially generated significant political and public debate, the system gradually stabilized over the following years and later became internationally recognized as a major public health approach to substance regulation.
Legalization
Legalization models do not affect the legal status of a substance totally (licit vs illicit), but impose rules on manufacturing, dispensing, marketing, and advertising. Rather than a free approach to an activity or a product, such as alcohol or cannabis, it imposes a framework for use. In the case of recreational cannabis, these are licensed dispensaries and carries purchase limits. Following the rescheduling of cannabis by the DEA from Schedule I to Schedule III, to align federal policies with state realities, more widespread use can be expected. Use framework is regulated by federal and state governments, and can include imposing age restrictions, licensing for sellers, taxes, and possession limits. Recent US legalization models applied only to cannabis are somewhat similar to alcohol-related frameworks from the last century, with the basis that cannabinoid compounds can have therapeutic value and are not considered as harmful as other substances.
This change incorporates cannabis into commercial markets, generating tax revenue and expanding access, but also raising new concerns related to commercialization and product potency. For example, cannabis concentrates and vape products sold in regulated recreational markets such as Colorado may contain THC concentrations exceeding 70% to 90%, substantially higher than traditional cannabis flower products. These highly potent products have raised concerns regarding anxiety, panic reactions, and psychosis-related presentations, particularly among vulnerable young adults.2 Meanwhile, restrictive frameworks may limit formal access but can also push use into less regulated settings. Legalization can lull users into a sense of safety even when research about long term effects of sustained use is lacking.
Psychiatric Effects
Legal markets can reduce criminal justice expenses and generate public revenue, yet they may also be associated with increased health care utilization for substance use conditions, including cannabis-related emergency department (ED) visits for severe anxiety, panic episodes, cyclic vomiting syndrome, and psychosis-related presentations.7 A review in JAMA network examining more than 13 million records shows that, over 3 policy periods in Canada—pre-legalization (January 2006 to November 2015), liberalization of medical and nonmedical cannabis (December 2015 to September 2018), and legalization of nonmedical cannabis (October 2018 to December 2022)—incident cases of schizophrenia associated with cannabis use disorders almost tripled when substantial liberalization of cannabis was allowed.8 Similarly, a positive association was found between the number of cannabis dispensaries and rates of psychosis ED visits across all counties in Colorado.9 Rigorous methodology is needed to assess detailed impact of frequency of use, age of first consumption, and THC content of products.10
For clinicians, these dynamics are concrete and tangible. They emerge in the clinic as variations in symptom presentation, patient understanding, and treatment needs. Elijah’s experience illustrates the importance of asking not only whether a patient uses cannabis, but how, where, and under what regulatory conditions. These contextual details may offer crucial insights into risk and symptom development.
Concluding Thoughts
Recent federal efforts to move cannabinoid products from Schedule I to Schedule III may further reshape cannabis commercialization, research accessibility, and perceptions of safety, potentially altering both economic dynamics and psychiatric outcomes associated with cannabis use. Research is desperately needed to assess effects and generate ways to protect users.
As cannabis policy continues to evolve, patients will move across jurisdictions with differing regulatory frameworks. These transitions can introduce new uncertainties, affecting patterns of use and the psychological context in which that use occurs.
For clinicians, cannabis policy is not simply a backdrop to clinical care, it is rather an active component of it. A more integrated approach, like one that considers economic structures, regulatory environments, and psychiatric outcomes together, may be essential for fully comprehending and addressing the complexities of cannabis use in clinical practice.
Ms Zaboube is a master’s student at Rice University. This manuscript was part of her MSc Bioscience & Health Policy project.
Dr Moukaddam is a professor of psychiatry in the Department of Psychiatry at Baylor College of Medicine and the director of outpatient psychiatry at Harris Health. She also serves on the Psychiatric Times Editorial Board.
References
1. America’s marijuana evolution.Third Way. August 23, 2017. Accessed July 7, 2026. https://www.thirdway.org/report/americas-marijuana-evolution
2. Crowley R, Cline K, Hilden D. Regulatory framework for cannabis: a position paper from the American College of Physicians. Ann Intern Med. 2024;177(8).
3. Colorado Code of Regulations. 1 CCR 212-3-3-1020: Packaging and labeling: Requirements for retail marijuana hospitality and sales businesses. Cornell Legal Information Institute. 2019. Accessed July 7, 2026. https://www.law.cornell.edu/regulations/colorado/1-CCR-212-3-3-1020
4. Colorado General Assembly. SB25-076: Intoxicating substances & social equity business. 2025. Accessed July 7, 2026. https://leg.colorado.gov/bills/sb25-076
5. Eykelbosh A. Unregulated cannabis: risky production practices raise concern for consumers. National Collaborating Centre for Environmental Health. 2021. Accessed July 7, 2026. https://ncceh.ca/resources/evidence-briefs/unregulated-cannabis-risky-production-practices-raise-concern-consumers
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7. National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. The National Academies Press; 2017.
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