Abstract
The increased availability of medical and recreational cannabis has facilitated a need for a change in health care practices. The language surrounding substance use disorders (SUDs) needs to be destigmatized. The necessity for utilizing “person-first” or “person-centered language” is fundamental to ensure that there is consistency among health care personnel for treating patients with an SUD and providing quality patient care. There also lies an enhanced need to more clearly define recreational cannabis use on a state versus federal level, in the workplace, and within higher education.
Keywords: cannabis, drug abuse, medical cannabis, recreational cannabis, tetrahydrocannabinol, regulation
Appropriate terminology regarding the use of cannabis is essential in medical practice to reduce common misconceptions and fallacies that have become more frequent in the health care community. Colleen Walsh, a staff writer at the Harvard Gazette, draws attention to the words “abuse” and “abuser” and how these words impact a reduction in care quality and increase stigma among those who use cannabis. She notes that the words “dependency” and “addiction” are utilized interchangeably, and their distinctions need to be made more apparent. There is a call to use person-first language to reduce inherent bias and ensure that people with substance use disorders (SUDs) receive quality treatment and are not stigmatized. The use of person-first language may reduce unconscious biases within health care.
SUDs are chronic medical conditions and need to be treated as such. The stigma that patients with SUDs feel creates barriers to obtaining high-quality health care. A recommendation to decrease the use of socially stigmatizing terminology, such as “abuser,” has been made.1 The health care community needs to incorporate “person-centered language” within policies and protocols to decrease patient stigmatization. All practitioners who utilize screeners and other tools to assess patients should be mindful of the terminology used.
Evidence has shown that primary care practitioners provide less than optimal care for patients with SUDs. By utilizing “person-centered language,” which focuses on the individual more than his/her condition, health care policies will benefit as the change in language may refocus a practitioner's attention on the condition's chemical dependency (vs. believing that SUD is a personal choice). A shift in the health care culture to utilize nonstigmatizing person-centered language will enhance the patient's expectations and offer opportunities that may otherwise have been negated.2
The health care community needs to implement a standardized language to decrease implicit biases and portray patients' true nature. By eliminating harsh words and using “person-first” language, we remove terminological barriers to treatment.1 Changing the words “substance abuser” to “a person with a substance use disorder” will significantly improve the quality of health care that the patient will receive.2 In addition, health care providers must take care not to label a patient a “substance user” and instead to specifically and objectively report the substance use. For example, “patient uses cannabis approximately once per month” instead of “cannabis user—once monthly.” This type of terminology avoids any complications from a patient being labeled a “user.”
Cannabis use disorder (CUD) should be a specific entity different from SUD.3 CUD is characterized by craving, tolerance, and withdrawal of cannabis. Practitioners and providers screening for cannabis use should specifically ask patients whether he/she has used cannabis. We would not recommend asking in general terms, such as whether he/she has used street drugs, illicit drugs, or substances, as these terms are likely to be misinterpreted with the current legal status of cannabis.
Based on the DSM-5 criteria, SUD is determined based on the number of measures an individual meets. If the patient meets two to three criteria, the disorder is mild, four to five is moderate, and severe if six or more criteria are met on the DSM-5 screener. The DSM-5 has established a similar method of screening for CUD. The DSM-5 has also established criteria for cannabis intoxication, withdrawal, intoxication delirium, cannabis-induced psychotic, anxiety, and sleep disorder.4 These differing disorders should be utilized in primary care practice, and the terminology should be associated with the condition that the patient is experiencing. An expressly stated question will alert practitioners to routinely screen for cannabis use, even if the patient does not think the use is frequent or problematic.3
In addition, the screening and acquisition of information need to be in a relaxed and nonjudgmental tone. The provider should consider asking about the indication and reason for use to assess whether the patient is using cannabis for medical or recreational purposes. This may help differentiate the need for follow-up with the patient to evaluate whether the medical goal is being achieved.5 Furthermore, the health care community needs to determine which terminology to utilize and differentiate between the terms for patients. A determination needs to be made to utilize words such as use versus misuse, abuse versus dependence, and illegal versus illicit. The legalization in most states has led to the general population perceiving a decreased risk with cannabis and cannabis use.5,6
Addiction and dependence also need to be differentiated when assessing for use as addiction may indicate health and social problems, whereas physical dependence only involves health.2 If these terms do become separate with their meanings, the term “disorder” or “disease” needs to be encompassed with addiction. This will reinforce the medical nature of the condition and destigmatize the meaning of cannabis addiction.2 We also recommend utilizing the terms “misuse” and “abuse” distinctly from one another due to the stigmatization associated with the word “abuse” or “abuser.” The term “misuse” offers a destigmatized version of “abuse,” as it does not blame the illness only on the individual, but also encompasses brain chemistry, as well as environmental and genetic factors, and the term “abuse” may pardon distributors of cannabis of any wrongdoing.2,7
We strongly advocate for using specific consistent health care-related terminology to be utilized in practice and incorporated into policies, procedures, and medical workflow. The use of particular terms related to CUD should be incorporated into practice to destigmatize the problems with retrieving help for a chronic medical condition such as CUD and offer the patient assistance, support, and care. A “person-first” or “person-center” language is a unique and excellent approach for working with patients who are misusing cannabis substances and will assure that they receive quality high-level health care.
We also call on a need to define terms utilized with recreational cannabis on usage on a federal versus state-level more clearly. Federal law indicates that cannabis is a Schedule I drug (substance with no accepted medical use and a high potential for abuse).8 State laws vary, and 36 states allow for medical cannabis use whereas 15 states allow recreational cannabis use.9 Terms such as legal, illegal, and decriminalized need to be further defined and differentiated. The table lists differing state and federal scheduling of cannabis use (Table 1). Individuals working for the federal government or covered by a federal drug-testing program are prohibited from cannabis use at any time.
Table 1.
Status of Medical and Recreational Cannabis Use by State
| State | Medical cannabis | Recreational cannabis |
|---|---|---|
| Alabama | CBD oil (low TCH) | Illegal |
| Alaska | Legal | Legal; decriminalized |
| Arizona | Legal | Legal; decriminalized |
| Arkansas | Legal | Illegal |
| California | Legal | Legal; decriminalized |
| Colorado | Legal | Legal; decriminalized |
| Connecticut | Legal | Illegal; decriminalized |
| Delaware | Legal | Illegal; decriminalized |
| District of Columbia | Legal | Legal; decriminalized |
| Florida | Legal | Illegal |
| Georgia | CBD oil (low TCH) | Illegal |
| Hawaii | Legal | Illegal; decriminalized |
| Idaho | Illegal | Illegal |
| Illinois | Legal | Legal; decriminalized |
| Indiana | CBD oil (low TCH) | Illegal |
| Iowa | CBD oil (low TCH) | Illegal |
| Kansas | Illegal | Illegal |
| Kentucky | CBD oil (low TCH) | Illegal |
| Louisiana | Legal | Illegal |
| Maine | Legal | Legal; decriminalized |
| Maryland | Legal | Illegal; decriminalized |
| Massachusetts | Legal | Legal; decriminalized |
| Michigan | Legal | Legal |
| Minnesota | Legal | Illegal; decriminalized |
| Mississippi | Legal | Illegal; decriminalized |
| Missouri | Legal | Illegal; decriminalized |
| Montana | Legal | Legal; decriminalized |
| Nebraska | Illegal | Illegal; decriminalized |
| Nevada | Legal | Legal; decriminalized |
| New Hampshire | Legal | Illegal; decriminalized |
| New Jersey | Legal | Legal; decriminalized |
| New Mexico | Legal | Illegal; decriminalized |
| New York | Legal | Illegal; decriminalized |
| North Carolina | Illegal | Illegal; decriminalized |
| North Dakota | Legal | Illegal; decriminalized |
| Ohio | Legal | Illegal; decriminalized |
| Oklahoma | Legal | Illegal |
| Oregon | Legal | Legal; decriminalized |
| Pennsylvania | Legal | Illegal |
| Rhode Island | Legal | Illegal; decriminalized |
| South Carolina | Illegal | Illegal |
| South Dakota | Legal | Legal; decriminalized |
| Tennessee | CBD oil (low TCH) | Illegal |
| Texas | CBD oil (low TCH) | Illegal |
| Utah | Legal | Illegal |
| Vermont | Legal | Legal; decriminalized |
| Virginia | CBD oil (low TCH) | Illegal; decriminalized |
| Washington | Legal | Legal; decriminalized |
| West Virginia | Legal | Illegal |
| Wisconsin | CBD oil (low TCH) | Illegal |
| Wyoming | Illegal | Illegal |
Numerous states have enacted workplace laws that conflict with federal law. The Occupational Health and Safety Act of 1970 contains a clause that employers need to maintain conditions to protect workers on the job. This clause may necessitate the exclusion of those who are impaired secondary to cannabis use. Employers who terminate or refuse to hire employees who use cannabis are not in violation of the Americans with Disabilities Act (ADA) or any other federal statutes, as long as cannabis is illegal under the federal government. The ADA also does not require employers to permit medical cannabis use as accommodation for a worker with a disability. Even if state law allows the use of medical or recreational cannabis, the employer in any state is not under any obligation to accommodate cannabis users. Furthermore, the Drug-Free Workplace Act (DFWA) requires all federal grantees to provide drug-free workplaces as a condition of receiving a government grant. And any federal contractor may be subject to punishment, including termination, if found to be utilizing cannabis, despite state law.
With so many states allowing for recreational and medical cannabis use, regulations and policies related to the workplace are becoming hard to define. Until state and federal laws coincide, all employers should receive legal counsel to ensure that they comply with state and local regulations regarding cannabis drug testing and policies for off-site use.8 Human resource departments at companies need to keep updated with the current local laws with regard to what they can or cannot do as courts have started siding with workers who say that their off-duty cannabis use has led to unfair termination.10
Controversy exists as to how much THC (the drug's psychoactive component) in blood equals impairment. Although alcohol has more clearly defined laws (federal rules define a blood alcohol content of 0.04% as a violation) as to what constitutes a high value, THC or cannabis does not, making it even more challenging to instill policies and procedures in the workplace, where cannabis use is allowed.10 Furthermore, universities need to set policies and procedures for their students impacted by cannabis use. Students at federally funded universities can suffer consequences if found to be utilizing cannabis, but how this applies to private institutions must be further clarified by the institution and its location. Higher education institutions who access any funds from the federal government agree to comply with the Drug-Free Schools and Community Act, which means that students' possession or use of any cannabis substance is not allowed on campus. Some schools will also prohibit using these substances off-campus as part of their student code of conduct.11
We encourage a more delineated language to be utilized with medical and recreational cannabis consistent among practices and health care professionals. The increased availability of cannabis stresses the importance of this topic. The terms and documentation implemented impact various providers, including emergency room providers, who may witness hyperemesis syndrome, to primary care providers, who encounter patients on routine visits and illness. The importance is stressed in many patient settings, including the outpatient/ambulatory care setting to the hospital setting, both of which will see patients who utilize cannabis. A variety of terminology has a negative meaning and changes depending on the site.
A more uniform language, incorporating “person-first” or “person-center” terms, will allow for more similar words to be applied throughout health care practice. The terms can be included and utilized to differentiate further and be applied within workplaces and universities and should fall in line with current terms such as legal, illegal, and decriminalized, incorporated into state terminology, and need to be further defined and specified.
Abbreviations Used
- ADA
Americans with Disabilities Act
- CBD
cannabidiol
- CUD
cannabis use disorder
- DFWA
Drug-Free Workplace Act
- SUD
substance use disorder
- THC
tetrahydrocannabinol
Author Disclosure Statement
M.M. is speaker for Merck.
Funding Information
No funding was received.
Cite this article as: Kabakov A, Polisetty RS, Murray M (2022) A call for person-centered language and consistent terminology regarding cannabis use, Cannabis and Cannabinoid Research 7:2, 122–125, DOI: 10.1089/can.2021.0073.
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