Medical cannabis in Puerto Rico: clinical maturity, harm reduction, and the next scientific leap

Puerto Rico has spent nearly a decade building an industry and a medical culture around medicinal cannabis. I have had the privilege of experiencing this evolution from multiple perspectives: as a clinician who has certified and supported thousands of patients, as a professor in the training of physicians since the program's regulatory inception in 2016, and as a close observer of a transformation that, with all its challenges, has brought real relief to countless people with chronic pain, anxiety, insomnia, cancer, spasticity, and multiple debilitating conditions.

That's why, when I recently sent a formal recommendation to my medical school about the urgent need to strengthen cannabis-related research and harm reduction programs, my intention was not to fuel fear or reverse the progress made. Quite the opposite. It was a call for scientific maturity.

The public debate on cannabis often falls into unproductive extremes. Some present it as a completely harmless substance. Others as an out-of-control social threat. The clinical reality is more complex and much more interesting.

Yes, medical cannabis has helped thousands of patients in Puerto Rico. But it's also true that there is a vulnerable subgroup, particularly adolescents and young adults with a genetic or familial predisposition, in whom frequent use of high-THC products can increase the risk of psychotic symptoms or psychiatric disorders. Denying this reality protects no one. Understanding it does.

Contemporary scientific literature no longer allows for simplifications. The meta-analysis by Marconi and colleagues in Schizophrenia Bulletin found a dose-response relationship between heavy cannabis use and the risk of psychosis, particularly among frequent users with high THC exposure. International studies also indicate that early initiation, especially before the age of 15-16, increases neuropsychiatric vulnerability.

But this is where the conversation needs to evolve. The correct message isn't "cannabis causes psychosis" universally. The correct message is that the risk isn't the same for everyone, and that many of those risks can be mitigated through education, intelligent formulation, harm reduction, and responsible clinical follow-up. That radically changes the paradigm.

Modern public health evidence, particularly the Lower-Risk Cannabis Use Guidelines developed in Canada, proposes a much more sophisticated and pragmatic approach. These recommendations include avoiding early initiation, reducing frequency of use, avoiding daily consumption of high-THC products, favoring balanced CBD formulations, avoiding synthetic cannabinoids, and educating vulnerable populations. I find this approach extremely reasonable.

Instead of demonizing the plant, we must learn to stratify risk, just as we do in medicine with cholesterol, alcohol, obesity, or cardiovascular genetics. The question is no longer simply, “Does he/she use cannabis?” The modern question is: What formulation do they use? What is the THC and CBD profile? What are the dominant terpenes? How often do they use it? At what age did they start? Do they have a family history of psychosis? Do they have severe anxiety, bipolar disorder, or trauma? Are they mixing cannabis with alcohol or other substances? Are they using cannabis as part of a comprehensive plan or as a chronic emotional escape?

This is where Puerto Rico can become a leader. We have over 200,000 patients enrolled in the program. We have sophisticated dispensaries, expert growers, modern laboratories, and physicians with nearly ten years of accumulated experience. What we haven't yet fully developed is the significant academic opportunity: systematic observational studies and collaborations between physicians, dispensaries, industry, and academia.

We need to shift from selling products to generating knowledge. I have proposed that Puerto Rico promote prospective studies where we can correlate cannabinoid and terpene profiles with real clinical outcomes related to pain, sleep, anxiety, quality of life, and adverse effects. We need to investigate which profiles appear to be more anxiolytic, which are more stimulating, which might generate greater psychiatric vulnerability, and which seem to offer the best protection. The so-called "entourage effect" likely contains invaluable clinical information that is still insufficiently studied.

We must also abandon the artificial isolation between doctors and clinics. The future of cannabinoid medicine will depend on a continuous dialectical relationship between clinicians, budtenders, growers, formulators, data scientists, and patients. The patient is an extraordinary source of observational clinical intelligence when we learn to systematically listen to their experience.

This could be Puerto Rico's next big leap in medical cannabis. It's not simply about access. It's about precision. For years we've talked about personalized medicine based on genetics and biomarkers. Cannabis will likely be one of the first areas where we see that personalization applied practically and on a daily basis: different formulations for different biological, psychological, and behavioral profiles.

And that's precisely why harm reduction isn't the enemy of industry. It's its natural evolution. A mature industry isn't afraid to discuss risks. It contextualizes them. It studies them. It reduces them. It educates better. It builds public trust. It produces higher standards.

The medical cannabis industry in Puerto Rico has achieved a great deal. But now it needs to take an additional step: to also become an ecosystem of clinical knowledge and public health. That is where academia has a historic role to play.

As a professor of family medicine and a clinician who deeply believes in the therapeutic potential of cannabinoids, I think the moment demands both enthusiasm and prudence; innovation and responsibility; access and education. We cannot allow fear to destroy the progress we have made. But neither can we allow commercial enthusiasm to replace scientific rigor.

The cannabinoid medicine of the future will not be ideological. It will be personalized, observational, integrated, and profoundly human. And Puerto Rico has everything it needs to help build it.

Dr. Jaime Claudio Villamil

Professor of Family Medicine – University of Puerto Rico

Professor of Clinical Medicinal Cannabis - Researcher in Integrative Medicine