Abstract
Objectives:
Despite expanded legalization and utilization of medical cannabis (MC) internationally, there is a lack of patient-centered data on how MC is used by persons living with chronic conditions in tandem with or instead of prescription medications. This study describes approaches to use of MC vis-à-vis prescription medications in the treatment of selected chronic conditions.
Design:
Participants completed semistructured telephone interviews with open-ended questions. Content analysis of qualitative data identified themes and subthemes relating to patient approaches to using MC products.
Participants:
Thirty persons (mean age = 44.6 years) living with a range of chronic conditions (e.g., rheumatoid arthritis, Crohn's disease, spinal cord injury/disease, and cancer) who had qualified for and used MC in Illinois.
Results:
Participants described a range of approaches to using MC, including (1) as alternatives to using prescription or over-the-counter medications; (2) complementary use with prescription medications; and (3) as a means for tapering off prescription medications. Motives reported for reducing or eliminating prescription medications included concerns regarding toxicity, dependence, and tolerance, and perceptions that MC improves management of certain symptoms and has quicker action and longer lasting effects.
Conclusions:
MC appears to serve as both a complementary method for symptom management and treatment of medication side-effects associated with certain chronic conditions, and as an alternative method for treatment of pain, seizures, and inflammation in this population. Additional patient-centered research is needed to identify specific dosing patterns of MC products associated with symptom alleviation and produce longitudinal data assessing chronic disease outcomes with MC use.
Introduction
A
Legal prohibitions against marijuana have severely constrained the scope and amount of clinical research into the use of MC. In the United States, marijuana's classification since 1961 as a Schedule 1 controlled substance has curtailed research into its medical properties. Reviews of the sparse clinical trial research on medical forms of cannabis indicate that cannabinoids demonstrate significant beneficial effects on chronic pain, 2 including neuropathy. 3 Cannabinoids have also been shown to alleviate patient-reported spasticity in persons with multiple sclerosis. 2,4
Even fewer clinical studies have been conducted on inhaled cannabis, which is the most common form of MC. 1 A few small studies have used patient-reported data to investigate symptom alleviation associated with inhaled cannabis. Smoked cannabis has been reported to decrease neuropathic pain in persons living with HIV 5,6 and reduce pain and improve sleep among persons with chronic neuropathic pain. 7 Significant reductions in pain and spasticity were reported in a study of persons with multiple sclerosis who smoked cannabis, 8 and when inhaled twice daily, cannabis has been found to decrease symptoms of Crohn's disease. 9 Recently, a study of persons with painful diabetic neuropathy who smoked cannabis found decreased spontaneous pain, 10 and vaporized cannabis has been associated with decreased neuropathic pain. 11
Emerging research has shown that patients may use MC in combination with or instead of prescribed pharmaceutical agents to manage pain. 12 –14 In addition to reported better symptom management through use of MC, patients in these studies cited concerns regarding side-effects and dependency as motives for reducing their pharmaceutical use and increasing MC use. 12,13 A recent study reported a 64% reduction in opioid use as a pain medication among MC users. 15 Such findings suggest a harm reduction approach among patients using MC to minimize potential harm associated with prescription opioid use. From a population perspective, recent ecologic studies in the United States report that states with MC laws have seen reductions in opioid overdose mortality, 16 opioid prescriptions among Medicare patients, 17 opioid treatment admissions, 18 and presence of opioids in fatal automobile accidents. 19
Despite the potential of MC to address a range of symptoms of chronic conditions, there is a lack of patient-centered data on how cannabis is used, in addition to or instead of prescription medications, by persons living with chronic conditions. The proliferation of dispensaries and MC products in the absence of tightly controlled clinical trial data has accelerated the need for additional research into patients' perspectives, motives, and utilization of MC. This study describes approaches to use of MC vis-à-vis prescription medications in the treatment of selected chronic conditions.
Methods
Data examined in this study derive from a larger study of patient and provider perspectives on MC and discussions in clinical settings regarding its use. This paper reports our analysis of the patient group and patient preferences for using MC vis-a-vis prescription medications to treat a range of chronic health conditions.
Recruitment
MC patients in Illinois were recruited through flyers distributed to selected MC dispensaries in the state. Dispensaries also forwarded electronic versions of the flyers through social media networks. Participants reported learning of the study at dispensaries in the Chicago metropolitan area (63.3%) or through postings on Facebook (36.6%). Persons interested in participating contacted study personnel by phone for a brief eligibility screening interview. Persons were eligible if they were 18 years or older, reported having one of the 39 qualifying health conditions for MC in Illinois, and had smoked MC in the past 3 months. Because of the focus on stigma related to smoking cannabis that informed the larger study, participants were not assessed for use of other MC ingestion methods at screening.
Study personnel scheduled telephone interviews with eligible persons and emailed the informed consent for review before the interview. Thirty-six persons responded to the flyers, expressing interest in participation, and 30 consented to and completed individual interviews (three persons were determined to be not eligible at screening due to lack of qualifying condition, and an additional three met eligibility criteria, but did not respond to phone calls after their interview had been scheduled). After participants had the opportunity to review the consent form and ask any questions, informed consent was obtained verbally immediately before each interview. The research protocol was approved by the Institutional Review Boards at DePaul University and Rush University.
Data collection
Our team developed a semistructured interview guide to explore patient perspectives on cannabis use and communication of these perspectives to their healthcare providers. Open-ended questions were designed to elicit specific and contextual data regarding patient attitudes, beliefs, and behaviors. The guide was structured in four distinct sections to assess (1) patient management of symptoms and side-effects, (2) discussions about cannabis use with medical providers, (3) beliefs regarding medicinal or therapeutic use of cannabis, and (4) recreational use of cannabis. Data analyzed in this paper were drawn chiefly from the symptom management section (“Can you tell me about the last time you used cannabis to manage symptoms you were experiencing?” “In your experience, which symptoms do you find that cannabis is helpful in managing?”).
Interviews were conducted by the first and second authors. Length of interviews ranged from 31 to 77 min with a mean length of ∼47 min. All interviews were digitally recorded and then transcribed by a professional transcription service. Once each transcript was cross-validated with its digital recording, the digital recording was destroyed. Each participant received, through e-mail, a $30
Data analysis
Content analysis is a qualitative method that involves close reading of text for the purpose of identifying patterns within the data. 20,21 Inductive coding procedures without the use of preexisting categories allow for concepts and typologies to emerge from the participants' descriptions of their own experiences. Content analysis typically involves two stages—(1) coding text by developing descriptive labels or “themes” that might apply across multiple cases and (2) analyzing the emergent themes to group them into meaningful, larger categories. 20,21
For this study, the first two authors coded the first 15 interviews to identify themes related to use of MC. Initial content codes were created by the lead author, and a coding scheme was created that included operational definitions of all codes. Subsequently, the coding scheme and corresponding data were analyzed by the team of all four authors to refine codes and identify broader categories related to the themes. Following this initial analysis, data from the subsequent 15 interviews were analyzed by the lead author using the refined coding scheme and checked for additional themes. The collaborative refining of codes and themes was then repeated until all categories and subthemes were identified across the entire sample. 20,22 No new themes or categories were identified at this point, indicating that data saturation had been reached.
Results
Summary of findings
Our analysis identified a range of approaches to MC use: (1) as an alternative to prescription medications; (2) as a means to taper off prescribed medications; and (3) complementary use with prescribed medications. Our results below are organized around these approaches, and we include direct quotes from participants that illustrate these approaches and themes within each. Participant characteristics appear in Table 1.
Participants may have indicated living with more than one condition.
Defined as using MC intentionally instead of prescription drugs.
Defined as using MC intentionally to taper off of prescription drugs.
Defined as using MC intentionally with prescription drugs.
MC, medical cannabis; SD, standard deviation.
MC use as alternative to prescription drugs
The approach most frequently reported by participants constituted using MC as an alternative to other medications—most commonly opioids, but also anticonvulsants, anti-inflammatories, and over-the-counter (OTC) analgesics. We have organized these results below into three subsections: opioids, other classes of medications, and multiple classes of medications. In each subsection, we present participants' reported motives for this approach to use of MC and include longer representative quotes in Table 2 illustrating these motives.
OTC, over-the-counter.
Alternative to opioids
Motives for using MC as an alternative to prescribed opioids included MC (1) acting more quickly, (2) having longer lasting effects, (3) reducing potential harm, (4) better managing symptoms, and (5) having fewer side-effects. Several participants reported quicker action with inhaled cannabis than with oral prescription medications, whereas one participant living with chronic regional pain syndrome reported similar effects using MC only in an oil application (Table 2). In general, participants reported the effects of MC lasted longer than prescribed opioids (“I find that it's longer lasting—as far as taking care of your symptoms—than anything else”). Several described experimenting with different MC products and strains and finding certain ones to be much more long lasting than other forms of prescribed pain medication, including the participant living with post-traumatic stress disorder (PTSD) quoted in Table 2.
Risk of addiction to opioids was reported as a significant concern by many participants, and MC use was viewed as a harm reduction measure that could provide as much, if not more, pain relief than prescribed opioids (“I mean it's not like cannabis is anywhere near as dangerous as a drug as Percocet”). The perceived harm reduction potential of MC use extended from addiction risk to concerns regarding overdose to toxicity of pain medications.
MC was viewed by some participants as providing better management of symptoms with fewer side-effects than opioids (“Back pain. Nausea, for sure…anxiety, fatigue, exhaustion. Helps out a ton better than prescription opioids that end up just making things worse.”) Finally, several participants reported MC conferring multiple benefits over opioids, and these extended to multiple motives for preferring MC. As an example, one participant quoted in Table 2 and living with multiple chronic conditions described better management of symptoms, harm reduction concerns, and fewer side-effects as overarching motives for using MC as an alternative.
Alternative to other classes of medications
Participants who were prescribed neurologic agents for nerve pain and anticonvulsants for multiple sclerosis described both improved management and fewer side-effects with MC over prescription medications. By contrast, participants who reported using MC as an alternative to OTC analgesics reported better management of symptoms and reduced potential for harm (to the liver) as motives, while those using MC as an alternative to anti-inflammatories reported a better side-effect profile.
Alternative to multiple classes of medications
Finally, a number of participants described motives for reducing harm by using MC as a replacement for multiple categories of medications, as well as multiple benefits from replacing a range of medications. Such benefits included improved sleep, reduced pain, improved appetite, less toxicity and adverse reactions, and reduced anxiety. In some cases, MC was perceived as conferring improved management of multiple symptoms, as suggested by participants living with epilepsy, Crohn's disease, and multiple sclerosis.
Complementary use
Participants reported using MC in combination with medications such as opioids, antinausea medications, OTC analgesics, and benzodiazepines. Such complementary use typically was not only associated with a need to manage side-effects of prescription medications (e.g., nausea, insomnia, and dystonia) but also used purposefully in combination with other medications to manage symptoms effectively. Representative quotes illustrating the range of complementary use appear in Table 3.
In terms of managing side-effects, some individuals described using MC in addition to prescription medication for treatment side-effects (“if I were to take a [pain] pill, within an hour I'll feel really groggy…and my stomach won't feel good, it'll hurt. After I smoke all those side-effects kind of mellow”), while others used cannabis exclusively. In particular, participants managing epilepsy reported insomnia-related side-effects associated with treatment, and MC was viewed as an effective means of decreasing insomnia (Table 3).
MC was also used in combination with prescription medications to alleviate symptoms associated with their chronic conditions. Pain was the most commonly reported symptom managed in this manner, while several participants described using MC in tandem with prescription medications to manage anxiety. For pain management, most complementary users reported using MC only in combination with opioids or with OTC analgesics, but one participant delineated a graduated approach to managing spinal pain using a range of methods (Table 3).
Although MC was viewed as an effective approach to managing symptoms in combination with prescribed medications, many participants were motivated to include MC in their repertoire to decrease the amount of prescribed medications they were ingesting (“I wonder what damage they are eventually gonna do to my organs, so I have been using cannabis more these past couple of weeks because of that”). The perceived need to reduce the amount of medications extended across drug classes such as opioids, OTCs, and benzodiazepines. This finding suggests patients' MC use may eventually decrease or replace reliance on prescribed medications. In the next subsection, we describe in more detail how participants intentionally use cannabis to taper off prescription medications.
Tapering off prescription medications
Drug classifications that participants reported using MC to taper off included anticonvulsants, anti-inflammatories, and pain medications. Opioids, in particular, were often viewed as problematic because of toxicity, dependence, and tolerance, yet stopping “cold turkey” was not viewed as a realistic option (“I'm realizing with the opiates, I got to reduce and quit, but you can't just quit something like that”).
Side-effects associated with anticonvulsant medications motivated some participants to want to reduce their use (dose and frequency), and several reported that MC helped them taper off of these medications (“As soon as I got my MC card I began to wean off of Gabapentin. In 3 weeks I was off of Gabapentin. So that is a good thing”). Reduced amounts of anticonvulsant medications with increased MC was viewed by participants with epilepsy as conferring equal if not more protection from seizures (Table 4).
Participants who reported anti-inflammatory medication use often described MC as aiding the taper typically associated with steroid regimens, including the participant quoted in Table 4. This same participant living with multiple chronic conditions also reported a strong desire to reduce multiple classes of prescription medications and stated that MC allowed her to do so.
Discussion
This study adds to the fledgling body of literature on MC use by patients who live with chronic health conditions. MC appears to complement prescription medications for symptom management, alleviate medication side-effects, and provide an attractive alternative to treat pain, seizures, and inflammation in this population. In addition, our results indicate that MC may be used intentionally to taper off prescription medications. These findings align with previous research that has reported substitution or alternative use of cannabis for prescription pain medication due to concerns regarding addiction 12 and better side-effect and symptom management, 23 as well as complementary use to help manage side-effects of prescription medications. 12,13,24 We also found that patients' complementary and alternative use extend beyond prescribed opioids and nerve pain medications to include anticonvulsants, anti-inflammatories, and OTC analgesics.
Patients' concerns regarding dependence, toxicity, and side-effects associated with prescribed medications emerged as a dominant theme that extended across the complementary, tapering, and alternative methods reported by participants. Multiple participants viewed MC as a viable option for reducing potential dependency on opioids, toxicities associated with opioids, other analgesics, and anti-inflammatories, and side-effects associated with nerve pain medication, anticonvulsants, and opioids. The patient narratives in this study suggest that the scope of harm reduction appears to not only overlap across the complementary, tapering, and alternative approaches we observed but also potentially functions progressively over the course of chronic illness. Through the voices of persons living with chronic conditions, our results illuminate how MC may provide an option for them to actively address acute and long-term effects of prescription medications.
Intriguingly, participants cited multiple benefits conferred by MC as they used it to address a range of symptoms and side-effects, and thereby reduced their prescription medication use across multiple categories of medications. Our participants described a range of MC products used, including smoked flower, gum or “dabs,” edibles, and topical oils. Additional patient-centered research investigating MC products is needed to inform dosing guidelines for relief from pain, spasms, inflammation, and other symptomatology that appear to respond to forms of MC. Several participants stated their preference for MC to prescription medications based on perceived quicker action of symptom alleviation. Whether this is due to the pharmacology of the particular products used or differing routes of administration exceeded the scopes of this study, but inhaled cannabis may be more rapidly absorbed into the bloodstream than orally administered routes of pharmaceutical agents. Similar findings regarding route of administration have been reported by chronic pain patients in a study comparing effects of inhaled cannabis and oral tetrahydrocannabinol. 25 More pharmacologic research is needed to more fully understand benefits associated with cannabinoids, phytocannabinoids, plant strains, and whole plant ingestion, 1,26 –28 and their potentially synergistic effects on cannabinoid receptors in the neurologic and immunologic systems.
Our findings are limited by the potential for bias present in a small qualitative study, as our strategically recruited volunteer sample represents a fraction of the 12,000 persons who had qualified for an MC card in Illinois at the time of study enrolment. The sample is also limited geographically (recruited from metropolitan Chicago) and demographically (overwhelmingly white). Population-based data and robust clinical trials are needed to further explore and test the associations described by participants in our study. In addition, we did not include lines of questioning regarding side-effects of MC or costs associated with its acquisition, although one participant reported feelings of cannabis “hangover” occasionally, and several noted that their use of MC was inhibited by cost concerns. Nonetheless, this study's qualitative methods allowed participants to explain their attitudes, beliefs, and behaviors in their own words and provide important patient-centered perspectives in this emergent research area.
Conclusions
MC appears to serve as both a complementary method for symptom management and treatment of medication side-effects associated with certain chronic conditions, and as an alternative method for treatment of pain, seizures, and inflammation in this population. In addition to expanded pharmacologic research on cannabis and cannabinoids, more patient-centered research is warranted to assess side-effects and costs of MC acquisition, to identify specific dosing patterns of MC products associated with symptom alleviation, and to produce longitudinal data assessing chronic disease outcomes with MC use.
Footnotes
Acknowledgments
Support for this study was provided through the Provost's Collaborative Research Fellowship, DePaul University. Our deep gratitude goes to our research participants whose thoughtful input made this study possible.
Author Disclosure Statement
No competing financial interests exist.