Self-Efficacy in Researching and Obtaining Medical Cannabis by Patients With Chronic Conditions

Abstract

Background. Due to the increasing availability of medical-grade cannabis for treatment of chronic conditions, we examined how prospective users navigate the process of researching, procuring, and using cannabis. Given the barriers prospective users experience, self-efficacy may be a factor for those who incorporate cannabis into treatment. Aims. The purpose of this study was to identify behaviors associated with self-efficacy in the context of researching, procuring, and using cannabis. We analyzed narratives of patients who obtained legal medical cannabis in the currently complex medical, legal, and social landscape. Method. Data were collected through 30 telephone interviews utilizing a semistructured interview protocol, which were analyzed using inductive coding. The protocol emphasized four topics: (a) symptom management/pain reduction, (b) provider communication about chronic conditions/cannabis, (c) perspectives on medicinal cannabis and stigma, and (d) views on recreational cannabis. Results. Participants demonstrated self-efficacy in three contexts: (a) self-directed experimentation with cannabis strains, dosages, and administration methods; (b) managing care by selecting and educating their providers; and (c) information-seeking and research behaviors. Discussion. High self-efficacy may be an important factor in navigating the medical cannabis process. Results suggest that providers who are not prepared to partner with patients as they seek information about medical cannabis may be replaced by dispensaries and websites with expertise in cannabis but without understanding of patients’ medical conditions and individual needs. Conclusion. Patients with higher self-efficacy may engage in various activities to investigate, procure, experiment with, and incorporate medical cannabis into their condition management outside the purview of their providers.

Keywords

cannabis chronic condition health navigation patient provider self-efficacy

Medical cannabis is a phenomenon that exists in a liminal social and political space, with various laws and historical attitudes influencing its adoption as a treatment. The legalization of medical cannabis has greatly expanded in the past decade; 33 states and Washington, DC now permit one or more forms of medical cannabis (National Conference of State Legislatures, 2019). The momentum behind the legalization of medical cannabis is spurred in part by recent empirical reevaluation of its therapeutic benefits in the context of its decreasing stigmatization in the United States (Bostwick, 2012; Earleywine, 2002; National Academy of Sciences, Engineering, and Medicine, 2017; Whiting et al., 2015). Due to the increasing availability of medical-grade cannabis as a treatment for chronic conditions, it is important to examine how prospective users navigate the complex and often-difficult process of researching, procuring, and successfully using medical cannabis.

Persons with legally approved chronic conditions who live in a state that has legalized access still face barriers to researching and procuring medical cannabis. Providers are often reluctant to participate in conversations, and legal regulations are confusing (Kahan & Spithoff, 2013; Nussbaum et al., 2011; Satterlund et al., 2015). Those with chronic conditions considering medical cannabis as an option may not discuss it with their care providers because of perceived social stigma or fear of legal repercussions (Satterlund et al., 2015). The documentation required for both patients and their providers also constitutes a barrier. Given these challenges for both patients and providers, self-efficacy may be a factor for those who successfully incorporate medical cannabis into their treatment, while simultaneously dealing with the debilitating symptoms of their chronic conditions.

Self-efficacy is broadly defined as an individual’s belief in their capacity to produce a certain outcome (Bandura, 1997). It reflects confidence in one’s ability to exert control over one’s environment, motivation, and behavior (Bandura, 1977, 1986, 1997). According to Bandura’s social cognitive theory (SCT; 1997), self-efficacy affects many aspects of human experience, such as goal-setting, the amount of energy expended toward achievement, and the effort to persist when facing setbacks and barriers. When faced with significant barriers to researching, obtaining, and successfully using medical cannabis (i.e., managing a chronic condition, provider reluctance to discuss usage, stigma, complexity in legality), self-efficacy is likely necessary for patients to integrate medical cannabis into their treatment. Self-efficacy could facilitate discussing medical cannabis usage and the documentation process with providers and persisting when faced with barriers. The purpose of this study was to identify behaviors associated with self-efficacy in this context. We analyzed the narratives of patients who had successfully obtained legal medical cannabis in the currently complex medical, legal, and social landscape.

Method

The data for this study were collected as part of a larger project examining patients’ use of medical cannabis for the treatment of their chronic conditions, primary care providers’ (PCPs) perspectives on medical cannabis, the communication strategies used by patients and providers to discuss medical cannabis use, and patients’ experiences of medical cannabis and more traditional pharmacological treatments for their chronic conditions (Bruce et al., 2018). In this study, we analyzed self-efficacy in patients’ narratives of researching, obtaining, and using medical cannabis. Success was defined by patients’ reports of reaching their goals for symptom and side-effect management by using medical cannabis; due to the recurring and complex nature of chronic illness symptoms (e.g., chronic pain), “success” does not necessarily refer to the complete eradication of symptoms.

Recruitment

Participants in the study were recruited in Illinois through flyers distributed at medical cannabis dispensaries and through advocacy group Facebook pages. Most participants (63.3%) reported that they learned of the study through a dispensary location and the remainder (36.6%) reported that they learned of the study through Facebook. Interested participants contacted researchers by telephone and were then prescreened for eligibility. To qualify for the study, individuals had to be 18+ years of age, report one of the qualifying conditions for medical cannabis use in Illinois, and report having used medical cannabis in the past 3 months. (See Table 1 for demographics and conditions.) Eligible participants received consent forms via email and were scheduled for phone interviews with one of two researchers trained in semistructured qualitative interviewing. All participants had the opportunity to review the consent form and to ask questions about the study prior to the interview. Verbal consent was obtained immediately prior to the interview. Thirty-six people expressed initial interest in the study, which included three individuals who did not meet the inclusion criteria and three who did not respond to follow-up; the final sample included 30 participants. This study was approved by both the DePaul University and Rush University Institutional Review Boards.

Table 1.

Participant Characteristics and Descriptive Statistics.

Demographic variables	n	%
Age, years, M (SD)	44.6 (15.9)
Gender
Male	19	63.3
Female	11	36.7
Race
White	26	86.7
Latino/Hispanic	3	10.0
Multiracial	1	3.3
Qualifying medical condition for medical cannabis^a
Rheumatoid arthritis	7	23.3
Spinal cord disease/spinal cord injury	6	20.0
Crohn’s disease	6	20.0
Cancer	4	13.3
Hepatitis C	4	13.3
Posttraumatic stress disorder	4	13.3
Severe fibromyalgia	3	10.0
Other (chronic regional pain, epilepsy, HIV, multiple sclerosis, Parkinson’s disease)	7	23.3

Participants may have indicated living with more than one qualifying condition.

Data Collection

Data were collected through recorded telephone interviews utilizing a semistructured interview protocol. The interviews were conducted by the first and second authors and took an average of 47 minutes (range, 31-77 minutes). The questions were open-ended and designed to elicit rich descriptions of patients’ experiences and perceptions of cannabis in the context of their chronic condition management. The protocol focused on four topics: (a) symptom management and pain reduction (e.g., which symptoms do you find that cannabis is helpful in managing?), (b) communication about chronic conditions and cannabis with PCPs (e.g., Did the stigma of using cannabis affect when you talked to your doctor about it for the first time?), (c) participant perspectives on medicinal uses of cannabis and social stigma (e.g., Can you describe what you understand about the use of cannabis as a medicine?), and (d) views on recreational cannabis use (e.g., What do you think about the use of cannabis for pleasure?). All audio recordings were professionally transcribed. After the transcriptions were cross-validated by the research team, the audio recordings were deleted from all devices and files. Each participant received a digital $30 gift card for their participation.

Data Analysis

The data were qualitatively analyzed for thematic content. Qualitative content analysis involves a close reading and interpretation to identify recurring patterns and underlying structure in textual data (Hsieh & Shannon, 2005; Lincoln & Guba, 1985). Because of the exploratory and descriptive purposes of the research, inductive coding was used to allow participants’ statements to determine the content categories rather than determining theoretically derived categories a priori (Corbin & Strauss, 2015). Content analysis proceeded in two phases (Hsieh & Shannon, 2005; Lincoln & Guba, 1985); the first phase involved close reading and identifying themes that were present across multiple cases (i.e., open coding; Corbin & Strauss, 2015); the second phase analyzed themes to group them into meaningful, superordinate categories (i.e., axial coding; Corbin & Strauss, 2015).

During the first phase of the analysis, the first two authors reviewed the initial 15 interviews to identify themes. Self-efficacy emerged as a salient construct during this first phase of analysis: in dosage and strain experimentation, in decisions regarding treatment with care providers, and in information-seeking behavior. Although no interview questions asked directly about participants’ self-efficacy, some questions consistently elicited descriptions of behaviors and attitudes representing self-efficacy. These questions addressed: (a) patients’ interactions with their care providers (“When was the first time you discussed with a health care provider your use of cannabis to manage symptoms?”); (b) experimentation with different strains of cannabis and forms of cannabis usage (“What is your preferred ingestion method? Smoke or edibles? Other?”); and (c) how participants first learned of cannabis as a potential treatment option (“How did you first come to learn about or understand medical cannabis’s uses with [your chronic condition]?”). Although we were initially interested in understanding conversation in the primary care context, the variation in how participants defined and accessed primary care led us to refer in this report only to “providers” rather than “primary care providers.” The first two authors identified additional themes relating to health self-efficacy and these were operationalized before the second author coded the remaining 15 interviews. No new themes were revealed during the coding of the second 15 interviews. The coding themes and categories were then examined collaboratively by all authors and modified until consensus was reached. When no new categories or themes were identified, it was determined that data saturation had been achieved (Lincoln & Guba, 1985; Miles & Huberman, 1994).

Results

Our analysis revealed that participants demonstrated health-related self-efficacy in three contexts: (a) self-directed experimentation with cannabis strains (n = 12 participants reported), dosages (n = 9), and administration methods (n = 6); (b) managing care by selecting or seeking out a provider open to cannabis (n = 5) or educating their current providers (n = 8); and (c) information seeking and research behaviors (n = 8 for examining research on effects of cannabis; n = 8, seeking info on dispensaries/providers). The following analyses are grouped under these three contexts, and quotations are provided in summary tables to illustrate participants’ self-efficacy in understanding, obtaining, and using cannabis to help manage their chronic illnesses.

Self-Directed Cannabis Experimentation

Cannabis experimentation was almost completely self- (as opposed to provider-) directed. Although medical cannabis can be obtained with an Illinois Medical Cannabis Registry Identification Card (MCRI card), no firm guidelines exist for the dosage, strain, or method of administration for treatment. Participants experimented with strains and products (at what time, mood, situation, or symptoms to use cannabis and which species—Cannabis sativa, Cannabis indica—or named strains to use); they experimented with dosage (amount to use and under what circumstances/symptoms), and they experimented with different methods of administration (smoking, edibles, etc.). In their responses, participants exhibited self-efficacy by striving to ascertain appropriate procedures for administration through trial-and-error and occasional requests for assistance from dispensary staff (see Table 2).

Table 2.

Examples of Self-Efficacy in Cannabis Experimentation.

Self-efficacy theme	Quotation
Dosing and administration method	I jumped around a little bit. I’m still kind of—well, I wouldn’t say I’m new to this. I’ve been doing this about a year now. And there’s so many different methods of taking the medication. I’m still actually trying to see what works best for me. What I think works best is an edible, part of an edible in the morning, with a drop of oil. And I feel—I don’t want to say I’m close to pain free, or I should say it’s like 100 percent pain free—but I would say I am close to pain free. Because when I take that in the morning, I’m good for about anywhere from six to eight hours. (33-year-old woman living with multiple sclerosis)
Dosing and administration method	The first couple months were very challenging to find the correct dose and delivery method, and I, oftentimes, wanted to quit . . . but I have a very patient medical [oncology] team, and the dispensary I work with was also very helpful in helping me sort of learn. (58-year-old male living with spinal cord injury)
Dosing and strains	I don’t know the potency of every time I’m gonna go get something . . . if I use a different strain, less potent, it may take two to three [hits]. I don’t believe there is a set standard of dosing. It’s trial and error. (54-year-old male living with fibromyalgia)
Administration method	Well, kind of like with a lot of cannabis patients, it evolves and changes a little bit, because they’ve just got new things coming out all the time, or new delivery methods, something that might work easier for me. For me, I vape most of my medicine. I rarely smoke at all. I mean, just rarely, rarely, rarely. But I vape or I use the oil, like RSO oil [Rick Simpson oil]. And even with the oil, I’ll—sometimes, I—they call it dabbing. I’ll dab that, or I’ll eat it. (39-year-old male living with epilepsy, migraines)
Administration method	I’ve had surgery—two surgeries—removing about 20 centimeters in my small intestine, and unfortunately, one thing—one product of the cannabis line that doesn’t work for me are the edibles. I’ve tried numerous of those, and just for some reason, they don’t work with my body . . . I think the doctors removed a couple of CB [cannabinoid] receptors in my intestines, so I can’t digest or absorb the cannabis correctly, how it should be absorbed. I don’t know. I wish it could work for me, but unfortunately, every product I’ve tried at the dispensary hasn’t yet. (23-year-old male living with Crohn’s disease)
Strains	And so I don’t get them [migraines] near as much as I used to, but the ones that I have had, and I have tried cannabis since—this is in the last year, since the dispensary has opened, I noticed a couple of different strains would affect it differently. Because when I would get them, I’d get them bad, you know. I mean, it was bad. I’m like out of it for a couple of hours when I have these migraines. And there was a couple of strains that I’ve taken that did almost take them completely away. (39-year-old male living with epilepsy, migraines)
Administration and strain/product	The last time my friend had what’s called dabs. More potent THC [tetrahydrocannabinol]. And when I took one of those, I didn’t have to take pain medication for three days. That was kind of a real big eye opener. (38 year old male living with spinal cord injury, PTSD [posttraumatic stress disorder])
Administration and strain/product	When they [dispensary] first started working with me, they recommended using the tincture, which is the liquid-based THC, and they provided me a titration schedule to get my body used to it . . . When I took it, it made my throat burn, it made my eyes really heavy, it always made me tired, and I didn’t really feel like I was getting any benefits from it . . . So the next thing that I tried were edibles, and my dispensary had two different types of gummi products, and so I tried one . . . The first ones were red, and every time I took it, it just made me feel really high. I could not do anything after it. I couldn’t function. I basically had to go to sleep . . . So I went back to the dispensary and they were like, “Oh, we have these orange ones. The ratio is different. They should be better,” and those made me even higher. When I went back to the dispensary to talk about those, one of the workers was like, “Oh my gosh, I tried it. This is not supposed to be how it feels. I don’t know why it’s so high, but totally don’t do that.” So it took a long time, but now what works best for me is the original, the red gummies, and I cut them in half. If I only take a half a dose, then that seems to be the right amount for my body. (30-year-old female living with Crohn’s disease, fibromyalgia)

Strains

Participants frequently reported variation in the effectiveness of managing symptom severity depending on the cannabis strain and purported cannabis species (i.e., Cannabis sativa, Cannabis indica, and hybrids). Participants reported a plethora of options at dispensaries, with several participants reporting feeling overwhelmed by the choices available. While dispensary staff were often queried for suggestions, most participants noted that finding a strain or product that worked well for their symptoms required experimentation. References to indica strains were most commonly associated with calming or sedative effects while sativa strains were typically associated with facilitating periods of activity. Self-efficacy was evidenced by participants’ experiences of experimenting to find differences between strains and finding the best strains to use under different circumstances.

Dosing

Participants expressed difficulty finding optimal dosages when initiating use of medical cannabis. Participants who had never used recreational cannabis prior to medical cannabis sought assistance from friends or dispensary staff. Some participants expressed frustration when the treatment did not initially work. Despite the necessary trial-and-error period and its potential frustration, however, participants’ self-efficacy is evidenced by their persistence in pursuing correct dosage for their symptom severity without expert guidance from medical providers.

Methods of Administration

Methods of cannabis administration varied across the sample and included smoking cannabis flower, using dabs (concentrated cannabinoids and THC [tetrahydrocannabinol]), “vaping” cannabis oil, applying cannabidiol (CBD) lotions, drinking teas, and consuming edible products. Participants often noted using different methods for different purposes. Fast-acting methods—such as smoking or using a vape pen—could be used when more immediate relief was required (e.g., sudden migraine). However, participants frequently used edibles, particularly earlier in the day, due to their longer-lasting effect in comparison to smoking, which was quickly effective but did not persist as long.

Managing Care From Providers

Many participants discussed their use of medical cannabis with their care providers. Self-efficacy was identified in how patients discussed medical cannabis use with their providers, how and when they sought out new providers, and how they exchanged information with their providers. Self-efficacy in patient–provider interactions fell into two categories: (a) seeking out a care provider that would be open to discussing or signing off on an MCRI card and (b) educating a current care provider about the benefits of medical cannabis and legality in Illinois (see Table 3).

Table 3.

Examples of Self-Efficacy in Primary Care Provider Choices.

Self-efficacy theme	Quotation
Choosing a new provider to receive eligibility documentation	Because the program is so new none of my doctors would make a recommendation for me. So I sought out another doctor and took all my medical records to him. He then signed off on my recommendation and that’s how I was able to get my cannabis card. (58-year-old male living with spinal cord injury)
Choosing a new provider to receive eligibility documentation	Certainly. There is an organization in Illinois—it may not be in Illinois but there’s people in Illinois called—I want to say Medical Cannabis Outreach, MCO, Medical—I believe is the name of the organization. They have a great website. I sent an email and spoke with some people and they said, “Oh yeah, that sounds like you’ve got a covered condition, a specified condition. Here’s a list of doctors. Where would you—we will have somebody meet you at that doctor’s office.” And they did. (58-year-old male living with spinal cord injury)
Choosing a new provider to receive eligibility documentation	I looked online, and I didn’t know what to do I just—I put in some kind of search engine, I think, for cannabis doctors, and this one doctor came up . . . and that’s where I went. (39-year-old male living with epilepsy, migraines)
Educating a provider	I’ve been seeing this doctor for two years, since I came back from Michigan and it’s taken me a year and a half to finally convince her that what she was doing wasn’t illegal, that she wasn’t prescribing, but she was just saying that this man has a condition that may or may not be helped by the use of cannabis. (54-year-old male living with fibromyalgia)
Educating a provider	But when I brought it up, he started doing his own research . . . He wanted to figure it out himself and see, okay, what’s been recommended, what are they saying that this helps? And he did his own research. And when I went to my next appointment, two weeks later, he’s like, I’m onboard. (32-year-old male living with spinal cord injury, chronic nerve pain)
Educating a provider	I’ve got a good team and I’m very involved. I do a lot of research (online about cannabis) and I bring it to them so I’m very active in my own treatment and recovery. I’ll bring stuff to them . . . So, they listen to me. They know I’m not stupid. They know I do my work and I’m not just reaching out blindly. . .You’ve got to be an active participant in your own health. (56-year-old female living with HIV, hepatitis C, and cancer)

Seeking Out a Provider Open to Medical Cannabis

Participants reported encountering care providers who were not interested in discussing medical cannabis as a possible treatment. Various reasons for this reported by participants included (a) providers thought the program was too new, (b) providers were unfamiliar with the eligibility process, (c) providers did not believe medical cannabis had beneficial effects for participants’ chronic conditions, or (d) providers believed that participants were seeking cannabis for pleasure (i.e., “drug-seeking”) instead of as a medical treatment. When participants found their care providers unwilling to provide the necessary documentation for an MCRI card, they often sought out another provider who would. This occasionally meant leaving the initial care provider; typically, participants kept their initial care provider and visited another doctor infrequently (or just once) to obtain eligibility documentation. A few participants sought out a new care provider when their current provider reacted negatively after participants initiated a discussion about medical cannabis. In one instance, the provider dismissed the patient from the practice, telling the participant to never return to the office.

Educating Their Current Care Provider

Some participants mentioned that their provider was open to discussing medical cannabis use, but was not knowledgeable about the potential health effects and legal status in Illinois. In some cases, the care provider said they would look up additional information on their own and then discuss it with the participant. In other situations, the participants brought in research material supporting the use of medical cannabis in the treatment of specific symptoms and the provider looked over this information before deciding whether to support the inclusion of medical cannabis in a treatment plan.

Information Seeking and Research Behaviors

Patients sought additional information on medical cannabis, either online or in-person, to better learn about the subject and better manage their own care. Participants reported a wide variety of self-directed information-seeking behaviors. These behaviors aligned with two subthemes: (a) gathering information on the medical effects of cannabis, including different strains and (b) looking up information on dispensaries (see Table 4).

Table 4.

Examples of Self-Efficacy in Info-Seeking Research Behaviors.

Self-efficacy theme	Quotation
Research on cannabis	You’d go to Leafly, the website, and you could see the strains. It would tell you exactly how that strain was going to work, what it was going to do. It would give a rating. It would be pictures of what the buds would look like, and they would match. So what I had in my hand matched what I was looking at and researching as opposed to going to see the guy on the corner. (62-year-old male living with HIV, hepatitis C, cancer [in remission])
Research on cannabis	Once I was diagnosed, I started researching different ways to find relief aside from taking prescription pills and that’s when I started just finding a ton of information online about the positive effects of cannabis with Crohn’s and colitis, so that’s when I first started really looking into it and I wanted to make sure that—I wanted to make an adult decision about it and so I initially just got some from a buddy just to try it, just to see what it would do to my body with Crohn’s and I just enjoyed it. It felt like I had my life back just for a little bit. So from there, I pursued it aggressively to get the card, get the medical card. (35-year-old male living with Crohn’s)
Research on cannabis	There’s one called Leafly and The Cannabist. It tells you exactly the percentage of the THC [tetrahydrocannabinol], the CBD [cannabidiol], all the other stuff that’s in it. It tells you how it affects you. It’s very scientific. Like I said, with this black market stuff you just don’t know what you’re getting which is ridiculous. (59-year-old male with Crohn’s)
Research on cannabis	Different websites, lot of cannabis websites, what their opinions on different strains are good for neurological pain, stuff like that. You’ll find a lot of answers on there with a lot of patients’ opinions. That’s what I love about Leafly, because there’s a lot of medical marijuana patients out there. Like, this strain is perfect for spinal cord injuries, or this one is better for this one. So I learned a lot of information on there to be honest. (38-year-old living with spinal cord injury, PTSD [posttraumatic stress disorder])

Gathering Information on the Medical Effects of Cannabis, Including Strains

Many participants used online sources for information about the efficacy of medical cannabis for their chronic conditions. Online sources included academic journal articles as well as organization-run websites such as Leafly.com or thecannabist.com, which catalogue and describe the reputed differences between strains, describe the potential effects of cannabis use and discuss methods of administration. Such websites were mentioned several times by participants as sources of information and were noted for providing the benefit of anonymity. Although less common, some participants discussed medical cannabis with friends or family to acquire more information on first-hand experience; however, personal encounters were impeded by fears of social stigma related to cannabis use.

Gathering Information on Dispensaries

Participants also used online tools to locate nearby dispensaries through websites, such as Leafly.com, and to examine reviews of dispensaries to find those that could provide the services they were seeking and to compare locations. Participants also discussed dispensaries with acquaintances and friends—once again, this was somewhat limited by social stigma surrounding cannabis use—to get recommendations based on factors such as the quality of assistance from staff and price of products.

Discussion

This study supplements the literature on medical cannabis and health care accessibility by reporting characteristics of health-related self-efficacy in people who reported successfully navigating the medical cannabis system in a state where medical cannabis was recently legalized. Our analysis found that participants engaged in a range of behaviors that indicate self-efficacy: direct experimentation, initiating conversations with care providers and personnel at cannabis dispensaries, discussing with members of their social networks, and other forms of information seeking, assimilation, and synthesis, despite a high level of social stigma. These self-efficacious behaviors were utilized despite significant barriers, such as the long and complex legal process involved in acquiring medical cannabis, potential challenges in navigating the process with a care provider, and the trial-and-error necessary to find the right dosage and strain that helped participants to manage their chronic condition symptoms. The prevalence of these behaviors among the participants in this study suggests they have both determination and self-confidence in identifying and acquiring the means to manage the effects of their chronic health condition.

Although no previous studies have examined self-efficacy within the context of researching, obtaining, and using medical cannabis, comparisons can be drawn between our findings and research examining self-efficacy in related domains, such as self-management of symptoms. Although there is likely no global, uniform construct of self-efficacy, as it is related to specific behavioral tasks (Bandura, 1981, 1986), self-efficacy learning may generalize to related domains (Lawrance & McLeroy, 1986). For example, self-efficacy in learning new information may generalize to self-efficacy in gathering information on the medical effects of cannabis or researching which strain varieties to use. Self-efficacy in gathering information on cannabis relates to the finding that self-efficacy is an important factor in learning and motivation (Zimmerman, 2000). Participants in this study actively gathered information on cannabis strains, methods of administration, and the medical effects of cannabis both in person and through the internet, and therefore may have had high self-efficacy in their ability to assimilate new information through independent learning.

For people with chronic conditions, self-efficacy could be important when adopting medical cannabis for its therapeutic effects, since self-efficacy is important in self-management of diabetes (Sarkar et al., 2006). Patients with diabetes and other chronic conditions may need high self-efficacy in their treatment plans due to the distressing symptoms of their illnesses. Self-efficacy in obtaining medical cannabis, often without the overt guidance of a medical provider, may align with research findings that self-efficacy was higher among those who successfully prevented smoking relapse (Condiotte & Lichtenstein, 1981; DiClemente, 1981), as most people who quit smoking do so without professional assistance. In sum, our findings align with other indications that self-efficacy is important for learning new information and managing the symptoms of chronic health conditions, including in self-directed health contexts.

When considering implications for practice, it is possible that one impetus for patients’ self-directed research is to avoid initiating uncomfortable conversations with care providers or seeking second opinions; as a result, they may seek out dispensaries and acquaintances for this information. A tendency to utilize community-based resources for social support has already been observed among chronically ill cannabis users (Reiman, 2008). At the same time, participants with chronic conditions may also have higher motivation to investigate alternative treatments because they have negative experiences with past treatments. For example, individuals with chronic pain may feel that they have exhausted conventional treatments and wishes to seek other sources for symptom reduction, but is hesitant to initiate discussion of medical cannabis with their care provider.

Providers who are uninformed on medical cannabis, resistant to its usage, or unwilling to discuss its usage with patients emerged as a barrier to medical cannabis use, which has clinical implications for the patient–provider relationship and access to care. Patient–provider communication has been examined as a factor that can facilitate or impede access to care and has been found to impact treatment outcomes (Li et al., 2017), particularly when it involves discussion of stigmatized topics. Some participants reported that their providers dismissed requests to discuss medical cannabis (i.e., did not explain their positive or dissenting stances on medical cannabis use). Insufficient information from providers led some participants to seek advice and information online and through dispensaries. These participants then often sought out other providers who supported their use of medical cannabis or completed their paperwork for an MCRI card. Some participants reported experiencing cannabis-related discrimination after disclosure of using medical cannabis, where providers attributed unverified negative health symptoms to cannabis use. These results—patients avoiding discussion of a stigmatized topic for fear of repercussions, uninformed providers leading participants to seek information from other sources, patients experiencing discrimination as a result of disclosure of a health-related fact—are mirrored in other areas of the literature surrounding patient–provider communication of stigmatized topics, such as discussion of sexual health concerns and sexual orientation (Fisher et al., 2018).

Optimal medical management of chronic conditions presumes that the care provider oversees and coordinates treatment and that the patient is self-efficacious in carrying out a treatment plan. However, our findings suggest that providers who are not prepared to partner with patients as they seek information about medical cannabis may be replaced by dispensaries and websites with expertise in cannabis but without understanding of patients’ medical conditions and individual health care needs. Thus, further education of providers on medical cannabis may facilitate better patient–provider communication regarding medical cannabis, regardless of the providers’ opinions on its use in treatment. Similarly, more education and support for providers on how to initiate difficult conversations and/or shared decision making may result in better integration of patients’ self-management efforts and providers’ oversight.

Since this study is exploratory, the relationship between self-efficacy and experiencing barriers to acquiring or successfully using medical cannabis is unknown. It is plausible that a certain amount of self-efficacy is required to start the process of obtaining an MCRI card but that self-efficacy may then increase or decrease as barriers are faced. The initial experience of facing a barrier may decrease self-efficacy (e.g., a provider refusing to discuss medical cannabis use) but overcoming these barriers may increase self-efficacy (e.g., finding an alternative medical provider). As a result, facing barriers may decrease self-efficacy until barriers are overcome; when barriers are overcome, self-efficacy in procuring and using medical cannabis may be reinforced.

One limitation of this study is that this sample is unlikely to represent all individuals who have qualified for the MCRI card. Because this study includes only persons who have successfully acquired a medical cannabis card, responded to an announcement seeking research participants, and completed a lengthy qualitative interview, it may be that participants in this sample are more likely to have a higher general self-efficacy; that is, these participants may represent individuals who have a strong belief in their capacity to achieve in their goals and persist when facing barriers. The small sample size did not allow us to examine differences in self-efficacy behaviors among different chronic illnesses. Results from this study should not be generalized to race/ethnic minority populations since most participants were non-Hispanic White. In addition, race/ethnic minority populations face additional barriers that could impact self-efficacy, such as access to care providers (Canedo et al., 2018; Do et al., 2010). Finally, it cannot be assumed that all persons with chronic illness will demonstrate self-efficacy by engaging in the behaviors described by the participants in this study.

Conclusion

Due to the difficulty and stigma of acquiring medical cannabis, those with chronic conditions may be more well-informed and confident than those who request or discuss other forms of treatment with their medical providers. To offset the stigma associated with its usage and to convince their providers of its efficacy, people living with chronic conditions may seek out additional sources of information. It is possible that those with challenging chronic conditions develop increased self-efficacy to procure a treatment that reduces their debilitating, continuous symptoms, even if it means pursuing a stigmatized modality. Providers caring for this population of patients should be aware of the possibility that patients who could benefit from medical cannabis may not seek it independently because they have low health self-efficacy. Conversely, patients with higher self-efficacy may engage in a range of activities to investigate, procure, experiment with, and incorporate medical cannabis into their chronic condition management outside the purview of their PCP.

Future research should establish the generalizability of findings to a larger sample. Given the implications of this research for the provider–patient relationship, future studies might also examine the characteristics of successful communication around medical cannabis use that leads to optimal care. Finally, it will be important to understand the social, political, and institutional barriers that prevent more effective shared decision making, and thus lead some patients to engage with cannabis as a therapy independently from their other sources of health care.

Footnotes

Acknowledgements

Our deep gratitude goes to our research participants whose thoughtful input made this study possible.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this study was provided through the Provost’s Collaborative Research Fellowship, DePaul University.

ORCID iD

John P. Brady

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