# data[].attributes.headline
Is medical marijuana a healthier and cheaper alternative to prescription drugs/alcohol?

# data[].attributes.subject
Is medical marijuana a healthier and cheaper alternative to prescription drugs/alcohol?

# data[].attributes.headline
How many doctors support the use of medical marijuana and why?

# data[].attributes.subject
How many doctors support the use of medical marijuana and why?

# data[].attributes.headline
Should people consider Medical marijuana as a normal house hold drug?

# data[].attributes.subject
Should people consider Medical marijuana as a normal house hold drug?

# data[].attributes.headline
would medical marijuana be considered a bad drug if people stopped abusing it?

# data[].attributes.subject
would medical marijuana be considered a bad drug if people stopped abusing it?

# data[].attributes.body
Should medical marijuana be legal for 18 plus?

# data[].attributes.body
Why are many people against Medical Marijuana?

# data[].attributes.headline
How accessible is medical marijuana to people?

# data[].attributes.subject
How accessible is medical marijuana to people?

# data[].attributes.headline
How would Medical marijuana be considered bad if we have no deaths just from it?

# data[].attributes.subject
How would Medical marijuana be considered bad if we have no deaths just from it?

# data[].attributes.headline
Can medical marijuana aid physical disorders/diseases that cause pain?

# data[].attributes.subject
Can medical marijuana aid physical disorders/diseases that cause pain?

# data[].attributes.headline
Can medical marijuana help pain within cancer patients that are undergoing chemotherapy?

# data[].attributes.subject
Can medical marijuana help pain within cancer patients that are undergoing chemotherapy?

# data[].attributes.headline
How many people passed away from the misuse of medical marijuana?

# data[].attributes.subject
How many people passed away from the misuse of medical marijuana?

# data[].attributes.headline
Can medical marijuana help calm PTSD and other mental disorders? 

# data[].attributes.subject
Can medical marijuana help calm PTSD and other mental disorders? 

# data[].attributes.headline
Does medical marijuana work better than other drugs?

# data[].attributes.subject
Does medical marijuana work better than other drugs?

# data[].attributes.attachment_link.title
Kami Export - 1_ medical cannabis program

# data[].attributes.headline
artical 1 - It's Time to Pass Comprehensive, Clinically Meaningful Cannabis Legislation

# data[].attributes.subject
artical 1 - It's Time to Pass Comprehensive, Clinically Meaningful Cannabis Legislation

# data[].attributes.headline
Artical 2 Mississippians Deserve Medical Marijuana university study

# data[].attributes.subject
Artical 2 Mississippians Deserve Medical Marijuana university study

# data[].attributes.attachment_link.title
Kami Export - 3_self reported medical marijuana

# data[].attributes.headline
Artical 3 Cannabis Legalization Must Address Medical Use, Not Just Recreational Use !!

# data[].attributes.subject
Artical 3 Cannabis Legalization Must Address Medical Use, Not Just Recreational Use !!

# data[].attributes.attachment_link.readable_text
Abstract

Background:

Over the past few decades in the United States, marijuana for medical purposes has become increasingly prevalent. Initial qualitative and epidemiological research suggests that marijuana may be a promising substitute for traditional pharmacotherapies.

Objectives:

This qualitative study examined perceptions relating to 1) using medical marijuana in comparison to other prescription medications and 2) user perception of policy issues that limit adoption of medical marijuana use.

Methods:

Qualitative interviews were conducted with Rhode Island medical marijuana card holders (N = 25). The interviews followed a semi-structured agenda designed to collect information from participants about their reasons for, and perceptions of, medical marijuana use. All interviews were audio recorded, transcribed verbatim, and de-identified. Qualitative codes were developed from the agenda and emergent topics raised by the participants.

Results:

Three themes emerged related to medical marijuana use, including (1) comparison of medical marijuana to other medications (i.e., better and/or fewer side effects than prescription medications, improves quality of life), (2) substitution of marijuana for other medications (i.e., in addition to or instead of), and (3) how perception of medical marijuana policy impacts use (i.e., stigma, travel, cost, and lack of instruction regarding use).

Conclusions:

Several factors prevent pervasive medical marijuana use, including stigma, cost, and the inability for healthcare providers to relay instructions regarding dosing, strain and method of use. Findings suggest that medical patients consider marijuana to be a viable alternative for opioids and other prescription medications, though certain policy barriers inhibit widespread implementation of marijuana as a treatment option.

Keywords: medical marijuana, qualitative interviews, cannabis, marijuana policy, prescription substitution

Introduction

In the United States, marijuana use for medical purposes has become increasingly prevalent over the past several decades ( Hill, 2015). Since 1996, 33 states and Washington DC have passed laws permitting the use of marijuana for medical conditions, and since 2012, ten states and Washington DC have legalized the use of marijuana for recreational purposes (" State Medical Marijuana Laws," 2019). Each state varies in endorsement of medical conditions for which marijuana is approved, with the most widely accepted conditions being cancer, HIV/AIDS, severe nausea, glaucoma, appetite stimulation (wasting and cachexia), chronic pain, muscle spasms, and seizures ( Volkow, Baler, Compton, & Weiss, 2014). Many clinical trials testing marijuana as a medication for symptom management have indicated that marijuana is effective in the treatment of nausea and vomiting, appetite stimulation in HIV/AIDS, spasticity due to multiple sclerosis, glaucoma, and Tourette's syndrome and, most commonly, chronic pain ( Goldenberg, Reid, IsHak, & Danovitch, 2017; Whiting, Wolff, Deshpande, Di Nisio, et al., 2015).

Chronic pain is a major health problem affecting 10-55% of adults depending on the population studied ( Nahin, 2015; National Academies of Sciences, 2017). It is considered one of the most debilitating medical conditions, yet the medical field lacks consensus on the best diagnostic and treatment method ( Volkow & McLellan, 2016). Currently, opioids are the most commonly prescribed drugs for both acute and chronic pain, accounting for approximately 259 million prescriptions ( Dowell, Haegerich, & Chou, 2016). Prescribing opioids places patients at a risk of misuse, addiction, and overdose ( Rosenblum, Marsch, Joseph, & Portenoy, 2008). Over the past 17 years, the rate of opioid overdose has significantly increased, resulting in a serious public health crisis in the United States ( Volkow & McLellan, 2016). The over-prescription, misuse, and increasing availability of opioids are major driving forces behind the opioid epidemic in the United States ( Bohnert et al., 2011). Because of this epidemic, it is crucial to find alternative treatments for diseases for which opiate medications are commonly overprescribed, including chronic pain.

As legalization of marijuana for medical purposes has expanded, noticeable changes have occurred in patterns of opiate use. A study by Bachhuber et al. (2014) found that states that permit use of marijuana for medical purposes reported significant reductions in opioid overdose mortality. Similarly, another study by Bradford et al., (2018) found that states with permissive medical marijuana laws display a significant decrease in opioid prescriptions among individuals with Medicare. Additionally, Boehnke et al. (2016) found that medical marijuana was associated with a 64% decrease in opioid use, and marijuana patients reported that they were experiencing a better quality of life and fewer medication side effects. Still other research has found that combining marijuana with opioids decreased pain significantly without altering opioid plasma levels, suggesting the potential for opioids to be prescribed at lower doses with fewer side effects ( Abrams, Couey, Shade, Kelly, & Benowitz, 2011). While these initial studies are highly promising, well-designed clinical trials are needed to examine whether marijuana may be a safer alternative treatment for chronic pain management.

Several qualitative studies suggest that many medical marijuana patients believe that marijuana may be a promising substitute for traditional pharmacotherapies ( Bruce, Brady, Foster, & Shattell, 2018; Coomber, Oliver, & Morris, 2003; Lau et al., 2015; Page & Verhoef, 2006; Pedersen & Sandberg, 2013; Peters II, 2013). Much qualitative research has focused on medical marijuana patients' personal beliefs and opinions regarding marijuana for therapeutic purposes ( Bottorff et al., 2013; Satterlund, Lee, & Moore, 2015). While these studies varied in location, sample size, and topics discussed, a number of pervasive themes characterize this research including stigma associated with marijuana use ( Bottorff et al., 2013; Pedersen & Sandberg, 2013), therapeutic benefits of marijuana, and substitution of marijuana for other prescription medications ( Bottorff et al., 2013; Bruce et al., 2018; Coomber et al., 2003; Lau et al., 2015; Page & Verhoef, 2006; Peters II, 2013). Although there is much literature on marijuana as a medication for symptom management, pain relief, and as an alternative for other prescription medications, little is known about how policy may affect the ability to incorporate marijuana into a treatment regimen.

Despite initial epidemiological and qualitative findings suggesting that marijuana may be a promising substitute for other prescription medications, more research is needed to fully understand the benefits associated with marijuana as a medication, how patients are using it, and whether it may be a promising alternative to traditional pharmacotherapies for various illnesses. There is a lack of patient-oriented research on how marijuana is used and the symptom relief that patients experience. As use of marijuana for medical purposes becomes more prevalent, it is imperative to better understand patients' perspectives and motives for use. This study will enhance previous literature by recruiting patients with a current physician recommended medical marijuana card, and will collect data on several understudied topics pertaining to medical marijuana use. The current qualitative study intends to describe why patients use marijuana, how they are using it in addition to or instead of other prescription medications, and how medical marijuana policy impacts their use.

Method

Participants

Medical marijuana users were recruited in 2016 from Rhode Island to participate in individualized semi-structured interviews to discuss their marijuana use, purchasing behaviors, beliefs about legalization, and the impact of medical marijuana card holding on use. To obtain a medical card in Rhode Island, a physician must provide a recommendation to the patient indicating that they believe using marijuana will alleviate the patient's symptoms associated with one of the approved medical conditions in the state (medical conditions endorsed by the current sample are presented in Table 1 ). Once the patient has obtained a medical marijuana card from the Department of Health, they are allowed to designate one caregiver and/or are permitted to attend a compassion center to obtain medical marijuana ( Rhode Island Department of Health, 2008).

Table 1.

Variable

n (%)

Household Income

$0 - 19,999

13 (52)

$20,000 - 39,999

4 (16)

$40,000 - 59,999

2 (8)

$60,000+

6 (24)

Race

American Indian/Alaska Native

0 (0)

Asian

1 (4)

Black or African American

0 (0)

White

18 (72)

More than one race

5 (20)

Unknown or Not Reported

1 (4)

Qualifying medical condition*

Cancer

2 (8%)

Glaucoma

0 (0%)

HIV/AIDS

0 (0%)

Hepatitis C

2 (8%)

Cachexia

1 (4%)

Severe, debilitating, chronic Pain

18 (72%)

Nausea/ Vomiting

8 (32%)

Epilepsy

2 (8%)

Multiple Sclerosis or Crohn's Disease

10 (40%)

Alzheimer's Disease

1 (4%)

Other

8 (32%)

Amounts of Marijuana used per week

≤ 1/16 th ounce

5 (20%)

1/8 th ounce

1 (4%)

1/4 th ounce

4 (16%)

3/8 th ounce

1 (4%)

1/2 ounce

4 (16%)

≥1 ounce

10 (40%)

The interviews were conducted as part of an ongoing larger experimental laboratory study examining marijuana demand and use patterns among recreational and medical marijuana users ( Aston, Farris, Metrik, & Rosen, 2019). Participants were required to meet the following inclusion criteria: English speaking, 18-70 years of age (to account for the broad age range among medical marijuana patients in Rhode Island), not seeking treatment or currently looking to quit marijuana use, and held medical marijuana registration cards.

Procedure and Measures

Study procedures were approved by the Institutional Review Board at Brown University, and all participants provided informed consent prior to study participation. Prior to the interview, participants provided demographic information and completed the Marijuana History and Smoking Questionnaire to assess age of onset of marijuana use, typical marijuana use quantity, typical mode of self-administration, medical conditions for using marijuana, and other questions related to marijuana use patterns ( Metrik et al., 2009). Interviews were moderated by the study's Principal Investigator (EA). The interviews followed a semi-structured agenda designed to collect information from participants about marijuana use, including obtaining a medical marijuana card. All interviews were audio recorded and lasted between 22 and 85 minutes ( mean = 53 min). Participants were compensated for their time and participation in this study.

Data Analysis Plan

The interviews were transcribed verbatim and all identifiers were removed. A qualitative coding structure was developed from the semi-structured agenda. This coding structure was refined throughout the coding process to include emergent topics. Each transcript was individually coded by two research assistants using an open coding process, where each line of the data was examined and evaluated to identify topics ( Glaser & Strauss, 2017). Codes were refined as the analysis progressed, and related codes were grouped to form categories within the data. Codes were entered into NVivo qualitative data analysis software for thematic analysis. After the initial open-coding review of transcripts was complete, all codes pertaining to reasons for using marijuana and marijuana as a substitute for other medications were reviewed. In addition, data mining tools in the software package were used to ensure that all passages relative to substitution were included. Specifically, the following search terms were queried: "opioids," "opiates," "substitution," "prescription," and "medication." The substitution-related content was then subjected to a secondary coding and analysis process: that is, additional, substitution-specific codes were created and applied to the data. These codes were then reviewed and summarized to identify key themes reported here. Illustrative quotes were subsequently selected to reflect each theme, and the assigned participant study number is presented in parentheses following each quote.

Results

Preliminary analyses

Participants ( n = 25; 40% male) reported using marijuana a mean ( SD) of 6 ( 2) days per week. Mean ( SD) age was 47 ( 12; range: 24 - 67). Table 1 displays other demographic and participant characteristics.

Qualitative Themes

Three medical marijuana specific topics emerged during the interviews: 1) comparing medical marijuana to other medications, 2) substitution of marijuana for other medications, and 3) how medical marijuana policy impacts use.

Comparing medical marijuana to other medications

Marijuana is superior to and has fewer side effects than prescription medications

Participants reported that marijuana was more effective for certain conditions compared to some pharmaceutical prescriptions. One participant preferred to use marijuana " because it's anti-inflammatory. It helps with muscle spasms. It's better for acute situations" (#24). Similarly, another participant said " I smoke marijuana 'cuz...it enables me to live and function alone with my conditions and it helps me so...much more than anything could ever help me" (#6). Relatedly, several participants felt that marijuana did not have as many side effects as other prescription medications. Some participants believed that certain prescriptions took a toll on their body, thus participants no longer wanted to use them. One participant noted " I was on medication for pain and I had to take pills, and my stomach was at a point where I was getting ulcers and I wanted to stop taking pills" (#7). Other participants explained " even though doctors had given me many prescription medications, I didn't like how they made me feel. And I didn't like the effects [they] had on my liver and kidneys and things like that" (#22) and " I have enough bad reactions with medications" (#12). Likewise, a different participant reported that " I'd rather use the marijuana, because I know it is safer" (#14). Other participants reported " the prescriptions will have horrible effects on them and they can just self-medicate with something natural, you know?" (#25) and said marijuana had " no side effects...no withdrawal effect " (#13).

Marijuana improves quality of life

Many participants claimed that compared to traditional pharmaceutical medications, marijuana appears to improve their quality of life by helping with multiple conditions including psychiatric conditions, appetite, and sleep-related disorders. One participant reported that marijuana " helps with the nausea [and] it helps with pre-menstrual cramps and everything. It helps with stress, it helps with depression, it helps with anxiety, everything" (#24). Furthermore, another participant explained that " marijuana does give me an appetite...prescription medications do not give me any appetite" (#25). One participant explained " I would not be here today if it wasn't for weed. For so many reasons" (#20). Another patient discussed the fact that his life was " affected in a positive way...I struggled with PTSD issues...cannabis helped me get over those past experiences and helped me to focus on the moment" (#11). Still another participant summarized these sentiments in stating that compared to other medications, marijuana " was easier and it helped so many different things that people can't understand " (#5).

How marijuana is used in relation to other medications

Use in addition to other medications

Several participants reported that when they use marijuana, it seems to alleviate negative side effects experienced with other prescriptions. One participant shared that " methylphenidate sometimes will kill your appetite. So [marijuana] does help with the appetite. Gives me an appetite to eat" (#5). Additionally, when this participant took prescription opiates for pain " they were pretty strong. I took them. I was like okay I'm here with the pain. I still need to go to sleep. So I needed to smoke" (#5). Other participants also reported using marijuana along with currently prescribed medications. One participant noted that they use marijuana in order " to use less painkillers" (#18). Still another patient stated that " I would do that [marijuana] before I took a pharmaceutical. If I smoked and I'm still feeling pain then maybe I might consider taking a pill but I would prefer not to " (#24).

Use instead of prescription medications

Of the participants interviewed, 7 participants reported that they were able to cut back on their medications, and 12 reported that they were able to completely stop taking other prescription medications once they started using marijuana for medical purposes. One participant explained " so many people...start medical marijuana and then they go down to almost no opioid pain medication, a little bit, or none...almost no one has said I have started taking more or kept it the same" (#3). Similarly, other participants explained " I know so many people...like me...I'm off my inhalers. I'm off codeine. I'm off my gabapentin" (#15) and " I'm not on anything anymore" (#20). Some participants found that marijuana actually worked better than their prescription pharmaceuticals. One participant explained " I think [edibles] work better than taking a sleeping pill. I have sleeping pills prescribed to me, but I don't use them very often" (#1). Another participant shared that " I was using the marijuana instead of pain medication anyways because I was having some bad reactions to the medications and I spoke to my doctor and we thought it would be better" (#12). Other participants started using medical marijuana because they did not want to use prescription pain medication. One participant stated " You know, I didn't go get codeine or a bunch of pain medicine. I just smoked a little and I was fine" (#21). Another added to this sentiment by explaining " when I got in the accident and of course first thing they did was prescribed Vicodin and I was like I'm not taking these" (#9). Relatedly, when one participant was asked why they obtained their medical marijuana card, they responded " it was a choice that the doctor gave me when he found out how much pain I was going through...it was pain pills, or medical marijuana card. And I was like medical marijuana card " (#17).

How perception of medical marijuana policy impacts use

Marijuana is perceived to be more stigmatized than prescription medication

Participants felt that the stigma associated with marijuana is different from other medications they use; and they reported encountering both job- and provider-related stigma. At times, participants reported resorting back to their non-marijuana medical prescriptions, such as opiates, to treat their conditions because medical marijuana could jeopardize job options. One said " We should have the same oversight as anyone who takes any medication" (#7). Another participant stated " I mean someone could take a Vicodin out of their purse and take it and no one is going to say anything" (#10). One participant was unable to use medical marijuana because " I'm looking for a job right now...I won't be able to smoke as much as I do now. I'll just have to take my pills for the pain " (#17). State policy on medical marijuana use and pre-employment drug testing is quite variable and still unclear in many states. Thus card holders tend to retain such concerns about their medical marijuna use and job options.

Stigma associated with marijuana use for medical purposes was also cited as an issue. Multiple participants reported struggling to obtain a medical marijuana card; some found that their physicians were not supportive of medical marijuana use. One participant said " I just asked [my doctor], 'How's your take on medical marijuana?' He said flat out, 'I'm not for it.' Then I just moved on to a different subject" (#25). Another participant explained that their doctor " didn't want to touch it...he didn't want to have anything to do with it" (#21). A participant shared that their doctor said " his colleagues were against the program...he thought it would be good for me but professionally he doesn't think it would be good for him to do it" (#19). A participant had a doctor who was supportive of medical marijuana, but unable to prescribe it: " my doctor advocated it. The only problem with him is [he's in] a federally funded HMO, so he couldn't just sign off...they're kind of on the fence with how they want to deal with the program, if they want to be the ones to sign off or if they want to send you somewhere...but he was all for it " (#20).

Traveling outside one's state with medical marijuana

Several participants discussed the fact that while medical marijuana is legal in the state in which they reside, they are unable to travel with their medication due to policy in other states and countries. Numerous participants (#8, #16, #18, #23, #24, and #25) discussed how they had to change their use routine or take their other less desirable prescription medications when they were traveling due to legal repercussions in different states. This resulted in some participants refusing to travel due to fear of prosecution. One participant said " you can't just use it in every place. You got to pick and choose where you can go" (#18). Another participant explained that because marijuana is not federally legal, they cannot legally bring their medications to other states. This participant explained " The only thing that affects that routine is when I am traveling in states where I can't use... sometimes I risk it and bring edibles with me...just like the most discrete form...but sometimes I just have to go back on prescription medication which have a lot of side effects so I try to avoid that " (#23).

Cost of marijuana in comparison to prescription medications

Throughout the interviews, the participants reported experiencing financial burden due to using marijuana because of its high cost and lack of insurance coverage. Frequently participants cited how other drugs like opiates were easier to obtain and afford because they are covered by insurance, unlike medical marijuana which must be purchased out-of-pocket. One participant discussed the fact that " you can't go to the store [i.e., pharmacy] and buy this stuff. It's not...covered by my insurance" (#6). Another participant commented that her insurance-covered medications are very inexpensive. She explained " I could pay 99 cents for the benzo but I have to pay this much money for something that I know isn't going to affect my liver" (#8). Similarly, another person reported that " the opioid pain medications were like a dollar for one prescription... It's covered...so it was essentially free...morphine, OxyContin, anything...but it just made me really depressed...my quality of life went down such a huge amount that it isn't worth it...it's free...versus like 350 dollars [for marijuana]" (#3). One participant explained " if I had to pay for all the drugs that I have out-of-pocket compared to marijuana, marijuana would be a lot cheaper " (#5).

Healthcare provider inability to relay instructions regarding dosing, strain, and method of use

Some participants reported struggling with initiation of marijuana use for medical purposes because they lacked knowledge and did not receive instructions from their healthcare provider. One participant explained " I don't believe that people know enough, when they're handed a card, it's like handing someone a bottle of Vicodin and not telling them what to do with it" (#10). Another participant reported that because the doctor did not give them instructions, they sought instruction from employees at their dispensary, but didn't find the privacy they needed in that environment. They said " I expected the first time you go to a compassion center they would have you go, one-on-one with someone, to figure out of what they have there and what you've already been using...which of their things would be the best. You're supposed to stand at a counter and discuss this stuff... I don't think so. What happened to HIPAA? I don't do that at a doctor's office.... Stand there in front of other people and discuss my concerns" (#4). Furthermore, one participant stated that they learned to use marijuana online. The participant explained that they "[watched] people get stoned on YouTube to find out how to use a water pipe " (#22).

Discussion

The current study collected narrative information about use of marijuana for medical purposes from medical marijuana card holders in Rhode Island. Three themes emerged during individual interviews: 1) comparison of medical marijuana to other medications, 2) substitution of marijuana for other medications, and 3) how perception of medical marijuana policy impacts patients' use. These data emerged within the context of a larger study examining marijuana demand. Consequently, the resultant themes were not a priori research questions.

Qualitative results from this study suggest that medical marijuana users may prefer marijuana to other prescription medications because they perceive it to alleviate disease-related symptoms without the side effects or adverse reactions that often accompany many prescription medications. This finding is well-aligned with research conducted by Reiman and colleagues (2017) where 2897 medical marijuana patients were surveyed. Of those who used opioids, 97% reported that they were able to decrease their opiate use when also using marijuana, and 89% agreed that opioid medications produce unwanted side effects ( Reiman et al., 2017). In this regard, many studies have reported that medical marijuana patients are concerned about dependence, toxicity, and side effects associated with traditional prescription medications ( Bruce et al., 2018; Coomber et al., 2003; Lau et al., 2015; Page & Verhoef, 2006; Pedersen & Sandberg, 2013; Satterlund et al., 2015). While participants reported preferring marijuana to other prescription medications, the current study cannot speak to an actual comparison of side effect profiles. Still, it is important to reiterate that patients perceive and subjectively report reduced side effects from marijuana compared to other prescription medications.

All participants in the current investigation reported that marijuana is effective in treating various symptoms related to a wide range of medical conditions. Of the 25 participants in this investigation, 60% reported using marijuana to treat chronic pain, and 48% reported successful substitution of marijuana for various pain medications, including opiates. These results align with and enhance previous findings suggesting patients are able to reduce or completely eliminate opiates and other prescription medications when using marijuana ( Bruce et al., 2018; Coomber et al., 2003; Lau et al., 2015; Page & Verhoef, 2006; Pedersen & Sandberg, 2013; Peters II, 2013). One study by Peters II (2013) suggests that marijuana can be used to reduce narcotic dependency, a prevalent concern with the prescription of opiates and other habit-forming medications.

Many participants in this study found marijuana to be a useful adjunct or alternative to conventional prescriptions, including opiates. They also suggested several policy-level factors that were perceived to limit their use of marijuana for medical purposes. First, while several healthcare practitioners were in support of the adoption of medical marijuana use for certain conditions, some participants reported experiencing stigma associated with the use of medical marijuana. Participants reported that some treatment providers may be unable or unwilling to recommend marijuana for alleviation of negative medical symptoms. This may indicate that marijuana is not often recommended to patients as a treatment option, necessitating that patients advocate for themselves in order to receive a medical marijuana card. Furthermore, patients conveyed that they believe marijuana is not always viewed as a prescription medication. Multiple participants explained that in contrast to other commonly prescribed medications that may have a high risk of misuse and dependence, they feel regulations on marijuana extend above and beyond those placed on traditional pharmacotherapies. For example, participants reported an inability to legally travel with marijuana, resulting in a necessity to switch back to their prescription medication when traveling is unavoidable.

Participants in this study indicated that cost could be a deterrent from wide-spread use because insurance companies do not provide coverage for marijuana. Patients explain that although the cost of marijuana out of pocket is less expensive than traditional prescriptions, because prescriptions are typically covered by health insurance, opioids and other prescriptions are available for a substantially lower cost. However, it could be difficult for insurance companies to contribute to the cost of marijuana when healthcare providers are unable to provide specific recommendations regarding how to best use marijuana medically.

Only a few states require physicians to complete additional medical education (e.g., New York) to provide recommendations for patient marijuana use. In most states, including Rhode Island, those actually dispensing marijuana to consumers (i.e., budtenders) do not require medical education to make recommendations ( Haug et al., 2016). These problematic policies may lead to potentially dangerous and unsubstantiated recommendations unsupported by research. For example, a recent study by Dickson and colleagues (2018) found that the majority of dispensaries in Colorado recommended marijuana products for morning sickness associated with pregnancy even though the American College of Obstetricians and Gynecologists suggest against any marijuana use in women who are pregnant. Findings from this investigation also suggested that these recommendations for marijuana use were based largely on personal opinion and there are currently no regulations for dispensaries providing recommendations or advice to patients in Colorado ( Dickson et al., 2018). The National Academies Press released key recommendations in 2017 in an effort to inform research agendas for medical marijuana. One such recommendation included expanding marijuana-related knowledge among both health care and public health professionals, thus addressing the need for continuing education programs pertaining to medical marijuana ( National Academies of Sciences, 2017). However, this is exceedingly complicated due to the fact that there are hundreds of strains and doses that may be administered in a variety of ways. Furthermore, many participants in the current study indicated that they had to learn how to use marijuana on their own due to the absence of instructions from healthcare providers. Vandrey (2018) states that there is a need to incorporate medical marijuana information in training and continuing education programs for physicians. In order to do so, there must be more data about the health outcomes among marijuana patients in order to evaluate, design, and implement marijuana policy and clinical decision-making ( Vandrey, 2018). Therefore, although our results suggest that patients believe marijuana may be used as an alternative for opioids and other prescriptions, policies regarding use of marijuana for medical purposes must be further investigated and adjusted in order to potentially implement this practice.

There are several limitations that shape the interpretation of these data. First, this is a small qualitative study that does not attempt to reflect the beliefs of the >18,000 medical marijuana users in Rhode Island. The study is also limited to the geographic region of Rhode Island and the sample is primarily Caucasian (68%) and female (60%). A study by Zaller and colleagues (2015) ( n=200) found that within Rhode Island, the median age of medical marijuana patients in 2015 was 41 years of age and patients were primarily male (73%), Caucasian (80%), college educated (68%), and had health insurance (89%). Moreover, due to our inclusion criteria, all participants in this study were current medical marijuana card holders. As a result, we did not collect information from individuals who may be using marijuana for medical purposes without a medical marijuana card, a practice commonly reported in other studies ( Metrik, Bassett, Aston, Jackson, & Borsari, 2018). Thus, additional research inclusive of participants who use marijuana medically but do not have a registration card is needed. In addition, the themes presented herein were emergent and thus not necessarily queried in every interview. Finally, as these data were collected from a sample who already use marijuana for medical purposes and have a medical marijuana registration card, they are likely to hold positive biases regarding marijuana use and the effectiveness of substituting this drug for other medications. Therefore, additional qualitative research is needed among a variety of subgroups, including health-care providers, policy-makers, individuals who are considering use of marijuana for medical purposes, and individuals who attempted to substitute marijuana for other medications but discontinued use, to further probe this practice.

The current findings are informative and suggest that additional research is needed on the effectiveness of substituting marijuana for other medications, and what policy-level factors should be modified to encourage this transition. Larger population-based studies and well-designed clinical trials are needed to examine marijuana as a potential substitution for prescription medications. Lastly, before marijuana can be considered as an alternative for prescription medication, policies that regulate medical marijuana and the associated cost may need to be reevaluated. Nevertheless, this analysis identified important qualitative information regarding use of marijuana as a medication, and contributes a user perspective to the developing literature about marijuana use as an alternative pharmacotherapy.

Acknowledgments

Supported by Grants: K01DA039311

Footnotes

Disclosure Statement: The authors report no conflict of interest.

References

Aston ER, Farris SG, Metrik J, & Rosen RK (2019). Vaporization of Marijuana Among Recreational Users: A Qualitative Study. Journal of Studies on Alcohol and Drugs, 80(1), 56-62. [[PubMed] PMC free article] [Google Scholar]

Bottorff JL, Bissell LJ, Balneaves LG, Oliffe JL, Capler NR, & Buxton J (2013). Perceptions of cannabis as a stigmatized medicine: a qualitative descriptive study. Harm Reduction Journal, 10, 2 10.1186/1477-7517-10-2 [[PubMed] [CrossRef] PMC free article] [Google Scholar]

Coomber R, Oliver M, & Morris C (2003). Using Cannabis Therapeutically in the UK: A Qualitative Analysis. Journal of Drug Issues, 33(2), 325-356. 10.1177/002204260303300204 [[CrossRef] Google Scholar]

Dowell D, Haegerich T, & Chou R (2016). CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR. Recommendations and Reports, 65 10.15585/mmwr.rr6501e1er [[PubMed] [CrossRef] Google Scholar]

Glaser BG, & Strauss AL (2017). Discovery of grounded theory: Strategies for qualitative research Routledge. [Google Scholar]

Goldenberg M, Reid MW, IsHak WW, & Danovitch I (2017). The impact of cannabis and cannabinoids for medical conditions on health-related quality of life: A systematic review and meta-analysis. Drug and Alcohol Dependence, 174, 80-90. 10.1016/j.drugalcdep.2016.12.030 [[PubMed] [CrossRef] Google Scholar]

National Academies of Sciences, E. (2017). The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research Retrieved from https://www.nap.edu/catalog/24625/the-health-effects-of-cannabis-and-cannabinoids-the-current-state [PubMed]

Peters II DC (2013). Patients and Caregivers Report Using Medical Marijuana to Decrease Prescription Narcotics Use. Humboldt Journal of Social Relations, 35(1), 24-40. [Google Scholar]

Rhode Island Department of Health. (2008). Rules and Regulations Related to the Medical Marijuana Program (No. R21-28.6-MMP) Providence, RI. [Google Scholar]

State Medical Marijuana Laws. (2019, March 5). Retrieved April 22, 2019, from http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx

# data[].attributes.attachment_link.title
Marijuana as a Substitute for Prescription Medications: A Qualitative Study

# data[].attributes.attachment_link.description
Over the past few decades in the United States, marijuana for medical purposes has become increasingly prevalent. Initial qualitative and epidemiological research suggests that marijuana may be a promising substitute for traditional pharmacotherapies.This ...

# data[].attributes.attachment_link.title
Medical Marijuana and Parkinson's Part 3 of 3

# data[].attributes.attachment_link.readable_text
There are few subjects that can stir up stronger emotions among doctors, scientists, researchers, policy makers, and the public than medical marijuana. Is it safe? Should it be legal? Decriminalized? Has its effectiveness been proven? What conditions is it useful for? Is it addictive? How do we keep it out of the hands of teenagers? Is it really the "wonder drug" that people claim it is? Is medical marijuana just a ploy to legalize marijuana in general?

These are just a few of the excellent questions around this subject, questions that I am going to studiously avoid so we can focus on two specific areas: why do patients find it useful, and how can they discuss it with their doctor?

Marijuana is currently legal, on the state level, in 29 states, and in Washington, DC. It is still illegal from the federal government's perspective. The Obama administration did not make prosecuting medical marijuana even a minor priority. President Donald Trump promised not to interfere with people who use medical marijuana, though his administration is currently threatening to reverse this policy. About 85% of Americans support legalizing medical marijuana, and it is estimated that at least several million Americans currently use it.

Marijuana without the high

Least controversial is the extract from the hemp plant known as CBD (which stands for cannabidiol) because this component of marijuana has little, if any, intoxicating properties. Marijuana itself has more than 100 active components. THC (which stands for tetrahydrocannabinol) is the chemical that causes the "high" that goes along with marijuana consumption. CBD-dominant strains have little or no THC, so patients report very little if any alteration in consciousness.

Patients do, however, report many benefits of CBD, from relieving insomnia, anxiety, spasticity, and pain to treating potentially life-threatening conditions such as epilepsy. One particular form of childhood epilepsy called Dravet syndrome is almost impossible to control but responds dramatically to a CBD-dominant strain of marijuana called Charlotte's Web. The videos of this are dramatic.

Uses of medical marijuana

The most common use for medical marijuana in the United States is for pain control. While marijuana isn't strong enough for severe pain (for example, post-surgical pain or a broken bone), it is quite effective for the chronic pain that plagues millions of Americans, especially as they age. Part of its allure is that it is clearly safer than opiates (it is impossible to overdose on and far less addictive) and it can take the place of NSAIDs such as Advil or Aleve, if people can't take them due to problems with their kidneys or ulcers or GERD.

In particular, marijuana appears to ease the pain of multiple sclerosis, and nerve pain in general. This is an area where few other options exist, and those that do, such as Neurontin, Lyrica, or opiates are highly sedating. Patients claim that marijuana allows them to resume their previous activities without feeling completely out of it and disengaged.

Along these lines, marijuana is said to be a fantastic muscle relaxant, and people swear by its ability to lessen tremors in Parkinson's disease. I have also heard of its use quite successfully for fibromyalgia, endometriosis, interstitial cystitis, and most other conditions where the final common pathway is chronic pain.

Marijuana is also used to manage nausea and weight loss and can be used to treat glaucoma. A highly promising area of research is its use for PTSD in veterans who are returning from combat zones. Many veterans and their therapists report drastic improvement and clamor for more studies, and for a loosening of governmental restrictions on its study. Medical marijuana is also reported to help patients suffering from pain and wasting syndrome associated with HIV, as well as irritable bowel syndrome and Crohn's disease.

This is not intended to be an inclusive list, but rather to give a brief survey of the types of conditions for which medical marijuana can provide relief. As with all remedies, claims of effectiveness should be critically evaluated and treated with caution.

Talking with your doctor

Many patients find themselves in the situation of wanting to learn more about medical marijuana, but feel embarrassed to bring this up with their doctor. This is in part because the medical community has been, as a whole, overly dismissive of this issue. Doctors are now playing catch-up and trying to keep ahead of their patients' knowledge on this issue. Other patients are already using medical marijuana, but don't know how to tell their doctors about this for fear of being chided or criticized.

My advice for patients is to be entirely open and honest with your physicians and to have high expectations of them. Tell them that you consider this to be part of your care and that you expect them to be educated about it, and to be able to at least point you in the direction of the information you need.

My advice for doctors is that whether you are pro, neutral, or against medical marijuana, patients are embracing it, and although we don't have rigorous studies and "gold standard" proof of the benefits and risks of medical marijuana, we need to learn about it, be open-minded, and above all, be non-judgmental. Otherwise, our patients will seek out other, less reliable sources of information; they will continue to use it, they just won't tell us, and there will be that much less trust and strength in our doctor-patient relationship. I often hear complaints from other doctors that there isn't adequate evidence to recommend medical marijuana, but there is even less scientific evidence for sticking our heads in the sand.

Image: robotboot/Getty Images

About the Author

Peter Grinspoon, MD, Contributor

# data[].attributes.headline
Mayo clinlic study about medical marijuana

# data[].attributes.subject
Mayo clinlic study about medical marijuana

# data[].attributes.attachment_link.title
What you can expect from medical marijuana

# data[].attributes.attachment_link.description
Marijuana is legal in many states to treat serious pain, nausea and other symptoms. How and when it can be used varies by state.

# data[].attributes.attachment_link.readable_text
Show authors

Harm Reduction Journal 18, Article number: 72 (2021) Cite this article

52k Accesses

26 Citations

245 Altmetric

Metrics

Abstract

Background

The use of cannabis as medicine (CaM) both prescribed and non-prescribed has increased markedly in the last decade, mirrored in a global shift in cannabis policy towards a more permissive stance. There is some evidence that cannabis functions as a substitute for prescription drugs, particularly opioids; however, more knowledge is needed on the motives of substitution users, their patterns of use, and perceived effects of substitution use.

Aims

To explore who substitutes prescription drugs with cannabis, the type of prescription drugs substituted and the type of cannabis used, and the impact that substitution with cannabis has on prescription drug use as well as the motives for substitution in terms of experienced effects and side effects.

Methods

A self-selected convenience sample was recruited through social media, public media, and patient organizations to take part in an anonymous online survey. Inclusion criteria were 18 years or older and use of cannabis (prescribed or non-prescribed) with a medical purpose.

Results

The final sample included 2.841 respondents of which the majority (91%) used non-prescribed cannabis, and more than half (54.6%) had used CaM with the purpose of replacing a prescribed drug. Compared to non-substitution users, substitution users were more likely to be women and to use CaM in the treatment of chronic pain and other somatic conditions. Pain medication (67.2%), antidepressants (24.5%), and arthritis medication (20.7%) were the most common types of drugs replaced with CaM. Among substitution users, 38.1% reported termination of prescription drug use, and 45.9% a substantial decrease in prescription drug use. The most frequent type of cannabis used as a substitute was CBD-oil (65.2%), followed by 'hash, pot or skunk' (36.6%). More than half (65.8%) found CaM much more effective compared to prescription drugs, and 85.5% that the side effects associated with prescription drug use were much worse compared to use of CaM.

Conclusion

CaM is frequently used as a substitute for prescription drugs, particularly opioids. More research is needed on the long-term consequences of use of CaM, including the impact from low and high THC cannabis products on specific somatic and mental health conditions.

Background

In recent years, there has been a global shift in perspectives on the utility of cannabis. While cannabis has predominantly been associated with recreational and/or problematic use, the plant or its components, cannabinoids, are increasingly regarded as a viable treatment option for medical conditions, such as chronic pain, spasticity, nausea, and epilepsy [ 1], and as a potential treatment of other conditions [ 2, 3, 4].

The medicalization of cannabis is in large part driven by the discovery of the endocannabinoid system in the late eighties, pharmaceutical interests in cannabinoids, and a growth in user demand for access to medical cannabis (cannabis prescribed by a doctor) [ 5, 6]. This development is mirrored in the rapidly shifting policy on the adoption of medical cannabis laws in more than 30 states in the USA [ 7], Australia [ 8], Canada [ 9] and several European countries [ 10], including Denmark [ 11]. However, the introduction of medical cannabis into medicine is controversial and highly debated. While critics caution use of medical cannabis due to the limited high-quality evidence [ 12, 13], proponents argue that medical cannabis constitutes an important harm reduction strategy and may function as a qualified substitute for prescription drugs, particularly opioids [ 14, 15] in the context of the opioid-epidemic in the USA [ 16] and Canada [ 17].

In drug research, the term "substitution" is conventionally associated with the use of opioid antagonists, such as methadone, in the treatment of opioid addiction [ 18, 19]. The concept of substitution has its origins in behavioral economics and involves the assessment of the interaction of multiple concurrent commodities [ 20]. According to this concept, a substance is regarded as a substitute if it acts as a replacement, or leads to reduced use of another substance (e.g., treating heroin addiction with buprenorphine) [ 21]. Conversely, two substances may be complimentary when the increased consumption of one substance enhances the consumption of the other (e.g., tobacco smoking is often linked to excessive use of alcohol) [ 22]. Lastly, if there is no interaction on consumption patterns between substances, they are independent (e.g., it has been found that a change in price of alcohol has no impact on consumption of ecstasy [ 23]).

Substitution of cannabis for prescription drugs

Emerging research indicates that the increased use of CaM (cannabis as medicine) has had a substitution effect on prescription drug use. In several cross-sectional surveys conducted in the USA and Canada users of CaM report substituting cannabis for prescription drugs, of which opioid, anti-depressive, and anxiolytic drugs are the most prevalent [ 24, 25, 26, 27, 28, 29]. In fact, substitution of prescription drugs is the most common motive among users of medical cannabis, surpassing substitution rates for alcohol and illicit drugs [ 24, 25, 30, 31]. Moreover, state medical cannabis laws in the USA have been associated with a sizeable reduction in prescription drugs [ 32], particularly opioid prescriptions [ 33, 34, 35], and with fewer prescription opioid-related hospitalizations, lower rates of opioid overdoses, and decreases in opioid-related healthcare costs [ 36]. A potential substitution effect of CaM on prescription drug use in a European context is much less explored, and findings from the USA in particular, may not be applicable, due to the considerable variations in health care systems [ 37, 38] and laws on prescription drugs and cannabis. However, a recent Italian study found that an unintended legalization of cannabis products with less than 0.6% Δ-9-tetrahydrocannabinol (THC; main psychoactive component of cannabis) between December 2016 and May 2019 [ 39] was associated with a considerable decrease in pharmacy sales of anxiolytics, sedatives and anti-psychotics, and a moderate decrease in the sale of opioids, anti-depressants, anti-epileptics, and migraine medication [ 40].

When evaluating the harm reduction potential of substituting prescription drugs with CaM, it is relevant to consider the subtype of cannabis used as a substitute. Emerging research shows that potential harms related to consumption of cannabis depend on the composition of active components (cannabinoids) in the cannabis used, as cannabis products with high levels of THC are more harmful in terms of negative impact on cognitive function, anxiety- and psychotic symptoms, and addiction, compared to low THC-products [ 41, 42, 43, 44, 45]. Moreover, other studies indicate that Cannabidiol (CBD; main non-psychoactive component of cannabis) has anxiolytic and antipsychotic effects [ 43, 44, 45], and therapeutic effects on addiction, including opioid, stimulant, and cannabis addiction [ 46, 47]. Further, some evidence suggests that CBD may protect against some of the harmful effects of THC [ 44, 48]. Taken together, these findings highlight the relevance of the subtype of CaM used in an evaluation of potential harm reduction related to the substitution effect of CaM.

Medical cannabis as the "lesser of two evils?"

In light of recent research findings on the substitution effect of CaM on opioid use, CaM has been suggested as a valuable intervention strategy in combatting the ongoing opioid epidemic in the USA and Canada [ 14, 15, 16, 17, 49]. The most frequent rationales behind this suggestion are the substantial evidence that cannabis is effective in treating chronic pain in adults [ 1], the prevalent use of medical cannabis in pain management [ 50], and the fact that, unlike opioids, cannabis has no reported deaths due to overdose [ 51], as acute effects of cannabis do not depress respiratory function [ 52, 53]. The non-psychoactive component of cannabis, CBD, has been of particular interest as a target for opioid use disorder [ 16, 54], as CBD has a discrete modulatory effect on the endocannabinoid system compared to the direct action of THC, giving CBD a broader therapeutic range [ 16]. Also, there may be an opioid-sparing effect of cannabis, as pre-clinical studies show that co-administration of cannabinoids with opioids enables a reduction in opioid dose without loss of analgesic efficacy [ 55]. On the basis of growing indications that cannabis may be a viable tool in targeting the adverse effects of opioid use, some US states have recently modified their medical cannabis laws, allowing patients to substitute their prescribed opioids with medical cannabis [ 56]. What is interesting about this development is that the medical value of cannabis appears to be based not only on what cannabis is, in terms of the available evidence on its efficacy, but also on what cannabis is not, when compared to opioids [ 14, 15, 17]. This perception has also been described in a qualitative study of physicians in Israel, where cannabis was presented as a justified treatment option and as a "the lesser of two evils" by emphasizing problems in standard medications [ 57]. However, opponents of this position argue that the current evidence for the use of medical cannabis is weak, that more clinical trials are needed [ 58, 59], and that other efficacious medications for the treatment of problematic opioid use are under prescribed [ 60]. Furthermore, some evidence suggests medical cannabis may not function as a long-term substitute for opioids [ 61], and cannabis use is associated with increased risk of problematic opioid use [ 62, 63]. Still, despite the recommendations to wait for more valid evidence on the long-term effects of substituting prescription drugs with CaM, several studies indicate that many of the current users of CaM are using cannabis as a substitute for prescription drugs, particularly opioids, and report fewer side effects and better symptom management as their motive for substitution [ 28, 64].

Cannabis as a substitute for prescription drugs in a Danish context

In Denmark, a four year Medical Cannabis Pilot Program (MCPP) was initiated in 2018 with the aim of providing a safe and legal framework for prescribed whole plant cannabis to patients with multiple sclerosis, spinal cord injury, chronic pain, or chemotherapy-related nausea, and vomiting [ 65]. Medical cannabis is not formally categorized in the MCPP as a potential substitute for any prescribed drug, and the Danish Medicines Agency recommends that only patients who have failed to respond to conventionally approved drugs are prescribed medical cannabis [ 65]. Thus, in Denmark, medical cannabis is not officially regarded as a tool to combat misuse of prescription drugs, but instead as a last resort. Despite the changes in policy, there are indications of a large use of medicinal (non-prescribed) cannabis occurring outside the legal framework of the MCPP [ 11]. In the first survey in Denmark on the use of CaM, we recently found that the vast majority of respondents (90.9%) reported use of CaM without a doctor's prescription [ 11]. Moreover, we found that most users of CaM reported limited recreational experience (63.9%) and a preference for low potency CBD-oil (65%) [ 11]. Of note, there are several other indications that cannabis oil has become more prevalent in Denmark in recent years, including a growth in web-shops selling low-potency cannabis oil [ 66], an increase in selling of cannabis oil at the illegal open drug scene Christiania [ 67], and an increase in police confiscations of cannabis oil [ 68]. All use of cannabis outside the MCPP is illegal, both sale and possession, except from cannabis products containing less than 0.2% THC. Such products are illegal to sell if they are considered to be medicine by the Danish Medicines Agency, but they are not illegal to possess [ 69].

The MCPP has set the legal parameters for the utility of CaM in Denmark, but we lack knowledge on the parameters users of CaM set in practice; do they substitute prescription drugs with CaM, and do they perceive CaM to be the lesser of two evils in terms of experienced effects and side effects? Examining the use of CaM as a substitute for prescription opioids is of particular public health interest, in the context of the increased use of prescription opioids in the Danish health care system, which has undergone recent media scrutiny in Denmark [ 70]. As a response, the Danish Medicines Agency started an investigation, which showed that use of the "weaker opioid" Tramadol was driving a substantial part of the rise in opioid use in Denmark [ 70].

Taken together, we lack knowledge about whether the emerging trend of using CaM in Denmark is related to a motive of replacing prescription drugs. Previous qualitative research found that using cannabis as a substitute for prescription drugs was a motive among Danish growers of cannabis for medicinal purposes, particularly opioids [ 71]. However, more knowledge is needed on user perspectives on the utility of cannabis as a substitute for prescription drugs, because user perspectives can unveil aspects of illegal drug use unseen by society at large [ 72]. Also, there is a need for exploring the type of cannabis used as a substitute, as the potential negative health effects of cannabis use varies according to the subtype of cannabis used [ 73]. Finally, the vast majority of studies have been conducted in the USA and Canada, and we lack studies examining potential use of CaM as substitution for prescription drug use in a European context.

Methods

Aims

The aim of the present study was to examine to what extent CaM is used as a substitute for prescription drugs in a convenience sample of Danish users of CaM, and to characterize the substitution users. Furthermore, the study aimed to examine what type of prescription drugs are substituted with CaM, what types of cannabis are used as substitution, and the perceived impact on prescription drug use. Finally, we aimed to compare perceived effects and side effects of CaM compared to prescription drugs used.

Study design

The study was based on data from the first survey on use of CaM conducted in Denmark (for more details, see [ 11]). A novel survey was developed, inspired by previous studies on users of CaM [ 27, 74, 75, 76, 77, 78, 79]. The full survey consisted of 44 structured questions and 19 possible follow-up questions answered in a Yes/No format, multiple-choice response, or rating scales. The survey took about 15 min to complete, and was available in Danish only. Data were collected through SurveyXact. IP addresses of the respondents were not saved or available to the researchers, as the respondent's anonymity was considered a greater issue than the possibility of repeated participation [ 80]. We have previously reported on the motives for use and patterns of use from 3.021 respondents from this survey [ 11].

Sampling and recruitment

The survey was made available online to a self-selected convenience sample of users of CaM from July 14th 2018 to November 1st 2018. Inclusion criteria were being 18 years or older and being a user of CaM, either prescribed by a doctor or non-prescribed with a self-perceived medical purpose. Users of CaM who had stopped using cannabis were included in the sample and characterized as former users of CaM. Participants were recruited via online material, flyers, and posters with information about the survey, and a survey link and QR code directing to the survey. The material was disseminated on social media, through patient organizations, in doctors' offices and hospitals, at the illegal open drug market in Denmark (Christiania), the first Cannabis Expo in Denmark, and via headshops selling cannabis-related items. Furthermore, the survey was made available through Smokeboddy (an app where users monitor potential police presence at Christiania) and was covered by the national media (The Danish Broadcasting Corporation).

Measures

The full survey included several key domains; sociodemographics, motivation for use, patterns of use, and evaluation of perceived efficacy and adverse effects. In the present study, the following domains were used for the data analyses (see description of the remaining measures in [ 11]).

Current and former users of CaM

Respondents were asked an introductory question: Do you use CaM?, and could answer either Yes/No or "I have used CaM, but I stopped". Respondents who answered "Yes" were defined as current users, while those who indicated having past experience with the use of CaM were defined as former users, and those that answered "No" were not included in the study sample.

Users who used CaM as a substitute for prescribed drugs

Respondents were asked if they had experience with using prescription drugs to treat somatic or mental health condition(s). Those who responded positive were asked a follow-up question on whether they had ever used CaM with the purpose of replacing a prescribed drug. Those who answered affirmatively were categorized as "substitution users", while all other respondents were categorized as "non-substitution users."

Type of drug substituted

Respondents were asked which prescription drugs they had replaced with cannabis and were provided with six response categories: Pain-medication, Anti-depressants, Anti-psychotic, Anti-epileptic, Arthritis-medication, and an "Other" category, and could choose more than one category. Each category was followed with an open-ended question, where respondents were encouraged to write the brand of the prescribed drug.

Impact of CaM on prescription drug use

Respondents were asked to evaluate how their use of CaM affected their use of prescription drugs on a 6-point scale from 'use of prescription drugs has increased substantially' (1) to 'use of prescription drugs has decreased substantially' (5), including an option to indicate cessation of prescription drug use; 'I have stopped using prescription drugs' (6).

Effects and side effects

Respondents were asked to evaluate the experienced effects and side effects of CaM compared to the substituted prescription drugs on a 5-point Likert scale from 'CaM is much more effective than prescription drugs' (1) to 'prescription drugs are much more effective than CaM' (5).

Data analysis

Data analysis was conducted using Stata SE/15 [ 81] and Nvivo 12 [ 82]. Figures were produced in Excel 2016 and Word 2016. Descriptive statistics were used to describe sample characteristics, conditions treated, and patterns of use. A histogram was used to assess normality in the variable for a number of conditions. As the variables were not normally distributed, the Mann-Whitney U test [ 83] was used to assess differences in means between substitution users and non-substitution users. We coded a dummy variable, distinguishing between substitution users and non-substitution users, with substitution users coded as 1 (both former and current users of CaM were include). This variable was used as the dependent variable in the logistic regression analysis. Odds ratios (ORs) from multiple logistic regression, controlled for age, gender, and current employment, were used to estimate the strength of association between substituted prescription drug and type of cannabis used. The distribution of the qualitative responses for brands of prescription drugs was quantified in Nvivo 12.

Data management

The 52 conditions that the CaM respondents could choose from, when reporting conditions treated with CaM, were categorized as either somatic conditions ( n = 36) or psychiatric conditions ( n = 13), except for "chronic pain", "sleep disturbances", and "stress", which were kept as independent categories (See "Appendix 2"). In order to explore CBD-oil use only, we coded a dummy variable for use of CBD-oil only (1) and use of other cannabis products (0). Of the 4.570 respondents who opened the survey, 3.140 answered all questions. Of these, 234 were excluded: 59 were under the age of 18, 115 answered on behalf of someone next of kin, seven had inconsistencies in answers, and 53 were identified as duplicates. Respondents with missing responses to the question on substitution as a motive for use of CaM ( n  = 65) were also excluded, leaving a final sample of 2.841.

The specific brand of prescription drugs entered in the open-ended questions was grouped together under their shared active ingredient. Non-specific entries (e.g., "strong pain killers" or "migraine medication") were discarded. All entries for drugs that are also available over the counter (e.g., Ibuprofen or Panodil) were assumed to be obtained via prescription, given the nature of the survey questions. A different approach was taken in the "Other" category, where all entries were coded into new categories. Specific entries such as "melatonin" and "imovane" were coded as "sleep medication" together with non-specific entries, such as "sleeping pills". The most prevalent new categories ( n  > 20) are reported.

Ethics

Respondents consented to participate and could drop out of the survey at any time before completion. Respondents were not compensated for participating. The data used for this study were collected and stored for monitoring on secure servers, and procedures for data handling and storage were approved by the Danish Data Protection Agency. No ethics evaluation was needed under Danish law.

Results

The majority of respondents were female (63.2%), and aged 45 years or older (64.1%) (see Table 1). The most prevalent level of education was "medium cycle higher-education" (28.7%) and "vocational secondary education" (18%). Employment status was mixed with 25.9% in full-time employment, 21.8% on disability pension, and 18.4% in reduced employment. All five regions of Denmark were represented in the study.

The most prevalent type of CaM was CBD-oil (65.1%), followed by "hash, pot or skunk" (36.4%), and THC-oil (24.5%), and oil was the most frequent form of intake (56.4%) (see Table 2). Most users had limited recreational experience (63.5%), and the vast majority were current users (91.1%), with no prescription for medical cannabis (91%). A majority of respondents used CaM in the treatment of a somatic condition (73.3%), followed by psychiatric conditions (37.1%), chronic pain (32.8%), sleep disturbances (27.9%), and stress (24.1%) (See Table 2). The most prevalent somatic condition treated with CaM was osteoarthritis (23.2%), and almost equally prevalent among the psychiatric conditions were anxiety (19.6%) and depression (19.5%).

Table 2 Patterns of use and illness/es treated

CaM used as a substitute for prescription drugs, and substitution user characteristics

The majority (70.1%) indicated that they had experience using prescription drugs in treatment of their condition(s), of which 77.7% ( n  = 1.546) had used CaM with the explicit purpose of replacing a prescribed drug. Thus, substitution users made up more than half of the total sample (54.6%).

The odds of using CaM as a substitute for prescription drugs were 1.25 times greater among women (95% confidence interval (CI): 1.05-1.47, p < 0.05), 2.21 times higher among users on disability pension (95% CI: 1.75-2.80, p < 0.001), and 1.76 times higher among users in reduced employment (95% CI 1.39-2.22, p < 0.001), compared to non-substitution users. Users with access to medical cannabis via prescription were 1.68 times more likely to be substitution users (95% CI 1.26-2.24, p < 0.001), while level of recreational experience was not significantly associated with substitution use (see Table 2). There were no significant associations between using cannabis as substitution and age, education, and region (see Table 1).

Substitution users reported a higher mean of conditions treated with CaM (M 3.6, SD 2.5) compared to other users of CaM (M 3.2, SD 2.5). Substitution users were 1.44 times more likely to use CaM to treat a somatic condition (95% CI 1.21-1.71, p < 0.001), and 2.30 times more likely to use CaM to treat chronic pain (95% CI 1.94-2.72, p < 0.001) compared to non-substitution users (see Table 2). There were no associations between a substitution motive and the use of CaM to treat "sleep disturbances", "stress", or "psychiatric conditions".

Prescription drugs substituted and impact of using CaM as a substitute

Pain medication (67.2%) was the most common type of prescription drug substituted, followed by anti-depressants (24.5%), "other" (24.1%), and arthritis medication (20.7%) (see Fig. 1). Specific brands or classes of prescription drugs were listed 1.887 times, of which 1.246 (66%) were pain medication with Tramadol (27.2%) and Morphine (15.5%) as the most common (see Table 3). In the "Other" category, 432 drugs were listed, and the most prevalent medications were "sleep medication" (16%), "ADHD medication" (13.7%), and "anxiety medication" (8.1%).

Table 3 Five most prevalent classes of prescription drugs substituted with CaM (brands in parentheses)

Among the 1.546 respondents who reported using CaM as a substitute for prescription drugs, the vast majority had stopped using prescription drugs (38.1%) or reduced their use substantially (45.9%). Very few reported a substantial/slight increase in prescription drug use (0.1%) as a consequence of their use of CaM (see Fig. 2).

Type of cannabis used as a substitute

CBD-only users made up one third of all substitution users (36.2%). Substitution users were 1.28 times more likely to use THC-oil (95% CI 1.07-1.53, p < 0.05) compared to non-substitution users, and less likely to be CBD-only users (OR: 0.79 (95% CI 0.67-0.93, p < 0.05). There were no other significant differences in patterns of use between substitution users and non-substitution users (see Table 2).

Type of cannabis used varied depending on the types of prescription drugs substituted (see Fig. 3). CBD-oil was the most prevalent type of cannabis used among those who substituted arthritis medication (74.4%), pain medication (66.6%), anti-epileptics (66.4%), and anti-depressants (60.7%), but not among those who substituted anti-psychotics (42%), where "hash, pot or skunk" were the most common types used (80%). The odds of using "hash, pot or skunk" were 1.45 times higher among users who substituted anti-depressants (95% CI 1.08-1.95, p < 0.05), and 3.37 times higher among users who substituted anti-psychotics (95% CI 1.87-6.08, p < 0.001). Users who substituted pain medication were 1.72 times more likely to use THC-oil (95% CI 1.30-2.27, p < 0.001), and users who substituted arthritis medication were 1.46 times more likely to use CBD-oil (95% CI 1.08-1.98, p  < 0.05).

Proportion of types of cannabis used by respondent in each prescription drug category. ( Notes: * p < 0.05; ** p < 0.01; *** p < 0.001. Covariates controlled for: age, gender, and current employment. For odds ratios and confidence intervals, see "Appendix 1 ")

Experienced effects and side effects

More than half (65.8%) indicated that CaM was a 'much more effective' treatment of their condition(s) compared to prescription drugs. A minority indicated that prescription drugs were 'slightly more effective' (2.2%) or 'much more effective' (1.2%) compared to CaM (see Fig. 4).

When comparing side effects between prescription drugs and CaM, the majority (85.5%) indicated that the side effects of prescription drugs were 'much worse' than the side effects of CaM, and a minority reported that the side effects of CaM were 'slightly worse' (1%) or 'much worse' (0.4%) than the side effects of prescription drugs (see Fig. 5).

Discussion

To our knowledge, the present study is the largest study to date on self-reported use of CaM as substitution for prescription drugs in a European sample. Further, the study is the first to explore the type of cannabis used as a substitute across different types of prescription drugs, providing valuable insights into user perspectives on CaM as a substitute for prescription drugs in treating somatic and mental health conditions.

Our findings show that substitution of prescription drugs is a leading motive among users of CaM in a Danish convenience sample, and that this practice is more common among women, people with reduced working capacity due to illness, and people with chronic pain and other somatic conditions. We found that pain medication by far was the most common type of prescription drug substituted, followed by anti-depressants and arthritis medication, and that Tramadol was the most common class of pain medication that was substituted with CaM. Furthermore, the self-reported substitution effect was considerable, as the vast majority of substitution users reported either a substantial decrease in, or cessation of, prescription drug use as a consequence of their use of CaM. Across prescription drug categories, we found that CBD-oil was the most common form of cannabis used as substitution, except for people who substituted anti-psychotic medicines, where the use of 'hash, pot or skunk' was the most prevalent. A majority of the substitution users reported that CaM was much more effective in treating their conditions compared to the prescription drugs that they had used, and a large majority reported that the side effects from their use of prescription drugs were much worse compared to the side effects when using CaM.

Prevalence of substitution and characteristics of substitution users

Studies from Canada and the USA indicate that use of CaM as a substitute for prescription drugs is prevalent among users with legal access to cannabis [ 24, 26, 27, 28, 30, 64, 84, 85]. Our study adds to this literature by showing that substitution of prescription drugs is also a prevalent motive among users of CaM in a European sample, where the majority of substitution use takes place outside a legal medical setting. While a recent international cross-sectional survey found that substitution of prescription drugs was not significantly related to having legal access to medical cannabis [ 29], we found that users with legal access to CaM were significantly more likely to be substitution users compared to users without legal access. This difference may be partly explained by the fact that in Denmark, legal medical cannabis is only recommended for specific conditions when other treatment options have proven inadequate [ 65]. Our finding that users with limited recreational experience with cannabis are just as likely to use cannabis as a substitute for prescription drugs as experienced recreational cannabis users is in line with previous research on substitution as a motive among prescription CaM users [ 26]. Overall, the present study adds to the growing body of research indicating that use of cannabis as a substitute for prescription drugs is a prevalent phenomenon.

Our finding that women are more likely than men to substitute prescription drugs with CaM resembles previous studies [ 24, 28, 29] and indicates that there may be a more general pattern of gender differences related to the use of CaM. Of note, a cross-sectional survey of cannabis users from the USA found that female users report significantly lower frequency and quantity of cannabis use and significantly higher rate of medicinal use for anxiety, irritable bowel syndrome, nausea, anorexia, and migraines compared to men [ 86]. Further, a qualitative study on legal medical cannabis use, also from the USA, found that gender may influence patterns and practices of use, as the narrative of female users included more collaboration with health care providers compared to the narrative of male users [ 87]. While other studies have found that older CaM users are more likely to be substitution users [ 29], our study showed that a substitution motive of CaM was not significantly related to age. The fact that substitution users in our study were more likely to be on disability pension or in reduced employment may indicate that these people encounter treatment barriers in the healthcare system that 'push' them towards alternative types of treatment. One such barrier could be the cost of treatment, as the current instability in the prescription drug market with large fluctuations in price [ 88, 89] may further an economic substitution motive among some low-income patients. However, the use of unregulated cannabis may still be more expensive for most compared to the price of prescription drugs, as government reimbursement of medicine costs in Denmark are substantial [ 90]. Furthermore, we found that CaM users who treat chronic pain were more likely to be substitution users, which may indicate insufficient treatment options for this patient group, as those suffering from non-malignant chronic pain are potentially undertreated [ 91, 92].

Type of prescription drug(s) substituted and the impact of substitution

Our finding that pain medications, particularly opioids, were the most common prescription drugs substituted with CaM, followed by anti-depressives and arthritis medication, corresponds with our findings on chronic pain, arthritis, and depression as the most frequent motives for use of CaM. These findings reflect findings from other survey studies; in a large international cross-sectional survey on cannabis users, Corroon et al. [ 29] found that opioids (13.6%), anxiolytics (12.7%), and antidepressants (12.7%) were the most common classes of prescription drugs substituted with cannabis, and a Canadian cross-sectional survey of medical cannabis patients found that opioid medications accounted for 35.3% of all prescription drug substitutions, followed by antidepressants (21.5%) [ 24].

The fact that Tramadol was the most common type of prescription drug substituted in our study may in part be explained by the prevalent use of Tramadol in treatment of non-malignant pain in Denmark [ 70]. However, it may also be related to the decision by the Danish Medicines Agency to surveil prescription patterns of Tramadol among physicians in September 2017, following a rise in Tramadol use [ 70] and growing concern among clinicians' regarding the abuse potential of Tramadol [ 93]. It is likely that this decision reduced access to prescribed Tramadol for some patients, who subsequently turned to CaM in order to treat their pain condition. In fact, the number of Tramadol users in Denmark decreased for the first time since 2008 in 2017 [ 94], and continued to decrease from 2017 to 2018 (23% reduction in Tramadol users) [ 95]. Indeed, problematizing and reducing opioid prescriptions leaves a vacuum that may motivate some patients to seek other therapies such as CaM [ 96]. Interestingly, the increased use of Tramadol in Denmark earlier occurred as a consequence of another vacuum in the management of non-malignant pain caused by the problematization of nonsteroidal anti-inflammatory drugs (NSAIDs) and the discovery of serious long-term side effects of these drugs [ 70]. Thus, there seems to be a "cycle of vacuums" in the treatment of non-malignant pain, underscoring the need to rethink the management of non-malignant pain in the Danish health care system [ 92], as this patient group is potentially undertreated [ 91].

Our findings on the cessation of and substantial decrease in prescription drug use show a considerable reported substitution effect related to the use of CaM, which is echoed in other studies on the reported substitution effect of CaM among patients with access to medical cannabis. In a survey of dispensary members in New England, the majority reported a decreased use of opioids (76.7%), anxiety medication (71.8%), migraine medication (66.7%) and sleep medication (65.2%) [ 26]. Similarly, in a survey of American medical cannabis users with chronic pain, the majority of users reported complete cessation of opioids (72%) benzodiazepines (68%), NSAIDs (44%), gabapentanoids (74%), disease-modifying antirheumatic drugs (80%), Serotonin-Norepinephrine Reuptake Inhibitors (78%), and Selective Serotonin Reuptake Inhibitors (80%) [ 28]. The link to a decrease in opioid use has also been shown over time in a small cohort study in New Mexico, comparing 37 chronic pain patients enrolled in a medical cannabis program to 29 non-enrolled chronic pain patients over the course of 21 months [ 35]. Findings from this study showed clinically and statistically significant associations between medical cannabis enrollment and opioid prescription cessation and reduction, as well as improved quality of life. Thus, findings from our study add to the growing body of research indicating that from a user perspective, CaM has a substantial substitution effect for a variety of prescription drugs, most notably opioids.

Type of cannabis used as a substitute for prescription drugs

The findings that, in our sample, CBD-oil is the most prevalent type of cannabis used as a substitute for prescription drugs, and that one third of the substitution users used CBD-oil only, are in accordance with findings from a recent survey of 1.483 medicinal CBD users in the USA where CBD was used as a specific therapy for medical conditions, particularly pain and inflammatory disorders, as well as anxiety, depression, and sleep disorders [ 97]. In the same study, the majority (65.3%) reported that CBD treated their condition(s) moderately or very well without the use of conventional medicine, and 30.4% reported that CBD was effective in combination with conventional medicine. Our findings are also in accordance with a recent Italian study, where the unintended legalization of CBD-based cannabis products with less than 0.6% THC was associated with a significant decrease in the sale of prescription drugs, particularly of anxiolytics, sedatives, and anti-psychotics [ 40]. This is of particular public health interests, as CBD has been shown to have a better safety profile in terms of side effects and abuse potential, relative to THC [ 42, 98, 99]. In line with this, a recent review and meta-analysis of clinical trials found that CBD was well tolerated and had few serious side effects across medical conditions [ 100]. The safety profile of CBD-based cannabis products may also be superior in terms of toxicology and abuse potential compared to some of the prescription medication that is substituted, such as opioids and benzodiazepines [ 49, 52, 53].

From a public health perspective, the problematic aspects of medicinal use of low THC/high CBD cannabis products are also, and maybe more, related to the fact that these products are unregulated and used without medical supervision [ 101]. Indeed, use of unregulated cannabis products increases the risk of consuming hazardous contaminants, such as fungi, bacteria, pesticides or heavy metals [ 1, 102] or consuming a product with undesired psychoactive effects. Interestingly, a recent examination of CBD-oils available in Denmark by Department of Forensic Medicine in Odense, revealed that 38% of CBD-oils tested contained between 0.2% THC and 1.2% THC, despite being advertised as below 0.2% THC1 [ 103]. Thus, users of CBD-oil may unknowingly use products that are illegal to consume.

Our finding that users of CaM, who substituted anti-depressants or anti-psychotics, are significantly more inclined to use "hash, pot or skunk" compared to other substitution users is of particular interest to public health, as the THC content in skunk is high, and the THC content in cannabis resin (hash) and herbal cannabis has increased markedly in the last decades in Europe [ 104] and the USA [ 105, 106]. In Denmark, we found a threefold increase in THC concentration in seized hash from 2000 (mean: 8.3%) to 2017 (mean: 25.3%), while CBD levels remained stable (mean around 6%) [ 107]. This trend is concerning, as increasing evidence suggests that exposure to high-THC and low-CBD cannabis products is associated with higher risk of cannabis-related harms, such as cannabis dependence [ 108, 109, 110], psychosis [ 111, 112], and cognitive impairment [ 99, 113], compared to low-THC and high-CBD products. The magnitude of the problem is further underlined by findings from naturalistic studies on users of smoked cannabis products, which indicate that users do not fully adjust their use to differences in THC concentration, suggesting that users of more potent products are exposed to higher levels of THC [ 114, 115]. Thus, it is possible that use of high THC cannabis products as a substitute for prescription drugs may exacerbate the condition that is the target of the treatment, particularly in relation to treatment of psychotic disorders.

In sum, there is considerable complexity related to the use of cannabis as a substitute for prescription drugs, as an evaluation of whether cannabis is in fact "the lesser of two evils" depends on various factors, such as the cannabinoid composition in the type of cannabis used, the dosage, and the type of prescription drug that is substituted. Recently, another "lesser of two evils"-dynamic is emerging from cannabinoid research, as it is increasingly plausible that low-THC cannabis products are less harmful compared to high-THC cannabis products, and that increased availability of low-THC cannabis products may hold a potential for harm reduction among users of high-THC cannabis products [ 42]. In line with this reasoning, the unintended legalization of low THC-cannabis products in Italy, was not only associated with a significant decrease in prescription drug use, but also with a decrease in confiscations of illegal cannabis and drug-related arrests [ 116], indicating a substitution effect of introducing low THC-cannabis products on the consumption of conventional illegal cannabis products.

Experienced effects and side effects

Findings from our sample show that most substitution users find CaM more effective in managing their condition(s) compared to prescription drugs, and that an overwhelming majority found CaM to have a better side effect profile compared to the prescription drugs that they had been prescribed for their condition(s). This is in line with recent findings from Canada and the USA. In a cross-sectional survey, Canadian medical cannabis users listed, 'relative safety of cannabis to prescription drug', 'fewer adverse side effects' and 'better symptom management' as their top three reasons for using CaM as a substitute for prescription drugs [ 24]. In a survey of medical cannabis patients in California who used cannabis as a substitute/in conjunction with opioid-based pain medication, 80% found that cannabis was more effective than opioids for pain, and 92% that the side effects of cannabis were more tolerable than opioids [ 27]. Moreover, in a survey of American medical cannabis users with chronic pain, respondents listed 'fewer side effects' and 'better symptom management' as their top reasons for using medical cannabis as a substitute for prescription drugs [ 28]. Lastly, a qualitative study on cannabis users in San Francisco showed similar perceptions among substitution users who found cannabis to be a safer and more effective alternative compared to prescription drugs [ 31]. It is interesting that substitution users in our and several other studies rate the side effect profile of CaM higher than its effects, when comparing cannabis to prescription drugs. This suggests that substitution users may have the same " lesser of two evils"-perspective on the medical utility of cannabis that was documented among some physicians in Israel [ 57], where cannabis becomes medicine not only on the basis of what it is in terms of effects, but on what it is not in terms of side effects when compared to prescription drugs. Considering the growth in use of CaM, it is likely that this perspective will result in an increasing number of people seeking information and advice about the effectiveness of CaM and use CaM as a substitute for prescription drugs, even in the absence of rigorous clinical trials and despite lack of legal access to medical cannabis. Future research is needed to assess effects and side effects of long-term use of CaM from longitudinal studies. Furthermore, placebo-controlled clinical efficacy trials are needed to explore the effects of cannabis beyond placebo, and current barriers to whole plant cannabis research need to be addressed [ 1].

Limitations

Our study has several limitations. First, this self-selected convenience sample is limited by selection bias, as it likely weighs towards successful users of CaM, users with internet access, a familiarity with online surveys, users engaged with the topic on social media, and with the resources necessary to answer such surveys. Therefore, the survey may not be representative of the population of CaM users or substitution users [ 117]. Second, the data used in the study may be subject to self-reporting biases, such as recall bias, confirmation bias, placebo effects or social desirability bias [ 118]. For example, users are likely to have optimistic expectations regarding the efficacy of CaM [ 119] and may exaggerate positive effects of CaM or under-report adverse effects. Also, recall bias may be more salient for the small group of respondents who were not current users. Third, although duplicates were excluded from the analyses, we cannot rule out multiple responses from the same person, as IP-addresses were not accessible to researchers. Fourth, the cross-sectional study design lacks a temporal dimension, and we do not know if the reported cessation or reduction in prescription drug use is sustained over time. Fifth, findings on prescription drugs substituted may be skewed by the fact that "sleep medication", "ADHD medication" and "anxiety medication" were not presented to respondents as independent categories. Sixth, the experienced effects and side effects of CaM and prescription drugs could potentially be affected by pharmacokinetic interactions between cannabis products and prescription drugs when taken simultaneously [ 120, 121]. Also, the reported effects and side effects were a mapping of substitution users experiences with various types of prescription drugs and different subtypes of cannabis, which likely vary in terms of effect and side effect profile.

Conclusions

The use of CaM as a substitute for prescription drugs is a leading motive among Danish users of CaM in our sample. Pain medication was the most prevalent prescription drug substituted with CaM, followed by antidepressants and arthritis medication. Tramadol was the most common pain medication substituted with CaM, which may be related to a change in prescription practices for Tramadol in Denmark. Across prescription drug categories, CBD-oil was the most prevalent type of cannabis used as substitution, except for anti-psychotics, where "hash, pot or skunk" were the most common types used, which is concerning due to the high levels of THC, particularly in hash and skunk. Substitution users reported substantial decrease or cessation of prescription drug use, and a greater effect and far better side effect profile of CaM compared to prescription drugs. Thus, from the perspective of substitution users, CaM may be viewed as the lesser of two evils compared to prescription drugs. More research is needed on the long-term consequences of use of CaM, including the impact from low and high THC cannabis products on specific somatic and mental health conditions.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available as it is part of an ongoing PhD project.

Notes

cannabis with less than 0.2% THC is legal to possess.

References

Download references

Acknowledgements

The authors would like to express their appreciation to all respondents of the survey and to those who helped distribute the survey. A special thanks to Professor Vibeke Asmussen Frank for comments on survey design.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The funding source was a PhD project at Aarhus University. The funding source was not involved in the project.

Author information

Authors and Affiliations

1. Center for Alcohol and Drug Research, Aarhus BSS, Aarhus University, Building 1322. Bartholins Allé 10, 8000, Aarhus C, Denmark

Sinikka L. Kvamme, Michael M. Pedersen & Kristine Rømer Thomsen

2. Center for Alcohol and Drug Research, Aarhus BSS, Aarhus University, Artillerivej 90, 2. Floor, 2300, Copenhagen S, Denmark

Birgitte Thylstrup

Contributions

SLK designed the study and wrote the first draft of the manuscript. SLK and MMP conducted the formal analysis. SLK, BT, KRT, and MMP interpreted data and wrote the manuscript. All authors have contributed significantly to the study and have read and approved the final manuscript. CRediT (Contributor Roles Taxonomy): SLK contributed to conceptualization, methodology, data curation, formal analysis, investigation, project administration, visualization, writing-original draft, and writing-review and editing; MMP contributed to methodology, data curation, formal analysis and writing - review and editing; KRT contributed with supervision and writing-review and editing; BT contributed to conceptualization, methodology, supervision, and writing-review and editing.

Corresponding author

Correspondence to Sinikka L. Kvamme.

Ethics declarations

Ethics approval and consent to participate

Respondents consented to participate and could drop out of the survey at any time before completion. Respondents were not compensated for participating. The data used for this study were collected and stored for monitoring on secure servers, and procedures for data handling and storage were approved by the Danish Data Protection Agency. No ethics evaluation was needed under Danish law.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendices

Appendix 1: Odds of substituting the five classes of drugs related to recreational experience and type of cannabis used, controlled for age, gender and employment

Pain medication ( n  = 1.039)

Anti-depressive ( n  = 379)

Anti-psychotic ( n  = 105)

Anti-epileptic ( n  = 134)

Arthritis ( n  = 320)

Other ( n  = 372)

Type of cannabis used

THC-oil

1.72*** (1.30-2.27)

0.91 (0.68-1.22)

0.83 (0.49-1.41)

0.90 (0.59-1.37)

1.19 (0.89-1.57)

0.92 (0.69-1.24)

CBD-oil

1.08 (0.84-1.40)

1.04 (0.79-1.37)

0.75 (0.47-1.20)

1.03 (0.69-1.55)

1.46* (1.08-1.98)

1.11 (0.84-1.48)

Hash, pot or skunk

1.23 (0.92-1.64)

1.45* (1.08-1.95)

3.37*** (1.87-6.08)

0.67 (0.42-1.06)

0.90 (0.66-1.25)

1.43* (1.06-1.95)

Cannabis based medicines

2.68** (1.48-4.88)

1.18 (0.72-1.94)

0.88 (0.37.2.09)

2.59** (1.49-4.51)

1.21 (0.76-1.95)

0.58 (0.31-1.08)

Whole plant

1.65 (0.68-4.01)

0.79 (0.32-1.92)

0.32 (0.04-2.58)

3.28** (1.39-7.73)

1.02 (0.44-2.37)

0.59 (0.22-1.62)

Other

1.17 (0.76-1.81)

1.06 (0.67-1.69)

0.68 (0.27-1.71)

1.11 (0.58-2.12)

1.29 (0.82-2.03)

1.80** (1.17-2.76)

*p < 0.05; **p < 0.01; ***p < 0.001

Appendix 2: All five categories

Somatic condition (36): Acne, Aids, Alzheimer's, Asthma, Chrons disorder, Herniated disc, Dystonia, Eczema, Epilepsy, Endometriosis, Fibromyalgia, Osteoarthritis, Rheumatoid arthritis, Psoriatic arthritis, Cataracts, Hepatitis, Brain damage, COPD, Cancer, FE(chronic fatigue), Chronic nerve inflammation, migraine, Menstrual pain, Multiple sclerosis, Neurodermatitis, IBS, Lupus (SLE), Palliation, Parkinson's, peripheral neuropathy, Psoriasis, Spinal cord injury, pain following operation, pain following an accident, tinnitus, trigeminal neuralgia.

Psychiatric condition (13): ADHD, Anxiety, dependence (alcohol), dependence (hard drugs), dependence (prescription drugs), Anorexia, Autism, Bipolar disorder, Depression, OCD, PTSD, Schizophrenia, Tourettes/tics.

Potential comorbidities (3); Chronic pain, Sleep disturbances, Stress.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Reprints and permissions

About this article

Cite this article

Kvamme, S.L., Pedersen, M.M., Rømer Thomsen, K. et al. Exploring the use of cannabis as a substitute for prescription drugs in a convenience sample. Harm Reduct J 18, 72 (2021). https://doi.org/10.1186/s12954-021-00520-5
Download citation
Keywords

# data[].attributes.attachment_link.title
Exploring the use of cannabis as a substitute for prescription drugs in a convenience sample - Harm Reduction Journal

# data[].attributes.attachment_link.description
Background The use of cannabis as medicine (CaM) both prescribed and non-prescribed has increased markedly in the last decade, mirrored in a global shift in cannabis policy towards a more permissive stance. There is some evidence that cannabis functions as a substitute for prescription drugs, particularly opioids; however, more knowledge is needed on the motives of substitution users, their patterns of use, and perceived effects of substitution use.

# data[].attributes.attachment_link.readable_text
Medical marijuana undeniably provides many health benefits to patients both young and old. As conventional methods and prescription drugs have failed to treat or alleviate debilitating medical conditions, low-THC cannabis and medical marijuana has proved an effective option to provide patients with a naturally therapeutic alternative.

As we get older, our years contain many wonderful memories and experiences, but unfortunately aging also comes with the need to take various amount of pills to take for many situations, which often bring a series of unpleasant side effects. So, it's obvious why more and more people are looking into medical marijuana as a replacement for prescription drugs. Here are the top seven reasons why cannabis is healthier to use than prescription drugs:

1. REPLACES HARMFUL OPIOIDS

Did you know that opioids have the potential to severely damage your essential organs over prolonged use? Additionally, it can contribute to addiction as the body becomes more and more tolerant of the drug or even result in overdose. Patients with severe pain don't have many options. With stronger painkilling capabilities comes possible organ damage, tolerance and addiction. Cannabis medicine works as a safe replacement for opioids without the risk of overdosing. It is extremely unlikely that you would ever ingest or smoke enough marijuana in a short period to actually overdose (you would need to consume about 1,500 pounds in 15 minutes.)

2. LESS DANGEROUS SIDE EFFECTS

While all medications have side effects, some can cause more harm than others. Certain prescription drugs can cause effects like organ damage or addiction. Medical marijuana has side effects, too, but they don't result in long-term damage and can often go away when dosage is adjusted.

3. ADDRESSES SPECIFIC CONDITIONS FOR SENIORS

Even some of the healthiest people begin to deal with chronic conditions as they age. As we get older, we become more susceptible to health problems that have symptoms that are difficult to manage. Fortunately, medical marijuana can assist with alzheimer's, dementia, osteoporosis, chronic pain, arthritis, glaucoma and other ailments that many elderly people suffer from.

4. EASY-TO-ADJUST DOSES AND MEDICATION

Oftentimes the medicine available to you is dictated by your insurance, your doctor and your tolerance to certain side effects. There may be times when none of the medicines are working for you and there are no other options. Also, when you change or stop taking a medicine, you have to ween yourself off or on your dosage before making the switch. However, cannabis comes in a variety of dosages and formulations that patients can easily try out without worrying about withdrawal effects. If a medical marijuana patient experiences side effects such as paranoia or increased fatigue, their doctor can easily reduce the dosage level to the right fit for the patient.

5. MULTI-SYMPTOM RELIEF ALL-IN-ONE

It doesn't matter if you have one medical condition/ailment or multiple, it can take multiple prescription medications to fully address all of your symptoms. Managing multiple medications can easily become expensive and will have you running to the pharmacy frequently. With medical marijuana, you can easily address many ailments, from cancer to epilepsy. One stop at the dispensary lets you get an all-in-one solution for many of your health problems.

6. INCLUDES A MULTITUDE OF OPTIONS FOR INTAKE

Prescription drugs typically only come in a few forms and don't always have alternative options available. However, while cannabis effectively treats many ailments, it can also be consumed in many different ways. If a patient prefers not to smoke, there are capsules, oils and even edibles available as well as many other alternatives.

7. A TREATMENT EXPERIENCE WHERE YOU'RE A PERSON AND NOT JUST A PATIENT

Medicinal cannabis doesn't just offer an alternative medicine - it also involves a compassionate healthcare experience. Since medical marijuana is so versatile and each individual is unique, physicians work one-on-one with you. They look at your specific ailments and determine what would serve as the best way to intake cannabis, especially if your ability to consume medicine in certain ways is limited. Patients can use cannabis as a supplement to their prescription drugs or as a total replacement. Of course, before you make a decision regarding any kind of medicine, consult your doctor first. Do you think you or your loved one might qualify for medical marijuana? If so, you can learn more about what health conditions are eligible under Florida law, see our office policies and fees, find dispensaries or request an appointment at Pensacola Wellness Solutions here.

# data[].attributes.attachment_link.title
Medical Marijuana vs. Prescription Drugs | Pensacola Wellness Solutions

# data[].attributes.attachment_link.description
Medical marijuana undeniably provides many health benefits to patients both young and old. As conventional methods and prescription drugs have failed to treat or alleviate debilitating medical conditions, low-THC cannabis and medical marijuana has proved an effective option to provide patients with a naturally therapeutic alternative.

# data[].attributes.attachment_link.readable_text
Cannabis continues its rise in popularity as more and more states legalize its use either as a medical or recreational drug. Cannabis remains illegal at the federal level, but a number of medical experts and researchers appear to disagree with this decision maintained by the U.S. Drug Enforcement Administration (DEA).

While more peer-reviewed clinical research is needed, myriad studies support cannabis as a legitimate and safe therapeutic substance when used properly under expert supervision. Learn more about the various medical conditions cannabis can help treat, as well as what industry experts have to say about cannabis use.

FEATURED PARTNER OFFER

What Is Cannabis?

Cannabis sativa, or cannabis, is a complex plant that belongs to the Cannabaceae family. It contains about 540 chemical compounds, including more than 100 cannabinoids, the most well known of which are tetrahydrocannabinol (THC) and cannabidiol (CBD).

The term "marijuana" typically refers to components of the cannabis plant that contain significant amounts of THC. Meanwhile, hemp describes components of cannabis plants that contain less than 0.3% THC by dry weight, according to the federal U.S. government.

THC is the compound that gives cannabis its reputation as an intoxicatingly psychoactive drug because of the feelings of euphoria, decreased anxiety, and increased relaxation it elicits. THC and other cannabinoids found in cannabis plants can have psychoactive effects on the human body due to how they interact with the endocannabinoid system, which regulates pain, appetite and the response to stress, says Daniele Piomelli, Ph.D., director of the Center for the Study of Cannabis at the University of California, Irvine.

Potential Health Benefits of Cannabis

New research supports a number of potential health benefits of cannabis containing THC (as opposed to containing CBD exclusively).

Managing Chemotherapy Side Effects

The U.S. Food and Drug Administration (FDA) approved several prescription drugs featuring synthetic substances similar to THC to help people navigate the uncomfortable side effects often experienced with cancer chemotherapy. Marinol and Syndros both contain dronabinol (synthetic THC), which is used to treat nausea and vomiting. Meanwhile, Cesamet contains nabilone, another synthetic substance similar to THC, and is also used to address nausea and vomiting, as well as loss of appetite and weight in patients with HIV/AIDS.

Managing Multiple Sclerosis Spasticity

Sativex, an oral spray medication available by prescription, contains both THC and CBD and is used in 25 countries to help treat muscle stiffness and spasms caused by multiple sclerosis. In Canada specifically, Sativex is used as an adjunctive treatment (alongside a primary treatment) in adult patients who haven't responded well enough to other therapies and show meaningful improvement during an initial trial with the drug. In the U.S., Sativex is still being tested as a treatment for adults with multiple sclerosis spasticity.

Addressing Chronic Pain

Evidence suggests medications that combine THC and CBD can be effective treatments for chronic pain, particularly neuropathic pain (pain caused by nerve damage), nociceptive pain (pain caused by ongoing inflammation and related damage) and nociplastic pain (pain arising from the altered function of pain-related sensory pathways), according to a 2022 review of clinical research in Inflammopharmacology. The researchers add that this combination of cannabinoids tends to be more easily tolerated, safer and less addictive than opioid-based analgesics.

Improving Sleep Quality

A 2018 study in Sleep found participants with obstructive sleep apnea (OSA) who took dronabinol (synthetic THC) before bed experienced a reduction in the number of times their breathing was interrupted during sleep. The 10-milligram dose performed better than the 2.5-milligram dose and placebo. Participants also experienced stronger sensations of sleepiness.

Another 2014 study in the Journal of Clinical Sleep Medicine also observed an association between dronabinol use and improved sleep metrics in patients with OSA.

More Potential Health Benefits of Cannabis

Krissy Bernazani, registered pharmacist and clinical director at medical cannabis dispensary Zen Leaf Maryland, says the most common health and wellness needs she and her team address with cannabis include:

Bernazani adds that many medical cannabis patients turn to cannabis after failing to find relief with other more traditional pharmaceuticals.

Potential Health Risks of Cannabis

Health care providers and cannabis experts stress that the general safety profile of cannabis is unlike most other drugs, including many legal pharmaceuticals. Still, cannabis use can cause short-term and long-term effects in different populations depending on the type and amount of cannabis used.

Side Effects

Consuming excessive amounts of THC may lead to side effects including:

Adverse side effects are more common in women, according to Dr. Piomelli. A small number of inexperienced users may experience vomiting, he adds, which can be treated easily with a hot shower or putting hot chili pepper ointment on the skin.

Smoking Risks

Smoking cannabis ( or any other substance, for that matter) poses a risk for people with pulmonary disease, adds Bernazani. When mixing cannabis and tobacco together, a person also assumes the risks associated with tobacco use, such as lung, head and neck cancer, warns Brooke Worster, M.D., chief medical consultant at Ethos Cannabis and assistant professor at Thomas Jefferson University.

Vulnerable Populations

For growing adolescents, it's unclear how regular cannabis use may alter their bodies and brains-perhaps forever, says Dr. Piomelli. Similarly, little clinical data exists to address how general cannabis use could affect a pregnant person and their fetus(es), he adds. Smoking cannabis is linked to smaller fetus size, although it's unclear whether the act of smoking or cannabis itself is responsible for this observation. Regardless, Dr. Piomelli cautions against regular cannabis use in both of these populations.

THC may also exacerbate symptoms of schizophrenia and other forms of psychosis in people already predisposed to such psychological conditions.

Drug Interactions

Cannabis may produce adverse effects when interacting with other drugs a person may already take, such as warfarin (a commonly prescribed blood thinner), certain chemotherapy agents, anti-seizure medications, anti-rejection medications used after a transplant surgery or other medications with a "narrow therapeutic index," warns Bernazani. Drugs where small differences in dose or blood concentration can lead to serious therapeutic failures and/or adverse, life-threatening reactions have a narrow therapeutic index, according to the FDA.

FEATURED PARTNER OFFER

25% Off All Products With Code FORBES

How Sourcing Can Affect Cannabis Quality

It's crucial to pay attention to the source from which you buy your cannabis to ensure that you're consuming safe, well-tested products.

"Getting cannabis from regulated state dispensaries certainly adds reliability to the composition and quality of the products," says Dr. Worster. "They must be tested and labeled so you know what's in them." Buying products online, from retail food stores or otherwise doesn't provide that same level of quality control. In doing so, a person risks purchasing a product containing potentially harmful undisclosed ingredients or substances, such as butane, propane and brodifacoum.

National cannabis provider Verano is an example of the level of quality and transparency a person should look for when purchasing any cannabis product. "Our seed-to-sale operations are specifically structured to maintain clarity, consistency and quality across the 13 states we currently operate in," says George Archos, founder and chief executive officer of Verano.

During a visit to Verano's New Jersey facility, Forbes Health learned that Verano clones its existing cannabis plants rather than growing them from new seeds each time to maintain consistency across products made from the plants. All products are then chemically tested by a third-party, state-accredited laboratory to confirm levels of THC, CBD and other cannabinoids in the products, as well as disclose the presence of any heavy metals, pesticides and molds. Verano publicly shares full reports of these results on each of its products in documents called certificates of analysis (COAs).

A Word of Caution

Cannabis farming and product manufacturing lack federal guidelines and fixed medical and recreational use regulations from state to state, leading to varying levels of quality and questions of safety.

For the best experience, visit a licensed dispensary and speak directly with a budtender, a cannabis expert who works at the dispensary, recommends Mack Hueber, president of New York-based cannabis beverage company Ayrloom and chief financial officer of its parent company Beak & Skiff. "Everyone has a different reason to consume cannabis," he says. "[Budtenders] know the brand, and they know all the products they're carrying. They [can] work with the customer to understand what they're looking for."

Your Gateway To Relaxation And Restful Nights

Unwind the mind with CBDfx Calming Tincture, featuring full spectrum CBD and CBN designed to help calm you down during the day or help prepare you for a good night's sleep.

Forbes Health covers CBD and cannabis products in accordance with FTC guidelines. Learn more about Forbes Health's practices and policies regarding how we cover CBD and cannabis as a publisher.

# data[].attributes.attachment_link.title
Health Benefits Of Cannabis, According To Experts

# data[].attributes.attachment_link.description
Learn more about the various medical conditions cannabis can help treat, as well as what industry experts have to say about the benefits of using it.