This survey provides a number of insights into medical cannabis use within the Australian community and updates our understanding of how consumer perspectives since the introduction of legal access pathways in November 2016. In many respects, little has changed in the two years since cannabis was legalised for medicinal purposes in Australia: users are still largely accessing illicit cannabis, self-medicating a similar range of health conditions (chronic pain, mental health and sleep problems), with similar perceived levels of effectiveness, side effects, and social and issues. The current survey recruited a slightly older (43.4 ± 13.9 compared to 37.9 ± 13.4 years) and more educated cohort than CAMS-16. Respondents reported using cannabis on fewer days in the past 4 weeks (15.8 ± 11.2 compared to 19.9 ± 10 days in CAMS-16), although they spent similar amounts for their medical cannabis, averaging just over AUS$80 per week (compared with under AUD$70 per week in CAMS-16). These differences in participant characteristics may reflect changes in recruitment sources strategies (more Twitter in CAMS-18 than Facebook), and/or may reflect the changing profile of Australian users.
There is little in the current survey results to suggest that two years of legal medical cannabis access in Australia has transformed the ‘landscape’ of medical cannabis. The vast majority of respondents had not used the legal avenues available for prescription, with many respondents perceiving difficulties in finding medical practitioners willing to prescribe, and/or citing cost and stigma as barriers. Whilst few study respondents (n = 25) had accessed legal medical cannabis, those that had generally had more favourable perceptions regarding the legal form of the drug than those who had only ever used illicit forms. Interestingly the majority of the respondents who used licit medical cannabis preferred it to illicit for its cost ease of access, however cost and ease of access were both endorsed as important barriers to accessing licit medical cannabis by respondents who had never obtained medical cannabis legally.
The predominant continuing use of illicit sources reflects the relatively limited uptake of TGA SAS-B approvals prior to the survey11. In the 6 months prior to September 2018, when the CAMS-18 survey opened, fewer than 1200 patients had been granted SAS-B approvals although approximately 3000 approvals were granted during the study recruitment period (September 2018 to March 2019). However, in the 6-month period following the close of the CAMS-18 survey in March 2019 over 13,000 approvals have been granted6. Future surveys will attempt to explore this expansion in regulatory approvals and the impact upon medical cannabis consumers.
Our findings identify ongoing concerns regarding illicit supplies. There was scant knowledge of the composition of the products being used with regard to cannabinoid content (e.g. THC, CBD). This represents a fundamental issue given that the two cannabinoids have quite distinct clinical indications and therapeutic effects. Even for those who thought they knew the composition of their cannabis products, it is worth noting that there is essentially no capacity for consumers to determine the strength or composition of illicit cannabis products in Australia, with no ability for laboratory testing of illicit cannabis products. In a previous study by our group, there was considerable discrepancy between perceived and actual cannabinoid profiles of illicit cannabis supplies used for children with epilepsy12. Similarly, almost two thirds of respondents were worried about potential contaminants. These are not ideal conditions for any therapeutic intervention in a modern healthcare system.
One positive trend in the current survey relative to CAMS-16 is a move away from smoking (joints, bongs) to non-smoked cannabis-based products – with greater numbers in the current survey using vaporisers and oral liquid extracts, a trend also emerging in other countries15 − 18. Whilst any non-smoked route is to be preferred, the apparent proliferation of artisanal medical cannabis producers reiterates concerns regarding quality control and standards of production in illicit operations, as highlighted in recent health concerns regarding vaporisation of illicit cannabis-based products19,20.
Demand for medical cannabis products does not seem to be abating. The experience of consumers surveyed here suggests minimal uptake of licit and prescribed products during the first two years, although there are indications that this is changing. The marked increase in SAS approvals since the close of this survey signals improved access to medical providers willing to engage in this area of medicine – coinciding with the emergence of a number of private clinics specialising in medicinal cannabis, which appears to have markedly increased access to medicinal cannabis products. Our survey indicates that medical practitioners (GPs and specialists) continue to be seen as valued sources of information regarding medical cannabis, although Australian GPs themselves feel relatively ‘under-educated’ regarding medical cannabis19. Finally, whilst most respondents in our survey continued to express disappointment with the legal models of medical cannabis availability, those who had actually pursued the licit avenue reported quite positive experiences.
The study design has inherent limitations, as described previously10. The reliance on self-report data is potentially associated with inaccurate information, such as incorrect diagnostic conditions, recall difficulties, or misinterpretation of effectiveness or adverse events. Furthermore, there is always likely to be a selection bias in any such survey towards recruiting people with favourable experiences of medical cannabis and cannabis legalisation generally. Whilst we were able to reduce the amount of missing data compared to the CAMS-16 survey, we acknowledge that valid responses to all questions were only available for 65% of respondents.