After Legalization
Our results showed that the most common target symptoms were pain (58%), insomnia (42%), anxiety (36%), or nausea (33%). The results of this study are strikingly similar to two 2019 reports from the USA. One report described a retrospective review of ambulatory palliative care clinic patients from New Hampshire and Vermont, and found a 27% current cannabis use rate, primarily for medical purposes. Patients were often treating multiple symptoms: pain (59%), anorexia (19%), insomnia (17%), nausea (16%), anxiety (10%) and depression (6%)[14]. It would be expected that a palliative care population would be more likely to be symptomatic than our unselected cancer centre-attending population, and therefore be more likely to use medical cannabis, yet our study reported the same prevalence and reasons for use. Very similar results were reported in an ambulatory Seattle cancer patient study [15].
Our results showed that current users often used multiple forms of cannabis products, but used oils the most (70%) followed by smoking (64%), eating (48%), vaporizing (33%) and topically (29%). Consistent with the findings in this study, a previous study in the US showed that the prevalence of using cannabis via inhalational and oral routes were equal [15]. The slight differences could be explained by the fact that at the time of this study (the post-legalization survey), the legal sources of gel capsules filled with oil were just becoming available and could possibly have been classified by some respondents as “edibles” rather than oils, whereas most “edibles” were in the form of cookies, brownies and candies which were (and remain) illegal. Legally obtained oils could conceivably have been compounded for topical use by the consumer, but pre-prepared creams, ointments or soft sticks for topical application would all have been illegal.
The similarity in results between studies conducted in the US and Canada suggest that other countries considering legalization can expect similar patterns.
Comparison Between Before and After Legalization Surveys
Comparing our two surveys, we found that legalization was associated with a 21% increase in the prevalence of current cannabis use, from 23·1% to 29·1% (p = 0·01). One explanation for this increase might be that in the run-up to legalization news and media outlets were filled with articles about dispensaries opening and closing,[16–18] products available,[19, 20], and new research[21–24] which may have emboldened more patients to try cannabis. Anecdotally, health care providers involved in cancer care reported a surge of inquiries about medical cannabis use from patients and their families at this time. If the prior medical system of access had been sufficient, we would have expected that any increase in use would have been due to recreational use, which was not the case.
There are no data comparing the prevalence of cannabis use before and after legalization in other jurisdictions.
Despite the increase in current users, the choice of cannabis products used and reasons for use remained the same between both surveys. The consistency between surveys strengthens the suggestion in that cannabis has the potential to reduce polypharmacy by providing patients relief for multiple symptoms.[9] Use of cannabis as a form of cancer treatment also remained one of the most common reasons for cannabis use between surveys.
Our survey identified issues that arose immediately following legalization. We showed that the increase in Current Users was also associated with an increased reporting of difficulty accessing medical cannabis andthat patients had been using the illegal system in preference to the legal system for accessing cannabis for medical needs. Dispensaries and other unlicensed sources were much more commonly used than the legal medical system.
More difficulty accessing medical cannabis after legalization was primarily due to closure of illegal dispensaries, which were abundant prior to legalization, but since legalization were forced to close while waiting for government-issued licenses[25]. Only one Health Canada-approved licensed storefront dispensary was open in BC on legalization day[17].
The second problem was that the new licenses for storefront dispensaries were also supposed to be just for recreational use, and the personnel in the dispensaries were prohibited from providing medical advice. Thirdly, patients could still purchase medical cannabis products online. Patients who had been accessing their product(s) from an unlicensed dispensary would have to negotiate the online system of access, including getting a medical authorization, which is clearly an additional barrier for many, although the process for this was also a barrier to individuals without credit cards, identification, a stable address, etc.
The complexities of two different licensing authorities, and confusion between medical and recreational use made it extremely difficult for patients and health care providers to figure out where to access reliable information and suitable cannabis products for medical purposes. It should be noted that BC was not unique in this respect in Canada[25, 26].
Similarly, respondents from the second survey identified the lack of legalization of certain products (primarily edibles), as their reason for accessibility barrier. Edibles are not the recommended route of administration of medical cannabis due to difficulty with dose labelling and slow time to effect, however this route was listed as the third most often used route of administration among Current Users in both survey cohorts. The lack of provision for this type of product to be available within the medical system caused significant distress for patients.
Implications and Suggestions
Other jurisdictions planning to legalize recreational cannabis should consider the impact it will have on medical cannabis users. Information about medical use should be provided in all vendor locations irrespective of vendor focus. This will require standardized and thorough training of vendors, clear labelling, and provision of appropriate educational materials, as well as public information directed at medical as well as recreational users. In order to ensure that medical users are fully informed about what products to take, in what doses and how often, what side-effects might occur, and counseled to avoid its use for purposes for which there is no evidence of benefit, health care providers will require extensive education. This education should be facilitated by high quality clinical research. Regulators need to be aware that if the process for medical access is made too challenging or stigmatizing, patients will instead use whatever other means to try cannabis that they have access to. Without adequate provision for expected sales after legalization, the ‘black market’ for cannabis products will not disappear quickly.
Strengths and Limitations
Results of this study provide new insights into cannabis use among cancer patients in British Columbia. The design of this study answered the research questions successfully. This study is the first to provide data on the impact of recreational legalization on medical users. Strengths of this study include the close comparability of characteristics among participants in both cohorts, and clear differences between cohorts for the questions exploring the impact of recreational legalization. Open-ended questions in the survey allowed participants to share their experience with regards to barriers in obtaining cannabis, which added depth to understanding of the survey results.
As with the limitations inherent in all surveys, the 27% response rate could reflect a sampling bias and causality cannot be determined. Also, the information was collected by self-report, which could have resulted in an underestimation of cannabis use among participants in the study. There also may have been a recall bias about respondents’ prior cannabis use.