Stigma, risks, and benefits of medicinal cannabis use among Australians with cancer

doi:10.21203/rs.3.rs-3403493/v1

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Research Article

Stigma, risks, and benefits of medicinal cannabis use among Australians with cancer

https://doi.org/10.21203/rs.3.rs-3403493/v1

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Journal Publication

published 27 Mar, 2024

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Purpose

People with cancer who use medicinal cannabis do so despite risks associated with limited clinical evidence, legalities, and stigma. This study investigated how Australians with cancer rationalise their medicinal cannabis use despite its risks.

Methods

Ten adults who used cannabis medicinally for their cancer were interviewed about how they used and accessed the substance, attitudes and beliefs underpinning their use, and conversations with others about medicinal cannabis.

Results

Participants used cannabis to treat a variety of cancer-related symptoms such as pain, poor sleep, and low mood. Cannabis was perceived as natural and thus less risky than pharmaceuticals. Participants legitimised their medicinal cannabis use by emphasising its natural qualities and distancing themselves from problematic users or riskier substances. Cost barriers and a lack of healthcare professional communication impeded prescription access. Similarly, participants navigated medicinal cannabis use independently due to a lack of guidance from healthcare professionals.

Conclusion

Findings highlight the need for robust data regarding the harms and efficacy of medicinal cannabis that healthcare professionals can disseminate to patients who choose to use the substance. Ensuring healthcare professionals are equipped to provide non-judgmental and evidence-based guidance may mitigate potential safety and legal risks.

cancer patient

medicinal cannabis

medical marijuana

Australia

Cannabis is reported to have antispastic, analgesic, antiemetic, neuroprotective, and anti-inflammatory qualities [1] which may benefit people with cancer. However, data supporting the usefulness and safety of medicinal cannabis – hereafter defined as illicit or prescribed cannabis for medical reasons – is limited. Current data consist of brief studies of small heterogenous population that utilise variable cannabis formulations, potencies, and dosing intervals [1–3]. Nevertheless, many Australians report their illicit and prescribed cannabis consumption is for therapeutic reasons [4, 5], and the benefits of self-medicating outweigh the risks of accessing cannabis illegally [6] and the experience of stigma [7]. This indicates that people who use cannabis medicinally for their cancer hold beliefs about its presumed benefits that trump risks associated with legalities, stigma, and limited evidence.

The 2016 amendment to Australia’s Narcotics Drug Act 1967 made cannabis available for specific patients under medical supervision [8]. Currently, only two medicinal cannabis products (Sativex and Epidyolex) are classified as approved therapeutic goods, with remaining products untested for safety, quality, and effectiveness. Australian medical cannabis can contain tetrahydrocannabinol (THC), cannabidiol (CBD), or both [9]. While THC is a psychotropic substance, CBD is non-psychoactive [8]. Healthcare professionals (HCP) can prescribe medicinal cannabis by applying to the Therapeutic Goods Administration (TGA), with most applications made for pain, anxiety, cancer symptoms, epilepsy, and neurological disorders [9]. Although approximately 4500 applications are made per month, Australians report underutilising prescription cannabis [10].

Prescription access is hindered by cost, as no subsidies are currently offered, as well as by difficulties finding prescribers and concerns regarding confidentiality and stigma [10]. Australian HCP are generally supportive of medicinal cannabis but report inadequate knowledge regarding its effectiveness, side effects or interactions, and prescribing protocols, which limit discussions or recommendations regarding its use [11–13]. A lack of communication or nondisclosure with HCPs may compel users to seek information from non-medical sources, including cannabis industry publications, word of mouth, the internet, and cancer support networks. Varying reliability of such sources may threaten safe healthcare delivery, lead to healthcare disengagement, and perpetuate stigma associated with medicinal cannabis [7, 14].

Medicinal cannabis users are vulnerable to stigma as they are often both chronically ill and illicit drug users. Consequently, they may experience shame, guilt, discrimination, or marginalisation [7]. Users report that stigma associating cannabis with escaping reality or getting high undermines its perceived therapeutic legitimacy [7]. In response, medicinal users distance themselves from those they perceive as abusing cannabis by de-identifying from negative connotations and asserting their use as necessary and controlled [7, 15]. Medicinal users also downplay or “neutralise” the risk of cannabis by comparing it to substances they view as more harmful, such as opiates [13, 15, 16]. Efforts to combat stigma reflect the ambiguities associated with cannabis in terms of its therapeutic potential and quasilegal status.

It is unclear how effective cannabis is compared to conventional therapies, and which types are most effective [17]. Adverse events are often minor and well tolerated (e.g., dizziness), but long-term risks are uncertain [2, 18]. Cannabis is associated with a moderately increased risk of chronic mental health issues, neurocognitive impairments, traffic accidents, and respiratory problems [19]. It also poses risks for certain populations, such as psychosis in people with a history of mental health issues, dependency and lower educational attainment among young users, and adverse maternal health outcomes among pregnant users [19–22]. Nevertheless, cross-sectional research has demonstrated that people with cancer use cannabis to treat physical and psychological symptoms [23–27]. Cancer patients also report using cannabis to treat their cancer through presumed anti-inflammatory, apoptotic and tumour suppressive qualities [23, 26], a position with preliminary data but lacking clinical and safety evidence [17, 28, 29].

The aforementioned research highlights that Australians with cancer who use medicinal cannabis not only contend with ramifications of their diagnoses, but potential risks and stigmas associated with their cannabis use. However, little is known about how this population rationalise using cannabis. This study aimed to investigate the normative beliefs encouraging medicinal cannabis use among Australians with cancer. It also sought to understand users’ experience of access, legalities, support, and marginalisation in relation to medicinal cannabis. Findings will help contextualise cancer-related medical cannabis use in Australia, which may inform regulatory and clinical responses by providing information to mitigate risks and support safe use.

This project was approved by Cancer Council Victoria’s Human Research Ethics Committee (#HREC2002). Participants were Australian adults (≥ 18 years) diagnosed with cancer who had used cannabis in any form since their diagnosis and for their cancer. No restrictions were placed on cancer type or time since diagnosis. Participants were recruited through Cancer Council SA and associate organisations via email, social media, and website promotion. Interviews were conducted via phone; verbal consent to participate and be audio recorded was obtained. Questions included demographic and cancer characteristics, followed by open-ended questions about cannabis access, use, beliefs, motivations, and conversations. Interviews lasted approximately 60 minutes. Recordings were transcribed verbatim.

A phenomenological qualitative approach was used to minimise interviewer bias and focus on the voices of people impacted by cancer regarding medicinal cannabis [30]. Two investigators undertook independent thematic analysis using a general inductive approach on two transcripts to establish consensus on a coding framework, after which one investigator coded remaining transcripts. Themes were analysed by frequency and salience (i.e., intensity with which sentiment was endorsed). Data collection ceased when thematic saturation was reached.

Participants

Ten participants completed interviews. There were equal men and women with a mean age of 50 (M = 53.3, SD = 8.9). Participants were in de-facto relationships or single and most lived with family. Participants received their primary diagnosis an average of five years earlier (M = 4.9, SD = 6.1), which comprised cancer of the bowel, skin, oesophagus, stomach, thyroid, breast, and Hodgkin lymphoma.

Reasons for using medicinal cannabis

While most participants first tried cannabis recreationally when younger, they only began using medicinal cannabis regularly following chemotherapy or surgery, or when their cancer metastasised. Medicinal cannabis was used to treat cancer-related pain, poor sleep, mood, appetite, nausea, and cognitive impairment. Two participants commented that medical cannabis had tumour blocking qualities, with one elaborating “I do believe that it has had something to do with my cancers shrinking”.

The most strongly endorsed theme across the interviews was a preference for medicinal cannabis versus pharmaceutical medication. Participants described experiencing less adverse side effects compared to prescribed opiate medications. They mentioned medicinal cannabis was made in “community-based dispensaries” and unlike prescription medications, it was a “natural” or “plant” product:

“I'm not a fan of medications, really. And I will avoid taking them on if I absolutely have to. But I don't mind sitting there and smoking a joint. I think because it's a natural product. So you know, it's grown in the earth and not made in a lab. I feel comfortable using it.” Female, 40s, Hodgkin lymphoma

Such comments were accompanied by sentiments of being “anti-pharma”, with parallels drawn between medicinal cannabis being “the lesser of all evils” versus medications that are “heavily processed”, “completely synthetic” or “put chalk into your body”. Several participants also compared cannabis to alcohol, arguing that “alcohol is more damaging than people smoking a bit of weed”, but is socially accepted:

“I've never been a drinker…Whereas my next-door neighbour, he would drink a dozen beers every day and not smoke. Because of his job that he goes to he gets drug tested every time he goes to work…So he [doesn’t] smoke weed or anything, but he drinks alcohol to excess…he actually openly says, you know, I can drink piss all day… Yet, if I said, I smoke weed all day, you know, I'm gonna get hammered and smoke weed all day. They will probably go fucken hell, he smokes weed all the time.” Male, 50s, myeloma

Participants proposed medicinal cannabis was non-addictive and that people who were addicted had “addictive personalities”. Relatedly, participants de-identified from recreational users, reflecting a discourse of substance use stigma:

“…other people, you know, became a pot smoker and dickhead, and all of a sudden, they're smoking crack…people like that type casts all of us into the same thing. And it's just not the case.” Male, 50s, myeloma

“I'm not off my face.” Female, 50s, breast cancer

“I'd never get into the everyday use or become a pothead.” Male, 50s, bowel cancer

This distinction between who should and should not use cannabis was reiterated by anecdotes shared by participants regarding family and friends who also used medicinal cannabis to treat mental and physical illness. Only one participant discussed a family member who used cannabis for non-medical purposes but described them as a “functioning” and “healthy type of person”.

Access and use

Two participants grew cannabis that they consumed via edibles, tea, vaping, or smoking. The remaining eight participants primarily used CBD oil. These participants, including those using CBD massage oil, consumed it orally, either administered directly via dropper or added to tea or food. One participant used it as a topical massage treatment. Two participants who primarily used CBD oil also smoked cannabis they acquired through friends. Besides the five participants who purchased over-the-counter CBD massage oil, participants acquired it through friends, or both via prescription and illicitly. This latter participant explained illegal access was more affordable than prescription:

“From a price perspective, you know, the bottle was 150 bucks for the prescription. From the dark web, you know, I got 10 times the quantity for half the price.” Male, 50s, melanoma

The cost of legal medicinal cannabis was repeatedly cited by participants as a barrier. Financial difficulties concerned participants, with one commenting they had “gone from a high wage earner to a disability pension”. The cost of medicinal cannabis at a time when they were working less because of cancer was a crucial factor:

“I was told [legal medicinal cannabis] was incredibly expensive. And finances weren't great while I was sick. So I couldn't afford to do it that way.” Male, 50s, stomach cancer

Legal access was also impeded by “red tape” and medicinal cannabis was accessed in ways that maximised cost and ease. Most participants knew of others who had accessed legal medicinal cannabis but felt “the fiery hoops you’ve got to go through is ridiculous”, particularly while navigating cancer:

“When I first got diagnosed, on the legal side of it, there was a doctor that was apparently able to prescribe cannabis and CBD oil. And I started to go down that that process, but I don't know just the red tape, just even with the surgery to get an appointment with the doctor was just all over the place. It got really frustrating.” Male, 50s, stomach cancer

Other participants were unaware that prescribed medicinal cannabis was an option:

“I just assumed I couldn't access it. And only found out since that it was legal at the time, I just didn't know that. And definitely, no one ever mentioned it to me. In terms of any of my doctors or anything.” Female, 30s, thyroid cancer

Most participants limited use to home, but some extended their use to include travel for holiday or treatment. Some participants commented that although earlier recreational use may have involved using cannabis with friends, their current use was private and only when required:

“I don't take it anywhere else, just at home. And not, you know, when people are over. And like I said, it's not every night…only when, I'm in a lot of pain or I have trouble sleeping.” Female, 50s, bowel cancer

Conversations about medicinal cannabis

All participants discussed using medicinal cannabis with others diagnosed with cancer. Conversations focused on reasons for use, advocating for its benefits, and exchanging tips regarding access:

“Since I've had cancer, it's like a club, I would have had maybe 10 people reach out to me to say that they know a source if I felt I needed it.” Male, 50s, melanoma

This informal network was discussed frequently and reinforced the benefits of medicinal cannabis to participants by providing them anecdotal evidence regarding its value. Participants were validated by friends and family, who were supportive of their medicinal cannabis use, and most had not received negative feedback. However, support they received was often qualified by perceived necessity of use:

“Everyone seemed to have the attitude that I was going through something pretty horrible and whatever I needed to do was the right thing.” Female, 30s, thyroid cancer

Participants were cautious about disclosing their cannabis use to preserve privacy or avoid judgment. For some, this restriction extended to their care team, with two participants not disclosing cannabis use to any treating HCP. One participant commented that they withheld this information based on their HCP reactions to other matters, including the COVID vaccine, believing they would be unsupportive of medicinal cannabis. However, disclosure varied by professional and situation:

“I wouldn't discuss it with my GP but when somebody is going to operate on my heart, they need to know.” – Female, 60s, melanoma

The ad-hoc nature by which participants informed medical staff was illustrated by one participant who felt supported by their general practitioner’s awareness but withheld this information from their oncologist as they “didn’t want the negative from him”. This participant then brought medicinal cannabis to hospital but did not disclose this to medical staff.

However, most participants disclosed their medicinal cannabis use to HCP. While some felt they were met with support, other described reactions of indifference or even dismissal:

“…they'd expressed a bit of surprise and went oh well, do what works.” Female, 50s, breast cancer

Navigating use

Participants learned about cannabis through self-directed research via books, documentaries, and online. Their research primarily focused on general knowledge about medicinal cannabis uses, access, dosage, and legalities. However, some participants sought in-depth information regarding growing cannabis, and one relied on independent research for advice on drug interactions:

“I did kind of do a bit more research about that online, read up a whole heap about it at the time…I'm on blood thinners as well, so I needed to check out what sort of likely interactions there may or may not be.” Female, 50s, breast cancer

A trial and error approach was commonly reported, including modifying dosages, consuming cannabis in different forms (i.e., smoking and oil) for specific symptoms, or moderating prescription medication intake. Three participants reported adverse side effects, two of which were a result of trial and error, leading to participants feeling “very, very high” or “too sleepy”. Participants framed their use as only what was needed to treat their symptoms and explained they were “not in it for the buzz” or “not wanting to get high”, echoing earlier distinctions from recreational drug users.

Navigating use around driving was a frequent concern. Participants observed that driving restricted use, and worried about returning a positive drug test. They dealt with this challenge by seeking alternative travel arrangements, limiting products with THC, or restricting use prior to driving:

“I've got a busy week of going places, I take an anti-inflammatory instead. And that's if I have to be driving and stuff. But if it's a quiet week at home, and I don't have to go places, I can safely use the cannabis instead at night.” – Female, 50s, bowel cancer

No participants encountered cannabis-related legal trouble. Some remarked that consuming medicinal cannabis did not impact their driving. Reference was made to alcohol consumption, indicating that perceived punishment for driving under the influence of cannabis was disproportionate to the risk it posed because “it’s just if you have it in your system…even though it’s not affecting you”.

Advocating for medicinal cannabis

All participants agreed medicinal cannabis should be legalised, and most would recommend it to others. This highly endorsed recommendation was based on personal experiences of “how effective it was and what a difference it made” in their lives. However, a few participants qualified their recommendation, proposing that use should be restricted to people “using it for the right reasons” such as “medical conditions and other conditions” or “for health reasons, not just to just go out and walk around getting stoned every day”.

Patients who use cannabis medicinally for cancer rationalise their use by asserting its superiority over pharmaceutical alternatives, highlighting perceptions of greater effectiveness and fewer side effects. They emphasised cannabis’ perceived natural qualities, contrasting descriptions of “synthetic” or “processed” pharmaceuticals. This preference reflects natural bias, a tendency to view “natural” drugs as better and safer than “synthetic” drugs [32]. Natural bias may be detrimental if a prescribed treatment plan is not followed [32], which was observed among participants moderating prescription medication when navigating how much cannabis to take, or bringing cannabis into hospital because they dislike pharmaceutical medication. Preference for the natural qualities of cannabis thus presents potential safety issues among this population, particularly when not discussed with HCP. HCP can mitigate natural bias by providing safety and efficacy information of synthetic versus natural medications to patients [32]. Equipping HCPs to provide such information is urgent, but requires addressing a knowledge gap hindering integration of medicinal cannabis in practice [11–13].

Cannabis was frequently neutralised by users emphasising the harm of other substances, particularly alcohol, which has been observed elsewhere [13, 15, 16]. Participants downplayed cannabis in comparison to alcohol by highlighting that stigma and legalities associated with the former were disproportionate to the risk posed by the latter. Research has indicated that cannabis effects driving less than alcohol [33] but where blood ethanol levels accurately indicate risks, correlations to cannabis is unclear [34]. Comparison to other substances may be problematic if these minimise safety implications of medicinal cannabis. This highlights a need for dissemination of safety information for all consumers, including the majority who are currently accessing medicinal cannabis illegally.

Similar to other research [7, 15, 35, 36], participants distanced themselves from those who purportedly abused cannabis to legitimise their own behaviour. Distinctions of problematic users were characterised by notions of dependency, unnecessary use, and antisocial behaviour. However, identifying necessary versus problematic cannabis use appeared arbitrary, as highlighted by the participant who condoned their family member’s recreational use by describing them as “functioning and healthy”. Attempts to disentangle oneself from problematic cannabis use highlights its pervasive stigma. Ironically, participants seemed to contribute to a discourse of cannabis being potentially problematic, thereby perpetuating stigma.

Our study highlighted considerable risk associated with medicinal cannabis due to ongoing stigma and access barriers. Cost of legal medicinal cannabis was an issue, a barrier cited elsewhere [9]. Out of pocket costs associated with medicinal cannabis use may contribute to financial toxicity, which is frequently experienced by people with cancer and seriously affects health and wellbeing [37]. Participants felt compelled to source cheaper illicit cannabis, introducing legal and safety risks. The purity and potency of illicit cannabis is uncertain, and it may have suboptimal benefits by containing mostly THC, little CBD, and contaminants [9]. Participants were also exposed to safety risks by navigating medicinal cannabis independently, as HCP were uninformed, offered little guidance, or were not consulted. Accounts of HCP indifference and even dismissal in this study raise concerns about patient safety, as does participants’ navigating use through trial and error. As in other research [14, 23], the lack of guidance from HCP likely reinforced the importance of informal support networks, and the need to undertake independent research. Participants in our study generally fared well with use, highlighted through few reports of adverse events and the majority recommending medicinal cannabis. However, their heavy reliance on informal networks and independent research introduces misinformation risks. This highlights a need for robust safety and efficacy data that HCP can utilise to guide medicinal cannabis users, and a need to facilitate open patient-provider communication to minimise potential harms.

Limitations

A strength of this study was that it investigated beliefs regarding presumed efficacy and benefits of medicinal cannabis in relation to cancer, thereby responding to a research gap [38]. A limitation was that, although recruitment was open to any person with cancer who used medicinal cannabis, it may have attracted people who had positive experiences, thereby limiting understanding of negative experiences. Understanding these latter experiences is a consideration for future research. We received little data on adverse events, which may accurately reflect participant’s experiences or be a result of recall bias. A checklist of possible adverse events may have been useful to prompt memory. Finally, as recruitment was online, we were unable to recruit people without internet access.

Australians with cancer who use medicinal cannabis encounter significant stigma and health, social, legal, and financial risks. Nevertheless, they perceive their use as therapeutically beneficial and downplay risks by contrasting problematic users and substances. Findings from this study highlight the need for robust data and information provision concerning the safety and usefulness of medicinal cannabis. Such data are integral to develop healthcare professional knowledge and confidence to facilitate open, non-judgemental, evidence-based conversations with individuals who choose to use medicinal cannabis for cancer.

Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing interests: The authors have no relevant financial or non-financial interests to disclose.

Author contributions: All authors contributed to the student conception and design. Data collection was performed by Dr Jason Blunt. Data analysis was performed by Dr Julia Morris and Dr Jessica Loyer. The first draft of the manuscript was written by Dr Julia Morris and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics: This study was granted ethics approval by Cancer Council Victoria’s Human Research Ethics Committee (#HREC2002).

Consent to participate: Written informed consent was obtained from all participants included in the study.

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No competing interests reported.

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First submitted to journal
01 Oct, 2023

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Stigma, risks, and benefits of medicinal cannabis use among Australians with cancer

Status:

Journal Publication

Version 1

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Method

Results

Participants

Reasons for using medicinal cannabis

Access and use

Conversations about medicinal cannabis

Navigating use

Advocating for medicinal cannabis

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1