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Beyond the high: Mapping patterns of use and motives for use of cannabis as medicine

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Official websites use. Share sensitive information only on official, secure websites. Sinikka L. Email: slk. In Denmark the boundaries between cannabis as an illicit drug and licit medicine have shifted rapidly in recent years, affecting also policy. However, the vast majority of Danes, who use cannabis as medicine CaM continue to rely on the unregulated market for supply. This study explores patterns of use and motives for use of CaM in Denmark. An anonymous online survey was made available to a convenience sample of users of CaM from July 14, to November 1, Participants were recruited through patient organisations, social and public media, and the illegal open cannabis market. Most had no prescription for CaM The most common form of intake was oil CBD oil Most frequent conditions treated were chronic pain Overall, users experienced CaM to be effective in managing somatic and mental health conditions and reported relatively few side-effects. CBD oil only users were more likely to be women, older, have limited recreational experience and have initiated use recently. A new user group has emerged in Denmark that, for the most part, use illegally sourced CaM to treat a broad range of somatic and mental health conditions, often with experienced effect and relatively low level of side-effects. The prevalent use of low-potency CBD oil indicates an interest in effects beyond the high normally associated with cannabis use. More clinical research into the effects and side-effects of CaM is needed to draw the boundaries of the medical utility of cannabis. Keywords: cannabis, CBD, medical cannabis, medicinal cannabis, motives for use, user patterns. In Denmark, the user demand has been a substantial factor in the public health debate, and in shaping the current cannabis policy. For years, patient organisations have advocated for access to medical cannabis i. In November , a large majority of the Danish parliament agreed to initiate a four-year medical cannabis pilot programme MCPP from January Thus, the MCPP marked a paradigm shift in Denmark, as it gave selected patient groups access to the cannabis flower as medicine, and from January to July , 2, patients have been included in the trial Danish Health Data Authority, b. However, several factors indicate that the vast majority of cannabis consumption with a medical purpose still occurs outside the safe and legal framework that the MCPP intended to create. Moreover, there are several Danish social media support groups offering guidance in medicinal use of cannabis oil. Users of cannabis oil are in a legal grey area, as sale and possession of a cannabis product with less than 0. The Danish Medicines Agency estimates that most cannabis oil sold online, containing less than 0. In order to evaluate the public health effects of the current use of CaM and to qualify future cannabis policy, two areas are important to investigate: patterns of use and motives for use. Patterns of use are important, due to the complexity of the cannabis plant and the various forms of intake, resulting in diverse effects of using CaM. To date, cannabinoids and non-cannabinoids have been identified Bonn-Miller et al. Moreover, the effects of cannabis use depend on mode of intake Newmeyer et al. An equally important area to investigate is motives for use, as it is relevant to know which conditions and symptoms drive some users to disregard advice from the medical authorities in Denmark and consult an illegal market for medicine. Users of CaM risk stigmatisation Satterlund et al. Motives for both medicinal and medical cannabis use have been explored on a larger scale in the United Kingdom Ware et al. The current body of scientific literature on the health effects of cannabis and cannabinoids has set the parameters for the legal use of medical cannabis in Denmark, but we lack knowledge about the parameters set by both the medical and medicinal users in practice. This is important, as user perspectives are instrumental in elucidating perspectives on cannabis use unseen by society at large Dahl, ; Hakkarainen et al. To our knowledge, the use of CaM in Denmark has, until now, only been explored in selected samples, i. It is of particular public health interest to study the use of low-potency CBD oil with a medical motive. In recent years, there has been a dramatic increase in the availability of CBD-based cannabis products globally, while regulatory control is lacking Hazekamp, ; Manthey, However, to our knowledge, there are no systematic studies on users of CBD products in Europe. The aim of this study was to characterise the users of CaM in Denmark, and to map patterns and motives related to the use of CaM. An additional aim was to explore user characteristics of those who use low-potency CBD oil only. The present study is part of a larger study on the use of CaM in Denmark. Questions used for the current study involved six key domains: sociodemographics, motivation for use, duration and frequency of use, method of administration, evaluation of experienced effect, and adverse effects. The questionnaire took approximately 15 minutes to complete, and was available in Danish only. Data were collected through Survey-Xact. The survey was made available online to a self-selected convenience sample of users of CaM from July 14, to November 1, Inclusion criteria were age 18 years or older and being a current or former user of CaM it was possible to answer on behalf of someone else — next of kin. Participants were recruited online and via flyers and posters containing survey information, a survey link and QR code. Additionally, the survey was made available to users of Smokeboddy an app where users monitor potential police presence on the illegal open drug market in Christiania and the survey was reported on by the national media, The Danish Broadcasting Corporation. Previous studies have found Facebook to be a valuable recruitment tool in hard-to-reach populations Weiner et al. Respondents were presented with a list of cannabis products, and could choose more than one. Respondents were presented with a list of forms of most frequent intake, and could choose only one. All users were asked to indicate their daily dose of cannabis, either as drops of oil or grams of plant matter. Respondents were presented with a list of 52 somatic and mental health conditions, and asked to indicate conditions for which they used CaM. Respondents were asked if they had used CaM with the purpose of replacing a prescribed drug. Respondents were asked which side-effects they had experienced when using CaM, and were presented with a list of 18 potential side-effects. Further, respondents were presented with a list of 17 potential symptoms, and asked to indicate on which symptoms they had experienced an effect of CaM. Respondents who indicated that CaM had an effect on relief from sleep disturbances were ask to report the increase in number of hours slept. Means with standard deviations and simple proportions were used to describe respondent characteristics, patterns of use and motives for use. The overall experienced effect of CaM was calculated by dividing the total experienced effect by the total number of conditions reported. Shapiro-Wilks tests were used to assess normality before choosing a test for comparison of means. As none of the variables were normally distributed, the Wilcoxon signed-rank test was used to assess the difference between means related to experienced effect of CaM on sleep and pain. We coded a dummy variable on CBD oil only use, distinguishing between those who exclusively used CBD oil and those who used other forms of cannabis, with CBD oil only coded as 1. This variable was used as the dependent variable in the logistic regression analysis. Odds ratios OR s were used to estimate the strength of association. All data collected were anonymous. Participants could withdraw from the survey at any time before completion without any data being included in the results. Participants who agreed to be contacted at a later stage for participation in a qualitative interview were asked to list their contact information. Data were stored on secure servers, and procedures for data handling and storage were approved by the Danish Data Protection Agency. Since the data used for this study were collected and stored for monitoring, no ethics evaluation was needed under Danish law. A total of 4, respondents opened the survey, and 3, answered all questions. Of these, respondents were excluded: 59 were under the age of 18 years, seven respondents had inconsistencies in answers, and 53 were identified as duplicates, leaving a total number of respondents of 3, see Table 1. More than half of the sample were women Current employment status was mixed, and the most prevalent categories were full-time employment More than a quarter of respondents had a medium-cycle higher education All five regions in Denmark were represented relative to the total sample size. About one third of the sample The total proportion of the sample who reported inhalation as the most frequent form of intake either smoke or vapour was The majority A majority of the sample Almost half Most of the respondents Of those with a prescription for CaM, Of those without a prescription, Of the THC oil users, The mean for THC oil was The mean daily dose indicated by THC users was 6. Users of plant material hash, pot, skunk reported means ranging from 1. The most frequent conditions treated with CaM were chronic pain Mental health conditions, such as anxiety Pain-related conditions such as fibromyalgia Further, 7. A large majority indicated treating a somatic condition with CaM A majority In total, the respondents reported using CaM for 9, conditions, with a mean of just above three conditions per respondent M 3. The reported mean effect of using CaM for each condition is indicated in Figure 1. The reported mean effect across all 9, conditions was 2. Seven respondents 0. The highest mean effect was reported on alcohol dependence M 3. The lowest mean effects were reported for tinnitus M 1. Almost all respondents In all, 3. Pain The average improvement of 4. An additional A total of There were few significant differences between CBD oil only users and other CaM users with respect to current employment and level of education. Using CBD oil only was negatively associated with duration of use and level of previous experience with recreational use see Table 4. To our knowledge, this is the first study mapping the use of CaM in Denmark. The study shows that users of CaM are far from homogenous when it comes to demographics, patterns of use and motives for use, and that the unregulated use of CaM is associated with treatment of somatic and mental health conditions not included in the MCPP. Most of the users of CaM in our study were women and a majority were 45 year or older. Nearly half of the users had a medium-cycle higher or a vocational secondary education, and employment status was diverse and nearly evenly distributed between full-time employment, disability pension, reduced employment, and retirement. Most of the users of CaM had initiated use within the last two years and a majority had little to no previous experience with recreational cannabis use. Furthermore, few had a prescription for CaM and more than one third of those with a prescription supplemented their use with cannabis from the unregulated market. Oil was the most frequent form of intake and CBD oil was the most frequent form of cannabis used. CaM was used for a variety of somatic and mental health conditions, of which the most prevalent were chronic pain, sleep disturbances, stress, osteoarthritis, anxiety and depression. Most users experienced substantial symptom relief from using CaM, limited or no side-effects and a positive impact on daily life function. CBD oil only users were more likely to be women, older, have initiated use recently and have no recreational experience. The study resembles previous studies in terms of recruitment strategies and findings on motives for use, but differs from some studies in terms of demographics and patterns of use. Two studies Lintzeris et al. The difference in samples and study findings is likely to reflect the rapid change in the use of CaM, due to the increasing popularity of medicinal use of CBD oil see also Hazekamp, ; Manthey, These findings match the findings from our study, where the odds of using CBD oil only were higher among women and increased with age. This discrepancy may be related to differences in setting related to use, as Dutch medical cannabis patients have access to medical guidance, while the Danish CaM users self-medicate. It is worth noting that the preference for low-potency CBD oil among the Danish medicinal cannabis users found in this study differs significantly from a recent development on the illegal cannabis market in Denmark. In analyses of hashish seized by police in Denmark we found a three-fold increase in THC concentration from mean: 8. From a public health perspective, it could be considered positive that most medicinal users in our study prefer CBD oil and bypass smoked plant material like hashish, as CBD oil may be less harmful, both in terms of cannabinoid composition Bergamaschi et al. Conversely, it has been suggested that the popularity of CBD products may have adverse net public health outcomes, as it may expose a subgroup of the population that otherwise would have remained cannabis novices Manthey, This may indeed be the case in our study, where CBD oil only users were more likely to have been cannabis novices before onset of CaM use. This is problematic as it increases the risk of exposure to undesired euphoric effects among users and could potentially leave the users unknowingly in violation of the Euphoric Substances Act, which prohibits the consumption of cannabis with more than 0. The challenges related to product quality do not only concern CBD oils, but all types of cannabis use, as the products may contain hazardous contaminants related to production fungi, bacteria, heavy metals, growth enhancers or pesticides or marketing lead or glass beads to increase weight or psychoactive substances to increase effect Lenton et al. The risks associated with product quality and marketing are relevant in the public health assessment of the unregulated use of CaM, as they may be particularly problematic in clinical populations Ruchlemer et al. The fact that sleep disturbances and stress were among the most prevalent conditions treated with CaM, may indicate a tendency to manage these conditions without formal medical advice and assistance, or that these conditions are more likely to be underdiagnosed, as they are often co-morbidities of other somatic or mental health conditions Cranford et al. The reported effects of CaM on pain and sleep found in this study were substantial, and while it can be argued that pain is a subjective experience Koyama et al. An improvement in sleep may mediate an improvement in somatic and mental health conditions. A plethora of studies have found that sleep disturbances are associated with an array of disease risk Laposky et al. Indeed, there is an intimate and bidirectional relationship between sleep and emotion Kahn et al. However, research on cannabinoids and sleep is in its infancy, and more research is needed regarding the long-term effects on sleep patterns Babson et al. The use of CaM in treatment of mental health conditions has raised concerns due to the limited scientific support for such use, for example regarding anxiety and depression Black et al. However, the current evidence is primarily based on observational and epidemiological studies on non-medical use of cannabis and may not be generalisable to the clinical implications of medical cannabis use in treatment of mental health disorders Walsh et al. Importantly, research shows that the clinical implications of medical cannabis use are related to patterns of use, due to the opposing effects of THC and CBD Boggs et al. Consequently, more research is needed into the safety and effects of subtypes of cannabis. The current re-medicalisation of cannabis has prompted Danish politicians to push the boundaries between cannabis as an illicit drug and as a licit medicine, with the initiation of the MCPP. It is also striking that the most prevalent conditions reported in our study chronic pain, sleep disturbances, stress, arthritis, anxiety, and depression differ from the recommended conditions in the MCPP, except for chronic pain. It could be argued that the need for safe and legal access to medical cannabis is relevant for other patient groups than the patients who are currently included in the MCPP. Conversely, it could be argued that even the current inclusion of chronic pain patients in the MCPP presents a considerable problem, as the current evidence does not allow a full recommendation of using CaM in treatment of chronic pain Hoffman, ; Stockings et al. Aside from the limitations of the MCPP in terms of available products and eligible conditions that can be treated, other factors may also contribute to the high rate of medicinal use found in our study, including: limitations on access to the MCPP, fear of stigma, and cost of medical cannabis. For one, access to the MCPP may have been limited, as some Danish GPs may be unwilling to prescribe medical cannabis to their patients. Moreover, fear of stigma has been shown to have a profound impact on treatment-seeking behaviour of potential medical cannabis patients Satterlund et al. Our study indicates that the pressure on politicians to formulate medical cannabis policy remains largely unresolved. Firstly, the majority of users of CaM remain outside the MCPP and therefore they continue to rely on an unregulated illegal market. Secondly, as use of CaM appears to be a growing trend among Danes and as many users find CaM effective in managing their conditions, the demand for safe access to medical cannabis is likely to increase. More clinical research on the effects and side-effects of whole-plant cannabis is needed, as this would allow for a more qualified drawing of boundaries of the medical utility of cannabis. The strengths of the study include the sample size, the wide distribution on age, geography, and the depth of exploration of patterns and motives for use. However, some limitations must be noted. The sample may weigh towards successful users of CaM, as those who have found cannabis either ineffective or experienced adverse effects may have disengaged from the topic. Moreover, the sample may weight towards users with internet access, a familiarity with online surveys, and the cognitive abilities to answer such surveys, and represent a part of the population that is more actively engaged in the topic of CaM on social media. We should also note that the data in this study may be subject to self-reporting biases such as recall bias or social desirability bias Althubaiti, Although duplicates were excluded from the analyses, we cannot rule out multiple responses from the same person. In the interest of mapping this new area in Denmark, we included previous users and answers on behalf of someone next of kin, which may have decreased the validity of the findings. Despite these limitations, the study provides a valuable insight in into the unregulated use of CaM in Denmark. 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 both survey and manuscript. The funding source was not involved in the project. As a library, NLM provides access to scientific literature. Nordisk Alkohol Nark. Find articles by Sinikka L Kvamme. Find articles by Michael M Pedersen. Find articles by Sagi Alagem-Iversen. Find articles by Birgitte Thylstrup. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Used CaM with the purpose of replacing a prescribed drug.

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