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There is a paucity of research on treatment outcomes of patients with psychosis and cannabis use disorder CUD. We aimed to compare the effectiveness of antipsychotics in reducing the risk of hospitalization in patients with first-episode psychosis FEP and co-occurring CUD. We utilized a nationwide Swedish cohort of patients with longitudinal register data from the year to The main outcome was hospitalization due to psychotic relapse. Hospitalization due to any psychiatric disorder or substance use disorder SUD were examined as secondary outcomes. Within-individual Cox regression models were used to study these associations. Clozapine 0. The association between the LAI formulation of olanzapine and hospitalization due to psychosis was statistically non-significant 0. Of oral non-clozapine antipsychotics, aripiprazole was associated with the lowest risk of hospitalization due to psychotic relapse 0. These findings support the use of clozapine, LAI formulations of second-generation antipsychotics other than olanzapine, or oral aripiprazole to prevent hospitalization in FEP and co-occurring CUD. Cannabis use is ubiquitous among first-episode psychosis FEP patients with a significant proportion continuing use after recovery. Real-world treatment outcomes of patients with psychotic disorders and substance use disorder SUD have been examined in nationwide register-based studies. The few existing clinical trials examining the efficacy of antipsychotic drugs in dual disorders have merged groups of patients with psychosis and co-occurring cannabis use or CUD and groups of psychosis patients inflicted by other types of substance use comorbidities. A limited number of antipsychotic drugs were encompassed in this body of literature and only one of these studies focused on FEP specifically. The data utilized contains information on all antipsychotic agents used in clinical practice enhancing the generalizability of the results. To overcome selection bias, a within-individual design is utilized in the main analyses. The study population consisted of all persons aged 16—64 years residing in Sweden with a registered first treatment contact due to non-affective psychotic disorder used as a proxy for FEP ICD codes F2x. Data regarding sickness absences were derived from the MiDAS register, which is managed by the Swedish Social Insurance Agency and provides information on periods during which individuals have received sickness benefits due to health-related incapacity for work. For CUD to be classified as co-occurring, the time of registration of this diagnosis had to be at most two weeks prior or no more than 2 weeks later than the registration of the respective FEP diagnosis. Persons with previous diagnosis of non-affective psychotic disorder since were excluded from analyses. Monotherapies of different antipsychotic agents ATC codes N05A excluding lithium N05AN01 were analyzed by drug formulation, in addition to AP polytherapy concomitant use of two or more antipsychotics. The reference condition or group in each within-person or between-person analysis was the non-use of any antipsychotic. Medications with fewer than 20 outcomes were not reported. The main outcomes of this study were 1 hospitalization due to psychotic disorder ICD diagnoses F2x. ICD codes denoting these hospitalizations inpatient stay at least overnight were obtained from the National Patient Register, a database with nationwide coverage on all specialized inpatient care. The reference category was the non-use of any antipsychotic agents. A within-individual approach was taken to eliminate selection bias. The follow-up time is reset to zero after each outcome event. The stratified Cox models were adjusted for time-varying factors which were the use of other psychotropic medications, time since cohort entry, and temporal order of antipsychotic treatments. Traditional multivariable between-person Cox-regression analyses were also conducted to examine the association between the use of specific second-generation antipsychotics SGAs , ie, olanzapine, quetiapine, risperidone, and aripiprazole , antipsychotic polytherapy, any LAI and other antipsychotics excluding the aforementioned SGA:s with hospitalization due to psychotic relapse. Statistical analyses were performed using SAS version 9. Forest plot figures were created using R version 4. Demographic characteristics of the sample are presented in table 1. The sample totaled individuals At study entry, During the follow-up, The mean follow-up time in this analysis was 6. The number of users, number of events, and mean follow-up times are presented in Supplementary table 1. The results of the within-individual analysis models for SGAs and antipsychotic polytherapy regarding this outcome are presented in figure 1. Long-acting injectable LAI formulations of risperidone 0. Effect sizes for second-generation SGA LAI formulations were uniformly greater than for their respective oral formulations. In contrast to other LAI, the LAI formulation of olanzapine did not reach statistical significance for effectiveness in preventing hospitalization due to psychosis 0. Of oral non-clozapine antipsychotics, aripiprazole was found to be associated with the lowest risk of relapse 0. The effect size of the oral formulation of olanzapine was moderate 0. Quetiapine was not found to be efficacious in preventing psychotic relapse 0. Association of second-generation antipsychotics with subsequent hospitalization due to psychotic relapse. The results of the between-person analyses are presented in Supplementary table 2. The HRs for first-generation antipsychotics with at least 20 events are presented in Supplementary table 3 for all outcomes. The number of users, number of events, and mean follow-up times are presented in Supplementary table 4. Results of the within-individual models for SGAs and AP polytherapy regarding this outcome are presented in figure 2. The lowest risk was found for LAI formulations of aripiprazole 0. The LAI formulation of olanzapine did not reach statistical significance for effectiveness in preventing hospitalization due to any psychiatric diagnosis 0. Of all non-clozapine antipsychotics, oral aripiprazole was associated with the lowest risk of hospitalization due to any psychiatric diagnosis 0. The aHR of the oral formulation of olanzapine was moderate 0. Oral formulations of quetiapine 0. Association of second-generation antipsychotics with subsequent hospitalization due to any psychiatric disorder. The number of users, number of events and mean follow-up times are presented in Supplementary table 5. The distribution of different SUD types for this outcome is provided in the Supplementary table 6. The results of the within-individual model for this outcome are presented in figure 3. Association of second-generation antipsychotics with subsequent hospitalization due to any substance use disorder. This is the first nationally representative register-linkage study focusing on treatment outcomes in first-episode psychosis FEP with co-occurring cannabis use disorder CUD. Most importantly, we found that LAI formulations of second-generation antipsychotics SGAs other than olanzapine were associated with the lowest risk of psychotic relapse and risk of any psychiatric hospitalization, in addition to oral clozapine. Clozapine seemed to be particularly effective in reducing the risk of subsequent SUD hospitalizations. Lastly, oral aripiprazole seemed to be the most effective oral non-clozapine SGA in reducing the risk of psychotic relapses and psychiatric hospitalizations. Only three previously published studies have focused exclusively on antipsychotic efficacy in psychotic disorders with co-occurring CUD. Only one previous study focused on FEP patients and found risperidone to be non-inferior to olanzapine in terms of effectiveness in this patient group. We found LAI formulations of SGAs excluding olanzapine to be equally efficacious as clozapine in reducing the risk of psychotic relapse and any psychiatric hospitalization in FEP patients. A Swedish nationwide register-linkage study focusing on treatment outcomes in persons with schizophrenia with lifetime SUD has been published previously. Also, clozapine was clearly associated with the lowest risk of subsequent psychiatric hospitalization in that study. However, that study cohort comprised of specifically schizophrenia patients, and many of them already had a long duration of illness. This is of significance, as treatment response in antipsychotic therapy is less likely after relapse to psychosis. We found clozapine to be associated with the lowest risk of hospitalization due to SUD. Findings from recent meta-analyses indicate clozapine to be superior to other antipsychotics in reducing substance use 19 and promoting abstinence 21 in patients with psychotic disorders and comorbid SUDs. Clozapine was also found to be superior to risperidone in reducing cue reactivity in a randomized fMRI study focusing on patients with schizophrenia and comorbid CUD. Our finding is also in line with the results of a previously published RCT focusing specifically on change in cannabis use. Switching to clozapine was found to be associated with a reduction of cannabis consumption. However, in another RCT focusing on this outcome, clozapine was not superior to ziprasidone in reducing cannabis use. Patients willing to initiate clozapine treatment may also be more ready to engage in the treatment of their comorbid SUD. Thus, it is possible that the results of clozapine represent a somewhat clinically selected patient group. In line with previous findings, 36 antipsychotic polytherapy was found to be associated with a reduced risk of all outcomes studied. This is of significance, as previous findings on the efficacy of antipsychotic polytherapy have been mixed 37 , 38 and this form of treatment has been discouraged in clinical guidelines. Lastly, aripiprazole was found to be the most effective oral non-clozapine antipsychotic. It has been proposed that patients with dual disorders might benefit from the modulation of dopaminergic pathways induced by partial agonists. Oral olanzapine was the most frequently prescribed antipsychotic in our study cohort. However, it was found to be associated with only a modest risk reduction with respect to any outcome studied. This was surprising, as meta-analytic evidence points to olanzapine and amisulpride to be more efficacious than other non-clozapine agents in FEP. Weight gain is particularly pronounced in young patients using olanzapine, 45 and this adverse effect has been associated with non-adherence to antipsychotic treatment. This study presents with several strengths: Focusing exclusively on co-occurring CUD among persons with FEP is to be regarded as a strength, as cannabis use, in particular, has been associated with more deleterious outcomes than the use of other substances within this population 10 Nationwide register-based data with information on all patients presenting with this type of dual diagnosis and all antipsychotics used provides with exceptional generalizability of these results. The use of within-person analyses reduces the possibility of selection bias. Attrition was small as very few patients emigrated or died during follow-up. However, there are limitations: Not having information on cannabis use trajectories during follow-up is to be regarded as a limitation, as continued cannabis use has been associated with poorer outcomes than discontinued use in FEP. Thus, it is reasonable to believe that a considerable proportion of patients continued their cannabis use after their first diagnosis of psychotic disorder. As underdiagnosis of SUD is common, 47 it is possible that some patients with CUD may have not been included in the study cohort for this reason. As we focused on FEP patients with a diagnosis of co-occurring CUD made in clinical practice, our findings are not necessarily representative of patients with less severe cannabis use. Finally, CUD was defined to encompass all F However, a diagnosis of CIP evidently implies the fulfillment of the criteria of F In FEP patients with co-occurring CUD, LAI formulations of SGAs other than olanzapine were associated with a similarly decreased risk as clozapine in terms of hospitalization due to psychotic relapse or other psychiatric disorders. While clozapine was found to be associated with a substantial risk reduction of subsequent hospitalization due to SUDs, this finding might not be void of selection bias. MDF has received honoraria for educational seminars from Recordati and Janssen. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. HT and AT performed data analysis. All authors approved the final version of the manuscript. Cannabis use in first episode psychosis: meta-analysis of prevalence, and the time course of initiation and continued use. Aust N Z J Psychiatry. Google Scholar. Demographic and clinical correlates of substance use disorders in first episode psychosis. Schizophr Res. Prevalence and impact of cannabis use disorders in adolescents with early onset first episode psychosis. Eur Psychiatry. Substance use disorders before, at and after first episode psychosis hospitalizations in a young national Swedish cohort. Drug Alcohol Depend. Cannabis use and symptomatic relapse in first episode schizophrenia: trigger or consequence? Schizophr Bull. Predictors of psychosis breakthrough during 24 months of long-acting antipsychotic maintenance treatment in first episode schizophrenia. Specific impact of stimulant, alcohol and cannabis use disorders on first-episode psychosis: 2-year functional and symptomatic outcomes. Psychol Med. Cannabis use and clinical outcome in people with first-episode schizophrenia spectrum disorders over 24 months of treatment. Psychiatry Res. Stopping cannabis use benefits outcome in psychosis: findings from year follow-up study in the PAFIP-cohort. Acta Psychiatr Scand. Poor medication adherence and risk of relapse associated with continued cannabis use in patients with first-episode psychosis: a prospective analysis. Lancet Psychiatry. Association between continued cannabis use and risk of relapse in first-episode psychosis: a quasi-experimental investigation within an observational study. JAMA Psychiatry. Cannabis and first-episode psychosis: different long-term outcomes depending on continued or discontinued use. Clinical and treatment predictors of relapse during a three-year follow-up of a cohort of first episodes of schizophrenia. Does a history of cannabis use influence onset and course of schizophrenia? Association of cannabis use with hospital admission and antipsychotic treatment failure in first episode psychosis: an observational study. BMJ Open. Longitudinal assessment of the effect of cannabis use on hospital readmission rates in early psychosis: a 6-year follow-up in an inpatient cohort. Clinical indicators of treatment-resistant psychosis. Br J Psychiatry. Associations between antipsychotic use, substance use and relapse risk in patients with schizophrenia: real-world evidence from two national cohorts. Efficacy, acceptability and tolerability of antipsychotics in patients with schizophrenia and comorbid substance use. A systematic review and meta-analysis. Eur Neuropsychopharmacol. The response of subgroups of patients with schizophrenia to different antipsychotic drugs: a systematic review and meta-analysis. Effects of clozapine treatment on the improvement of substance use disorders other than nicotine in individuals with schizophrenia spectrum disorders: a systematic review and meta-analysis. J Psychopharmacol. A randomized trial of clozapine vs. J Dual Diagn. Olanzapine vs. Ziprasidone versus clozapine in the treatment of dually diagnosed DD patients with schizophrenia and cannabis use disorders: a randomized study. Am J Addict. Natural course of schizophrenic disorders: a year follow-up of a Dutch incidence cohort. Medication for attention deficit-hyperactivity disorder and criminality. N Engl J Med. Stockholm : Swedish Social Insurance Agency ; Google Preview. External review and validation of the Swedish national inpatient register. BMC Public Health. Allison DP. Fixed Effects Regression Models. Does relapse contribute to treatment resistance? Antipsychotic response in first- vs. Effect of long-acting injectable antipsychotics vs usual care on time to first hospitalization in early-phase schizophrenia: a randomized clinical trial. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry. Comparing the effect of clozapine and risperidone on cue reactivity in male patients with schizophrenia and a cannabis use disorder: a randomized fMRI study. Clozapine use and relapses of substance use disorder among patients with co-occurring schizophrenia and substance use disorders. Association of antipsychotic polypharmacy vs monotherapy with psychiatric rehospitalization among adults with schizophrenia. Antipsychotic combinations vs monotherapy in schizophrenia: a meta-analysis of randomized controlled trials. Antipsychotic augmentation vs. World Psychiatry. World Federation of Societies of Biological Psychiatry WFSBP guidelines for biological treatment of schizophrenia, part 1: update on the acute treatment of schizophrenia and the management of treatment resistance. World J Biol Psychiatry. Peris L , Szerman N. Partial agonists and dual disorders: focus on dual schizophrenia. Front Psychiatry. Late reduction of cocaine cravings in a randomized, double-blind trial of aripiprazole vs perphenazine in schizophrenia and comorbid cocaine dependence. J Clin Psychopharmacol. Head-to-head comparison of 1-year aripiprazole long-acting injectable LAI versus paliperidone LAI in comorbid psychosis and substance use disorder: impact on clinical status, substance craving, and quality of life. Neuropsychiatr Dis Treat. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet London, England. Efficacy and safety of individual second-generation vs. Int J Neuropsychopharmacol. Antipsychotic-induced weight gain in chronic and first-episode psychotic disorders: a systematic critical reappraisal. CNS Drugs. Obesity as a risk factor for antipsychotic noncompliance. Comparison of data sources on alcohol problems: an exploratory exercise using surveys vs. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign in through your institution. Schizophrenia Bulletin Journals. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Article Contents Abstract. Conflict of interest. Author contributions. Journal Article. Alexander Denissoff , Alexander Denissoff. Oxford Academic. Heidi Taipale. Department of Clinical Neuroscience, Karolinska Institutet. Jari Tiihonen. Marta Di Forti. Ellenor Mittendorfer-Rutz. Antti Tanskanen. Antti Mustonen. Select Format Select format. Permissions Icon Permissions. Abstract Background and Hypothesis. Table 1. Open in new tab. Demographic Characteristics of Cohort. Open in new tab Download slide. Google Scholar Crossref. Search ADS. Does a history of cannabis use influence onset and course of schizophrenia. Google Scholar PubMed. Issue Section:. Download all slides. 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Cannabis use continues to increase worldwide, and a number of nation states are changing their cannabis policies. Policy changes require research into key populations, namely, people who use cannabis. This study aims to examine sociodemographic differences of young Finns who reported using cannabis mainly for self-medication versus mainly recreationally, as well as their reported effects of cannabis use. The authors focused on whether various demographic indicators differed between those who reportedly used cannabis mainly for recreational purposes and mainly for self-medicinal purposes. Being older and female, living in a smaller city and earlier age of initiation of cannabis use were statistically significant in predicting the medicinal use of cannabis. The majority of recreational effects were related to themes such as relaxation and pleasure, but many participants also reported desired medical effects. Similarly, many participants reported several undesired effects. This study gives a nuanced account of sociodemographic factors and motivations of young people who use cannabis in Finland as well as the reported effects it has on them, which complements data from national drug surveys. Hupli, A. Published by Emerald Publishing Limited. European countries such as Germany, Malta, Luxembourg, The Netherlands and the Czech Republic have implemented or announced plans to legally regulate the non-medical use of cannabis Government of Luxembourg, ; Government of The Netherlands, ; Sabaghi, Recently drug policies have been under debate also in Finland Hakkarainen and Kainulainen, and other Nordic countries Tham, Nordic drug policies are said to be at a crossroad and affected by the situation and development in other European countries Tham, , p. In general, motivations for cannabis use vary; beyond numerous medical indications that cannabis-based medical products have been investigated and used in both clinical research and real-world settings Schlag et al. Studies from North America comparing medical and recreational cannabis users have found that medical cannabis users often report lower use of alcohol and other recreational drugs compared to recreational cannabis users, report more frequent cannabis use, and perhaps not surprisingly, report more health-related problems, both physical and psychological Goulet-Stock et al. Thus, medical and recreational cannabis use are not mutually exclusive, and the use of cannabis for medical reasons often happens without an official prescription, blurring the boundary between medical and recreational use Hakkarainen et al. Cognitive enhancement among university students is also a reported motivation to use cannabis Franke et al. In addition, entheogenic or spiritual use of cannabis has been reported Johnstad, ; Heide et al. Thus, motivations for cannabis use can go beyond merely recreational or medical, as the validated Marijuana Motives Measure developed by Simons et al. Motivations include enhancement, coping, conformity, expansion and social motives Simons et al. It is also important to note that as demonstrated by these different motivations, people who use cannabis do not form a homogenous group, and although we focus on medical and recreational motives and related factors in this study, these groupings are, in part, constructs to aid the data analysis. It has been estimated from the national drug survey data that 2,—5, people in Finland used cannabis mainly for medical reasons but without an official prescription Hakkarainen and Karjalainen, It is likely that this amount has increased since then with the general increase of cannabis use among the Finnish population Karjalainen et al. However, despite medical cannabis being legal to prescribe for over a decade in Finland, practically no domestic clinical research has been done in this field, and prescription prevalence has decreased in recent years from about in to in and to around in Honkasalo, ; Vihervaara and Hupli, Fewer than 50 prescriptions were given in the first half of , as reported in the media Harmaala, This is counter to global trends; for example, in Australia between and , more than , medicinal cannabis prescriptions were approved Henderson et al. In The Netherlands, the number of medical cannabis prescriptions also increased from 6. These comparisons exemplify that taking the country-context into consideration is important when researching medical and non-medical use of various drug technologies Hupli, , including cannabis Hakkarainen et al. This local context would also require research into local use practices, for example, in Finland, smoking has been the most prevalent way of using cannabis Despite the criminalization of use for more than half a century Hakkarainen and Kainulainen, , the prevalence of cannabis use has increased in Finland since the s, especially among young adults Karjalainen et al. Young people, in particular, increasingly perceive that cannabis use should not be punished, and the general perceptions of risks around cannabis use have somewhat abated Karjalainen et al. However, great variability exists, for instance, among age groups. An international cannabis grower study also found that medical growers reported using cannabis more frequently than recreational growers Hakkarainen et al. Our study aims to fill the gap in the research by exploring factors associated with medical and recreational cannabis use. It is important to focus on people who use cannabis in Finland, especially younger people because research about their lived experiences is limited. People who use cannabis continue to have a marginalized position in Finnish society Kekoni, , as do people who use illegalized drugs in general Hakkarainen and Kainulainen, This is reflected in the way young people find it difficult to talk about their cannabis use due to its illegal status because they are afraid it might affect their school, work or private life Holma et al. Our study hence provides further information on this key population. The research questions of this study were as follows: RQ1. What are the main demographic differences between people who use cannabis in Finland for recreational purposes and those who use it for self-medication? The study participants were relatively young Finns. There were Finnish respondents in the data, males, 64 females, 4 missing gender data, 4 who did not want to declare their gender and 2 others. Our study was based on data collected in an evaluation study of the project Intervention for Young Cannabis Users —, funded by the European Social Fund Hupli, The project developed a cannabis mini-intervention model and several other harm-reduction tools for health and welfare professionals see www. The first author designed the study protocol. Data collection was done by an anonymous online survey on the Surveypal platform. It was launched on 17 April and remained open until 31 August The online survey had a national focus, and it was distributed by the first author and two Finnish non-governmental organizations responsible for the intervention project, the Finnish Association for Substance Abuse Prevention and Youth Against Drugs, mainly on social media. However, people over 30 also responded to the survey. These were filtered out in the original evaluation report Hupli, but included in our analysis. The design of the evaluation study and related research ethics were approved by a multidisciplinary steering committee of the mentioned intervention project before launching the study. Participation was voluntary, and they were informed about the aims of the study. Three digital gift cards worth 20 euros were offered as a raffle prize for those who participated. No personal information was collected that could be used to identify the respondents, and the data were kept safe in an external computer requiring a password. We also follow the general guidelines of the international research ethics guidelines e. We provide information on the sample in regard to the most common type of cannabis used in the past month as well as the most common method of use in Supplementary Tables 1 and 2. As these were asked in an extra section of the survey, we were not able to distinguish and compare these use practices between respondents who used cannabis mainly for recreational purposes and those who mainly used it medically. However, we believe this information is valuable to share to contextualize the findings and the sample. However, the main interest of the study relied on the differences between those who use cannabis for mainly recreational purposes and those who use it mainly for self-medication purposes. Independent variables included gender, age, education, city size, frequency of cannabis use, amount used and onset age of use. Thus, the analysis included observations. Similarly, we asked about the quantity they used, with options ranging from 0. The scores were converted to a scale ranging from 1 to 19, with a mean of 6. The respondents were also asked via open-ended questions about their experienced effects of cannabis use in an extra section of the survey. Thus, these qualitative reports could not be coupled with the quantitative data of the survey. The desired effects were categorized based on the content along recreational or medical use. The desired medical effects were categorized under psychological, somatic and psychosomatic effects Table 4. Some respondents also reported undesired societal effects and some did not have or did not report undesired effects Table 5. The exploratory nature of the study includes both qualitative and quantitative methods based on a relatively small sample size. The questionnaire items were designed to better understand the profiles of young people who use cannabis, which resulted in inquiries about their demographic characteristics and cannabis engagement. Statistical models were conducted with multiple logistic regression MLR. The R programme was used to conduct the MLR analysis, and recreational cannabis use served as the baseline for comparison. We also report goodness-of-fit tests and pseudo coefficients of determination. For the respondents, descriptive statistics and unweighted frequency distributions of variables were examined Table 1. Until the age of 24, a majority of respondents said they used cannabis primarily for recreational purposes. No significant difference was observed in the distribution of onset age and monthly usage across cannabis use purposes. Although the mean age of onset for medical cannabis use is slightly lower The Hosmer—Lemeshow test was used for the goodness-of-fit test, which determines whether the observed event rates match the expected event rates in population subgroups Hosmer et al. Results show that the p -value was 0. Out of seven independent variables, four were found to be significant predictors of cannabis use for medical purposes after adjusting for other factors. For gender, after adjusting for all the confounders, the OR was 3. Therefore, the odds of using cannabis for medical purposes are more than three times higher for females than it is for males. Looking at age, after adjusting for all the confounders, the OR was 1. Living in a smaller city is also an important predictor of cannabis use for medical purposes. The OR was 0. The participants were asked through open-ended questions about their desired and undesired effects relating to their use of cannabis. The questions were part of an extra section of the survey and could not be coupled with the quantitative data of the main part. Many respondents listed several desired recreational effects due to which Table 3 showing recreational effects has more categorizations than the total number of respondents. Each response was assigned a maximum of two categorizations. The table shows the categorization percentage in proportion to the number of respondents, and each category is illustrated with example answers that have been translated from Finnish to English by the first author. Similar to reported medical effects, the answers related to undesired effects were thematically grouped as psychological, somatic and psychosomatic undesired effects. Some respondents reported undesired societal effects and some did not report undesired effects. Table 5 shows the categorization percentage in proportion to the number of responses for all reported undesired effects, then those reporting more undesired effects from recreational use and finally, those reporting undesired effects from medical use. These are illustrated with example answers. Proportionally the medical and recreational groups do not seem to differ greatly in terms of undesired effects. Also, qualitatively the reported undesired effects did not differ greatly between the two groups. In relation to psychological undesired effects, impaired memory and increased anxiety were commonly reported by both groups. Dry mouth and eyes, as well as headache, were common undesired somatic effects. Feeling fatigued or tired was also commonly reported, which was categorized under psychosomatic undesired effects. Illegality was the most common societal undesired effect. About a quarter in both groups did not report any undesired effects. What is noticeable is that occasionally the reported undesired effects are the exact opposite of the desired effects. For instance, sometimes when the desired effect is reported to be calming, relaxing or otherwise anxiolytic, the undesired effect is reported to be increased anxiety. In this study, we analysed the demographic differences between young adults who reported using cannabis mainly for recreational purposes and compared them to those who use cannabis mainly for medical reasons in Finland. Our quantitative analysis showed that the sociodemographic factors of being older and female, living in a smaller city and an earlier onset age of initiating cannabis use were statistically significant in predicting motives for medical cannabis use. This finding is somewhat in line with a survey study from Denmark looking at medical cannabis users, which found that especially CBD oil-only users were often older women Kvamme et al. However, CBD oil-only users had initiated their use recently, unlike in our sample, and had little recreational experience. The survey was also directed to Danes who used cannabis as medicine in particular, so it is difficult to make concrete comparisons between the studies. However, as in the study by Kvamme et al. Similarly, many participants from both studies reported undesired effects ranging from psychological ones like memory problems and increased anxiety to somatic undesired effects like dry mouth and headache. The study by Kvamme et al. Sometimes the reported desired and undesired effects were polar opposites, the reported desired effect being, for instance, feeling less anxious while the reported undesired effect was reported as increased anxiety. Several factors influence the effects from cannabis, which is not a single drug as it contains hundreds of chemical compounds Andre et al. While we provide some general information on self-reported types and methods of cannabis use see Supplementary Tables 1 and 2 , we were not able to match these between the groups of users. In addition, the actual consumed cannabinoid content would have remained unknown, not only to us, the researchers, but most likely to the people who use cannabis as well, partly due to its illegal status in Finland and most European countries. Thus, while the information on motives and effects of cannabis use in Finland remains limited, we believe our study can guide future research endeavours and also provide real-world evidence about desired and undesired effects from cannabis use and the often blurred boundary between recreational and medical cannabis. The results, in part, confirm the blurred boundary between recreational and medical use of cannabis found in earlier studies Hakkarainen et al. For instance, several participants in our study reported medical use mostly or primarily as their motivation to use cannabis and experienced a variety of desired medical effects. This was despite the relatively young age of the participants, although motivation for medical use also increased with age. Nonetheless, young people who use cannabis are often not seen as potentially using cannabis for medical purposes, which is an important factor to consider also from a harm reduction perspective. Motivating someone to stop using cannabis, or at least use less, can be challenging if there are perceived medical benefits from that use. This shows that the line between medical and recreational use, in general, is not clear-cut; young people often try to balance between desired and undesired effects of a variety of psychoactive drugs, including cannabis Hupli et al. People who use cannabis often report both medical and recreational cannabis use motives Ogborne et al. Young people have perceptions in relation to cannabis and what works in terms of drug prevention that should be considered when designing prevention and harm reduction programmes as well as treatment services Canadian Centre on Substance Abuse, ; Hupli, ; Holma et al. Although survey studies on this issue are mixed Chong et al. However, they did find increased alcohol and tobacco use Vanderbruggen et al. In Finland, Oksanen et al. While our study remains speculative on this issue, the impact of COVID pandemic on drug use, in general, remains a topic worth investigating Chong et al. Important in this regard is not only the type of drug but the method of use. Smoking cannabis continues to be the most common route of administration both in Finland Hakkarainen and Karjalainen, and, for instance, North America Russell et al. Use of cannabis by smoking was the most common method of use in our data set as well; more than half of the participants also mixed tobacco when using cannabis, increasing health-related risks Russell et al. Researching and discussing various types of inhalation methods, including vaping, which as a route of administration has less of a public health effect Russell et al. Knapp et al. To conclude, our findings raise several questions that should be explored in future studies; for instance, is there a transition period related to age when mainly recreational use of cannabis becomes more medically motivated, as our findings suggest? What can explain the significant relation between urban settings of large cities versus smaller ones that seem to influence motivations to use cannabis, and what makes women more prone to use cannabis for medical reasons compared to men and vice versa? Although the statistically significant results and reported effects found in this study require confirmation from larger and more representative data samples, they give direction and insight into where to focus future research efforts as cannabis use continues to increase both in Finland Karjalainen et al. As legislation alone, whether lenient or punitive, does not seem to have an impact on youth cannabis use prevalence in Europe Gabri et al. Our study was limited to Finland, limiting its generalizability to other countries as well by its cross-sectional design and self-reported information also in relation to reported motivations and experienced effects of cannabis use. In addition, even though the survey was nationwide, the geographic distribution of participants was uneven, and we have fewer respondents from the capital area of Helsinki than expected. Several questions related to cannabis use were asked in a relatively short extra section, and the survey did not ask about other substance use besides cannabis, except if they mix tobacco when smoking cannabis. Nor did it inquire in detail about several other confounding factors, like health status or experiences with health services, that could play a significant role in explaining reported effects and motivations. While the amount and type of cannabis, method of use and possible simultaneous use of other drugs, like tobacco and alcohol, most likely have an impact on the experienced effects and motivations, further studies are needed to provide information on these confounding factors. Despite these limitations, our exploratory study provides important insights into a population of which there is a very limited amount of information about, namely young adults who use cannabis in Finland. Future studies should include additional measures on subjective well-being and health behaviours that could also give more insights into people who use cannabis for medical and other purposes. Our quantitative analysis of survey data shows that sociodemographic factors such as being older and female, living in a smaller city, and earlier age of initiation of cannabis use are statistically significant in predicting the medicinal use of cannabis. Qualitative analysis of reported desired and undesired effects also showed that although the majority of recreational effects are related to themes such as relaxation and pleasure, many participants also reported desired medical effects, ranging from finding relief for psychological problems such as ADHD, depression, sleep disorders, bipolar disorder and anxiety but also somatic and psychosomatic symptoms related to multiple sclerosis, pain and inflammation. Similarly, many participants reported undesired effects ranging from memory problems and increased anxiety to dry mouth and the fear of being caught engaging in illegal activities. Both proportionally and qualitatively, the undesired effects did not differ greatly between those who reported desired medical effects versus recreational ones, even though recreational users reported somewhat more psychosomatic undesired effects and medical users more undesired societal effects. Understanding and communicating also about undesired effects is important to enhance the well-being of young people who use cannabis and in designing relevant harm reduction and treatment programmes. Andre , C. Braun , V. Benschop , A. Bonnet , U. Chong , W. Ekendahl , M. Fox , C. Franke , A. Gabri , A. Goulet-Stock , S. Grotenhermen , F. Hakkarainen , P. Harmaala , M. Heide , F. Henderson , L. Holma , P. Honkasalo , V. Hosmer , D. Hupli , A. Johnstad , P. Karjalainen , K. Kekoni , T. Tampere University Press. Knapp , A. Kuhn , M. Kvamme , S. Lake , S. Lemyre , A. Lin , L. McFadden , D. Moeller , K. Ogborne , A. Oksanen , A. Prowse , R. Roy-Byrne , P. Russell , C. Sabaghi , D. Published 4th of November , available at: www. Savonen , J. Schlag , A. Schoeler , T. Simons , J. Stith , S. Tham , H. Tjur , T. Unlu , A. Vanderbruggen , N. Van Schipstal , I. Vihervaara , M. Wadsworth , E. Woodruff , S. Riboulet-Zemouli , K. Otto A. Malm Lahjoitusrahasto. Personal grant for A. Suomen Kulttuurirahasto. The authors would like to thank the reviewers and the participants of Addiktio seminar at Tampere University as well as Huumeseula seminar organised at the Finnish Institute for Health and Welfare for their comments and suggestions for this manuscript. Please share your general feedback. Contact Customer Support. Article Supplementary Material Abstract Purpose Cannabis use continues to increase worldwide, and a number of nation states are changing their cannabis policies. Findings Being older and female, living in a smaller city and earlier age of initiation of cannabis use were statistically significant in predicting the medicinal use of cannabis. What kinds of desired and undesired effects from cannabis do they report? Figure 1 Predicted probabilities of medical cannabis use. Appetite and sweet tooth increase. Mild anxiety sometimes. Supplementary materials Supplementary materials of this article can be found online. Aleksi Hupli can be contacted at: aleksi. Related articles. All feedback is valuable Please share your general feedback. Report an issue or find answers to frequently asked questions Contact Customer Support. Monthly usage a. R 2 Tjur 0.

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