Research paper
Do recreational cannabis users, unlicensed and licensed medical cannabis users form distinct groups?

https://doi.org/10.1016/j.drugpo.2016.11.010Get rights and content

Abstract

Background

This study aims to gain a more nuanced perspective on the differences between recreationally and medically motivated cannabis use by distinguishing between people who use cannabis for recreational purposes, unlicensed and licensed medical users.

Methods

Data collection was conducted online from a convenience sample of 1479 Israeli cannabis users. Multinomial regression analysis compared unlicensed medical users (38%) with recreational (42%) and licensed medical (5.6%) users in terms of sociodemographics, mode, frequency and problematic cannabis use.

Results

There were more variables distinguishing unlicensed from licensed users than there were distinguishing features between unlicensed and recreational users. Recreational users were more likely to be male, less likely to eat cannabis, to use cannabis frequently and to use alone and before midday than unlicensed users. Licensed users were older than unlicensed users, they reported less hours feeling stoned, less cannabis use problems and they were more likely to report cannabis use patterns analogous of medication administration for chronic problems (frequent use, vaping, use alone and use before midday).

Conclusion

This study suggests that a sizable proportion of cannabis users in Israel self-prescribe cannabis and that licensed medical cannabis users differ from unlicensed users. This is, in turn, suggestive of a rigorous medicalized cannabis program that does not function as a backdoor for legal access to recreational use. However, due to methodological limitations this conclusion is only suggestive. The most meaningful differences across recreational, unlicensed and licensed users were mode and patterns of use rather than cannabis use problems. Current screening tools for cannabis use problems may, however, not be well suited to assess such problems in medically motivated users. Indeed, when screening for problematic cannabis use there is a need for a more careful consideration of whether or not cannabis use is medically motivated.

Introduction

Cannabis is the most commonly used illicit substance in the world. In Israel 8.9% of adults (18–40) reported use in the last year (Bar-Hamburger, Ezrachi, Roziner, & Nirel, 2009) which is similar to rates in Europe (EMCDDA, 2015) and in the U.S. (Hasin et al., 2015). Only a minority of cannabis users experience clinical or social problems associated with their use (Eisen et al., 2002, von Sydow et al., 2001, Wagner and Anthony, 2002). Nevertheless, cannabis consumption is linked with elevated risk of adverse consequences (e.g. accidents and poor psychosocial outcomes, Hall, 2009, Hall, 2015) and cannabis constitutes a substantial share of the drugs that people seek addiction treatment for (EMCDDA, 2015, Roxburgh et al., 2010, Rush and Urbanoski, 2007, Sznitman, 2008, UNODC, 2015; Urbanoski, Strike, & Rush, 2005).

In addition to the detrimental effects of cannabis use, a surge of clinical trials have started to mount, some of which shows promising efficacy of medical cannabinoids in a wide range of diseases and conditions, including neuropathic pain, chemotherapy-induced nausea and vomiting and loss of appetite (Iskedjian, Bereza, Gordon, Piwko, & Einarson, 2007; Machado Rocha, Stefano, De Cassia Haiek, Rosa Oliveira, & Da Silveira, 2008; Wilkie, Sakr, & Rizack, 2016). In addition, it has been suggested that cannabis may alleviate some or all symptoms of an increasingly large range of medical conditions, including but not limited to multiple sclerosis, Alzheimer disease, attention deficit disorders, post-traumatic stress disorder, epilepsy, Crohn disease, sleep disorders, Tourette and glaucoma (Bonn-Miller, Babson, & Vandrey, 2014; Hill, 2015, Pedersen and Sandberg, 2013, Wilkinson and D’souza, 2014; T. Wilkinson, Rajiv, & Deepak Cyril, 2016). However, most of these effects are supported by anecdotes rather than controlled clinical trials, and in general the existing evidence, albeit sometimes promising, remains insufficient (Hill, 2015; Parmar, Forrest, & Freeman, 2016; Whiting, Wolff, Deshpande, & et al., 2015).

Despite the limited evidence-base, increasingly more jurisdictions are allowing legal access to medical cannabis for a wide range of symptoms and conditions (e.g. Israel, Canada, the Netherlands and 23 states in the U.S.) (Sznitman & Bretteville-Jensen, 2015; Williams, Olfson, Kim, Martins, & Kleber, 2016). The shifting policy landscape, along with increased public discussion regarding the medical properties of cannabis, raise new questions about the different motives and types of cannabis users and how these may be related to different rates of harms and benefits. Yet, the research has not yet caught up with the swift changes in policies and popular demand for medical cannabis. In particular, few studies have examined the sociodemographic characteristics, patterns of use and negative consequences of medical cannabis use and how this compares to use that is recreationally motivated (Pacula, Jacobson, & Maksabedian, 2016). Within the limited literature, evidence show that among current users, self-reported medical use is relatively widespread (Schauer, King, Bunnell, Promoff, & McAfee, 2016). Research has also found that medical cannabis users tend to use cannabis more frequently than recreational users (Lin, Ilgen, Jannausch, & Bohnert, 2016; Pacula et al., 2016, Richmond et al., 2015, Roy-Byrne et al., 2015). In terms of differences in harms, one study found that compared to recreational users, medical cannabis users were more likely to screen at moderate as opposed to light or high risk for cannabis use problems (Richmond et al., 2015). Another study, however, did not find any difference in cannabis use disorders between recreational and medical users of cannabis (Lin et al., 2016).

Just a few studies differentiate between medical use that is licensed and that which is unlicensed and thus best described as a form of self-prescription. One study based on a Canadian sample found few differences between licensed and unlicensed users with regard to symptoms treated and patterns of use, but differed considerably with regard to mode of access (Walsh et al., 2013); unauthorized users were less likely to access medical cannabis from authorized, or semi-authorized (i.e. dispensaries) sources. In another Canadian study of medical cannabis users it was found that rural respondents, lower income groups and those with poorer health were most likely to report having received federal authorization to possess medical cannabis (Belle-Isle et al., 2014).

Certainly, a substantial portion of people reporting medical cannabis use and who live in jurisdictions with medical cannabis licensing procedures report cannabis use for medical purposes without a physician recommendation (Pacula et al., 2016). Furthermore, long before the current policy environment towards greater legal access to medical cannabis, research showed the existence of cannabis use for medical purposes for a wide range of symptoms and diseases including HIV (Belle-Isle & Hathaway, 2007; Ogborne, Smart, Weber, & Birchmore-Timney, 2000a; Ware, Rueda, Singer, & Kilby, 2003) nausea, pain (Ogborne, Smart, & Adlaf, 2000b), and mood (Clark, Ware, Yazer, Murray, & Lynch, 2004; Grotenhermen & Schnelle, 2003; Swift, Gates, & Dillon, 2005). The UK, for instance, has no medical cannabis programs; nevertheless, a cross sectional survey of chronically ill patients with a range of comorbid conditions showed that 32% reported lifetime use of cannabis for medical purposes, and 18% reported continued medical use (Ware, Adams, & Guy, 2005).

This study aims to gain a more nuanced perspective on overlaps and differences among people who use cannabis for recreational and medical purposes. The study does this by distinguishing between people who use cannabis for recreational purposes, unlicensed medical users and those with a medical cannabis license.

The study uses a sample of current Israeli cannabis users. Israel has one of the worlds’ largest and longest running medical cannabis programs. In Israel medical cannabis licenses are only granted for specific symptoms and conditions (MOH, 2013a), the two largest groups of patients with medical cannabis licenses in Israel are chronic pain and oncology patients, respectively comprising 52% and 27% of the entire medical cannabis patient population (Personal communication with Dr. Yehuda Baruch, 2012). Licenses are only granted following the exhaustion of other “conventional” therapeutic options (most often the major classes of pharmaceutical treatments). Potential candidates for medical cannabis licenses need to have been under the supervision of a physician specialist for at least 1 year in which other conventional treatments have been tried and shown to fail. Medical cannabis licenses are given to individual patients after approval of the treating specialist physicians’ recommendation by medical professionals in the Medical Cannabis Unit of the Ministry of Health. The exception to this process is for oncology patients who can get a medical cannabis license directly approved by one of 11 authorized oncologists. Licenses are approved for 6–12 months after which a renewal needs to be sought through the treating physician and/or the Ministry of Health. In recent years the rate of medical cannabis licenses granted in Israel has grown significantly – from just a few hundred in 2007 to an estimated 22,000 in 2015 (MOH, 2013b; Shelef, Mashiah, Schumacher, Shine, & Baruch, 2011; Sznitman & Lewis, 2015).

Section snippets

Sample

The study is based on a sample of 1479 current cannabis users (reported use during the last 6 months) recruited through the most popular cannabis internet forum in Israel (http://www.קנאביס.com/). The link to the online survey was placed on the website and the forum moderator encouraged users to participate through social media. After informed consent was provided and inclusion criteria fulfilled (age >17), respondents filled the anonymous internet survey. The study was approved by the

Results

The largest group of cannabis users in the current study was recreational users, comprising 41.6% of the sample. The second largest group was unlicensed users comprising 38.1% of the sample, whereas 5.6% of the sample reported that they had a medical cannabis license from the Ministry of Health.

Table 1 shows sample characteristics overall and by the three different cannabis user groups. The average age was 26.9 years (S.D. = 7.18) and the sample was predominantly male (89.2%). χ2 tests indicated

Discussion

Policy shifts towards legal access to medical cannabis has sparked fierce interest regarding the medical benefits of cannabis in the mass media and public discussions (Kaiser, 2011; Lewis, Broitman, & Sznitman, 2015; McGinty et al., 2016, Sznitman and Lewis, 2015). Research also show extensive use of cannabis for medical purposes, licensed and unlicensed (Pacula et al., 2016, Schauer et al., 2016). A better understanding of the potential differences between medical and recreational cannabis

Conclusion

This study suggests that a sizable proportion of cannabis users in Israel self-prescribe cannabis for a chronic medical problem and that licensed medical cannabis users differ from unlicensed users. This is indicative of a rigorous medical cannabis program that does not simply function as a backdoor for people to get easy and legal access to cannabis that is used for recreational purposes. Due to methodological limitation this conclusion is, however, only suggestive. Furthermore, the study

Declarations of competing interest

None.

Conflicts of interest

There are no conflicts of interest related to this work.

Acknowledgements

The author would like to thank Yuval Zolotov for helping collect the data and Oren Ishii, the cannabis forum moderator for hosting the survey and helping with recruitment. The author would also like to thank the respondents who shared their experiences through taking part in the survey.

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