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Who Are Medical Marijuana Patients? Population Characteristics from Nine California Assessment Clinics

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Abstract and Figures

Marijuana is a currently illegal psychoactive drug that many physicians believe has substantial therapeutic uses. The medical literature contains a growing number of studies on cannabinoids as well as case studies and anecdotal reports suggesting therapeutic potential. Fifteen states have passed medical marijuana laws, but little is known about the growing population of patients who use marijuana medicinally. This article reports on a sample of 1,746 patients from a network of nine medical marijuana evaluation clinics in California. Patients completed a standardized medical history form; evaluating physicians completed standardized evaluation forms. From this data we describe patient characteristics, self-reported presenting symptoms, physician evaluations, other treatments tried, other drug use, and medical marijuana use practices. Pain, insomnia, and anxiety were the most common conditions for which evaluating physicians recommended medical marijuana. Shifts in the medical marijuana patient population over time, the need for further research, and the issue of diversion are discussed.
Content may be subject to copyright.
Journal of Psychoactive Drugs, 43 (2), 128–135, 2011
Copyright © Taylor & Francis Group, LLC
ISSN: 0279-1072 print/2159-9777 online
DOI: 10.1080/02791072.2011.587700
Who Are Medical Marijuana Patients?
Population Characteristics from Nine
California Assessment Clinics
Craig Reinarman, Ph.D.*; Helen Nunberg, M.D., M.P.H.**;
Fran Lanthier, M.A.*** & Tom Heddleston, M.A.***
Abstract Marijuana is a currently illegal psychoactive drug that many physicians believe has sub-
stantial therapeutic uses. The medical literature contains a growing number of studies on cannabinoids
as well as case studies and anecdotal reports suggesting therapeutic potential. Fifteen states have passed
medical marijuana laws, but little is known about the growing population of patients who use mari-
juana medicinally. This article reports on a sample of 1,746 patients from a network of nine medical
marijuana evaluation clinics in California. Patients completed a standardized medical history form;
evaluating physicians completed standardized evaluation forms. From this data we describe patient
characteristics, self-reported presenting symptoms, physician evaluations, other treatments tried, other
drug use, and medical marijuana use practices. Pain, insomnia, and anxiety were the most common
conditions for which evaluating physicians recommended medical marijuana. Shifts in the medical
marijuana patient population over time, the need for further research, and the issue of diversion are
discussed.
Keywords anxiety, cannabis therapeutics, insomnia, medical marijuana, pain
Medicinal preparations containing marijuana
(cannabis) were widely used in many societies for
centuries. Dr. William O’Shaughnessy introduced it as
a modern medicine in Europe in 1839. Marijuana was
The authors thank the medical marijuana patient-applicants for
providing the data, the RAND Corporation for funding data collec-
tion and data set construction, MediCann for administrative support, the
Rosenbaum Foundation for financial support for this research, and Lester
Grinspoon and anonymous referees for helpful comments. An earlier ver-
sion of this article was presented at the 59th Annual Meeting of the Society
for the Study of Social Problems, San Francisco, August 9, 2009.
Professor and Chair, Department of Sociology, University of
California, Santa Cruz.
∗∗Private practice, Santa Cruz, CA.
∗∗∗Instructors and PhD candidates, Department of Sociology,
University of California, Santa Cruz.
Please address correspondence and reprint requests to Craig
Reinarman, Sociology Department, University of California, Santa Cruz,
CA 95064; phone: (831) 459-2617, fax: (831) 459-3518, email: craigr@
ucsc.edu
prescribed for therapeutic use in American medical prac-
tice for a variety of conditions from the mid-nineteenth
century into the twentieth. Marijuana was admitted to
the United States Pharmacopoeia in 1850 and listed in
the National Formulary and the US Dispensatory. Major
pharmaceutical companies including Lilly, Burroughs-
Wellcome, and Parke-Davis produced cannabis-based
therapeutic agents (Brecher et al. 1972).
In 1936, the Federal Bureau of Narcotics advocated a
law prohibiting its use, which Congress passed in 1937,
against the advice of the American Medical Association
(Grinspoon & Bakalar 1993:9–11). This law, along with
increased prescribing of aspirin and barbiturates, pushed
cannabis out of the United States Pharmacopoeia and
common medical practice by 1942.
After nonmedical cannabis use spread in the 1960s,
the number of Americans reporting lifetime prevalence
Journal of Psychoactive Drugs 128 Volume 43 (2), April – June 2011
Reinarman et al. Who Are Medical Marijuana Patients?
increased sharply. Recent estimates from the National
Survey on Drug Use and Health show that 102,404,000
Americans have used this drug, 41% of the population aged
12 and over, or about half the adult population (SAMHSA
2010). This widespread use led to a gradual rediscovery
of the therapeutic uses of cannabis, albeit largely without
physician involvement.
Alongside the spread of nonmedical use, in 1964 sci-
entists determined the precise chemical structure of delta-9
tetrahydrocannabinol (THC), thought to be the most sig-
nificant psychoactive ingredient in cannabis (Gaoni &
Mechoulam 1964). This stimulated research in the clin-
ical pharmacology of cannabinoids. Many physicians in
clinical practice also recognized the therapeutic potential
of cannabis (Irvine 2006; Charuvastra, Freidmann & Stein
2005), specifically, for example, for pain (Woolridge et al.
2005), as an antiemetic for chemotherapy patients (Doblin
& Kleiman 1991), or for symptoms of AIDS (Abrams
et al. 2003). More recently a broader medical litera-
ture documenting the therapeutic properties of endogenous
cannabinoids has developed (e.g., Nicoll & Alger 2004;
Lehmann et al. 2002; Hall, Degenhart & Currow 2001).
Numerous case reports in the medical literature also have
suggested that cannabis has therapeutic potential for a vari-
ety of conditions. But rigorous experimental research that
might determine more precisely the therapeutic efficacy
of cannabis for specific conditions has been blocked by
the Drug Enforcement Administration (see Zeese 1999;
Alliance for Cannabis Therapeutics v. Drug Enforcement
Administration 1994).
This combination of increasing therapeutic use and
federal government opposition ultimately led to passage of
new state laws providing for the medical use of cannabis
upon physician recommendation. Since 1996, 15 U.S.
states and the District of Columbia have passed such
laws: California, Alaska, Oregon, Washington, Nevada,
Colorado, Maine, Montana, Michigan, and Washington,
DC by ballot initiative; Rhode Island, New Mexico,
Vermont, Hawaii, and New Jersey by state legislation.
The first of these laws was California’s Proposition
215, the Compassionate Use Act, passed in 1996 (San
Francisco Chronicle 1996). This act made it legal under
state law for patients to possess and use cannabis if recom-
mended by their physicians. Numerous medical and scien-
tific associations endorsed medical use of cannabis and/or
supported further research into its therapeutic poten-
tial. These included the American College of Physicians
(2008), the American Public Health Association (1995), the
British Medical Association (1997), the Canadian Medical
Association (2005), and the Institute of Medicine of the
National Academy of Sciences (1999).
Such elections and endorsements notwithstanding, the
Bush Administration’s Office of National Drug Control
Policy threatened to revoke the licensesof physicians
who recommended cannabis to patients. One physician
challenged this policy and the U.S. Court of Appeals ruled
(in Conant v. Walters) in 2002 that it unconstitutionally
infringed physicians’ First Amendment rights to freedom
of speech with their patients (McCarthy 2004). Subsequent
legislation and case law have left medical marijuana (MM)
patients and their physicians in legal limbo:
• In 2003, the California legislature passed SB 420
to provide specific implementation guidelines for
Proposition 215, including how counties should han-
dle MM patient ID cards.
• Most drug law enforcement, however, is done by
local police who enforce state, not federal, drug
laws. In 2005, The California Attorney General ruled
that Proposition 215 is the legitimate will of the
voters and is therefore valid under the California
Constitution for purposes of state law enforcement.
He advised the Highway Patrol and other state law
enforcement agencies that under California law MM
patients were legally entitled to possess and use
cannabis for therapeutic purposes (Hoge 2005).
In 2006, Bush administration Attorney General
Gonzales sought to invalidate state MM laws, and
the U.S. Supreme Court ruled (Gonzales v. Raich
2006)that the Compassionate Use Act—its legiti-
mate electoral provenance notwithstanding—neither
supersedes nor invalidates federal laws that prohibit
marijuana use (see Mikos 2009 for a legal analysis of
the states’ neglected power to legalize behavior that
is criminalized under federal law).
In 2008 the Supreme Court denied without comment
an appeal by two California counties that had refused
to implement Proposition 215 (County of San Diego
v. San Diego NORML 2008), thereby letting stand a
lower court ruling that upheld SB 420’s provisions
regarding counties issuing MM identification cards.
In 2009, Attorney General Eric Holder issued a pol-
icy stating that federal drug control agencies would
no longer raid MM dispensaries if they operated
within state and local laws (Moore 2009).
That policy notwithstanding, the DEA has continued
to raid MM dispensaries in California into 2011 (e.g.,
Blankstein 2009).
Within this grey area between conflicting state and
federal laws, the number of patients who have received rec-
ommendations for medical marijuana from physicians has
continued to grow, albeit by how much remains unknown.
Over 1,000 MM dispensaries, delivery services, and coop-
eratives are said to be operating in California to meet
the demand (NORML 2007). A rough estimate of the
number of MM patients in California can be extrapolated
from Oregon figures. Unlike California’s Compassionate
Use Act, Oregon’s MM law set up an Oregon Medical
Marijuana Program that requires centralized record keep-
ing. As of July, 2009, some 2,983 Oregon-licensed physi-
cians had approved 20,307 applications for MM (Oregon
Journal of Psychoactive Drugs 129 Volume 43 (2), April – June 2011
Reinarman et al. Who Are Medical Marijuana Patients?
Department of Human Services 2008). The population of
California is 9.7 times that of Oregon (U.S. Census 2007),
which yields a crude estimate of 196,978 MM patients
in California. This is likely an underestimate because the
California statute affords greater latitude to physicians
regarding the conditions for which they can recommend
MM (“. . . any other illness for which marijuana provides
relief”). Americans for Safe Access (2008), a MM patient
advocacy group, has estimated that there are well over
200,000 physician-sanctioned MM patients in California.
Despite their growing numbers, however, the ambigu-
ous legal status of MM patients renders them a half-hidden
population whose characteristics are not well documented,
with the partial exception of the San Francisco Bay Area
(O’Connell & Bou-Matar 2007; Reiman 2007a). Medical
marijuana will likely continue to be a contentious issue,
but across fifteen states and the District of Columbia several
hundred thousand people are using marijuana as a medicine
recommended by physicians, and yet little is known about
them as a patient population.
We intend this study as a modest contribution toward
filling this gap. It presents data on the demographic char-
acteristics, presenting symptoms, physician evaluations,
conventional treatments tried, and MM use practices of
patients from a network of MM assessment clinics in
California.
METHODS
These data were drawn from 1,746 consecutive
admissions to nine MM assessment clinics operating in
California in July, August, and September 2006. These
assessment clinics are not dispensaries and are not con-
nected to dispensaries. They were located throughout the
state—in the north and south, coast and central valley,
and large and small cities: Modesto, Oakland, Sacramento,
Hollywood, San Diego, Santa Cruz, Ukiah, San Francisco,
and Santa Rosa. They charged $100 to $125 for an assess-
ment. At the time our sample was drawn, these assessment
clinics had evaluated over 54,000 MM patients. Without
a comprehensive patient database or representative house-
hold surveys, there is no way to determine precisely how
representative this sample is of the overall population of
MM patients. Moreover, there is a large albeit unknown
number of people who use marijuana medicinally but who
have not sought physician recommendations or official
patient ID cards, perhaps because of the expense of the
assessment.1
Evaluating physicians interviewed potential patients
and evaluated their patient medical histories for purposes of
recommending MM and issuing patient identification cards
under the Compassionate Use Act and SB 420. The eval-
uation instruments were (1) a basic patient-administered
medical history questionnaire covering demographics, pre-
senting symptoms or conditions, brief medical history,
conventional and alternative medical treatments tried, drug
use history, and MM use practices; and (2) a physician eval-
uation form using International Classification of Diseases
codes (ICD-9). Each patient received and signed an exten-
sive informed consent form noting confidentiality, which
was approved by the clinics’ IRB.
Most prior studies of MM patients are based on small,
symptom-specific samples. Initially, the population of MM
patients in the San Francisco Bay Area were people with
HIV/AIDS and cancer (e.g., Harris, Mendelson & Jones
1998). Later, physicians began to recommend cannabis to
patients with chronic pain, mood disorders and other psy-
chiatric conditions (Gieringer 2002). The data reported
here describe what is among the largest and most symp-
tomatically and demographically diverse samples of medi-
cal cannabis patients to date (cf., O’Connell & Bou-Matar
2007).
RESULTS
As Table 1 indicates, the MM patients are three-fourths
male and three-fifths White. Compared to the US Census
of California, the patients in this sample are on average
somewhat younger, report slightly more years of formal
education, and are more often employed. The comparison
also indicates that women, Latinos, and Asian Americans
are underrepresented. Given the limitations of our data, we
can offer only informed speculation as to why.
The underrepresentation of women may be in part
an epidemiological artifact of the gender distribution of
certain kinds of injuries (e.g., workplace, sports, and motor-
cycle accidents). It may also have to do with the double
stigma women face in seeking MM—for using an illicit
drug and for violating gender-specific norms against ille-
gal behavior in general. Moreover, as with alcohol use,
pregnant women and women considering pregnancy are
likely to have health concerns and many may fear that MM
could put them in jeopardy if discovered by child protection
agencies.
Given the high poverty rate among Latinos and their
concentration in the manual labor end of the occupational
structure, Latinos are exposed to equal or greater risks
of work-related injuries and to no less epidemiologic risk
of other conditions for which MM is sometimes used. It
seems likely that their under-representation has to do with
the undocumented status of many Latinos in California.
The undocumented often avoid contact with government
agencies for fear of apprehension by law enforcement,
for beyond arrest and incarceration this carries the risk of
deportation. Such fears reduce the likelihood of Latinos
accessing health care in general and MM in particular.
Asian Americans are also underrepresented, but this may
be because they have lower prevalence of marijuana use
than other racial/ethnic groups and/or because they have
their own venerable traditions of herbal medicine.
Journal of Psychoactive Drugs 130 Volume 43 (2), April – June 2011
Reinarman et al. Who Are Medical Marijuana Patients?
TABLE 1
Demographic Characteristics of California Medical
Marijuana Patients Compared to California
Census 2000, Age 18 and Over {n =1746}
MM
Patients
U.S. Census
2000 – California
Female 27.1% 50.7%
Male 72.9% 49.3%
White 61.5% 59.5%
Latino 14.4% 32.4%
African American 11.8% 6.7%
Native American 4.5% 1.0%
Asian/Pacific Islander 4.2% 11.2%
Other 4.3%
18–24 Years Old 17.9% 17.1%
25–34 ” 27.5% 15.4%
35–44 ” 21.3% 16.2%
45–54 ” 20.4% 12.8%
55> 12.6% 18.4%
<High School 8.8%
High School Graduate 42.2%
Some College 27.1%
College Graduate>23.8%
Employed 64.8% 57.5%
Health Insurance 73.4%
Data not available in California Census.
African-Americans, conversely, are over-represented
in this sample. This does not appear to stem from their
prevalence of marijuana use, for representative national
surveys show that Blacks generally do not have signif-
icantly higher prevalence of marijuana use than Whites
(SAMHSA 2005). African-Americans may be more likely
to seek MM for any of several reasons: because they
are disproportionately poor, more often lack health insur-
ance, are significantly less likely to be prescribed other
medication for pain (Pletcher et al. 2008) or to receive
treatment for cancer (Gross et al. 2008), and because
African-Americans are a growing proportion of HIV/AIDS
cases. Some of these same reasons may help to explain why
Native Americans are also overrepresented, although their
proportion of both this sample and the general population
is too small to judge representativeness accurately.
In their medical history questionnaires, patients were
asked “Which of the following best describe the therapeu-
tic benefit you receive from medicinal cannabis? (Check
the most important).” Patients typically reported more than
one therapeutic benefit (mean =3). Early studies showed
most patients used MM to relieve symptoms of HIV/AIDS
(Woolridge et al. 2005) or cancer, and it is likely that the
majority of patients in our sample who reported “nausea”
were cancer patients receiving chemotherapy. However,
Table 2 suggests that cancer and AIDS patients are now a
TABL E 2
Patient Self-Reports of Therapeutic Benefits from
Medicinal Marijuana
Percent
To Relieve:
Pain 82.6
Muscle Spasms 41.1
Headaches 40.7
Anxiety 37.8
Nausea/Vomiting 27.7
Depression 26.1
Cramps 19.0
Panic Attacks 16.9
Diarrhea 5.0
Itching 2.8
To Improve:
Sleep 70.7
Relaxation 55.1
Appetite 37.7
Concentration/Focus 22.9
Energy 15.9
To Pr ev en t:
Medication Side Effects 22.5
Anger 22.4
Involuntary Movements 6.2
Seizures 3.2
As Substitute for:
Prescription Medication 50.9
Alcohol 13.0
N=1,745; patients could report more than one benefit in more than
one category.
significantly smaller proportion of the total (e.g., “to relieve
nausea/vomiting” 27.7%, “to improve appetite” 37.7%)
and that the MM patient population has become more
diverse since the Compassionate Use Act was passed in
1996 (cf. Ware, Adams & Guy 2005, on MM use in the
UK, and Grotenherman 2002 on MM use in Germany).
Instead, relief of pain, muscle spasms, headache, and
anxiety, as well as to improve sleep and relaxation were
the most common reasons patients cited for using MM.
Chronic pain also topped the list of maladies for which MM
was used in another California clinical sample (Reiman
2007b).
Table 3 shows the ICD-9 diagnostic codes most fre-
quently recorded by evaluating physicians. Pain from back
and neck injuries was the most frequently coded. This
appears consistent with a nationally representative Medical
Expenditure Panel Survey, which found a 19.3% increase
in the prevalence of spine problems between 1997 and
2005 (Martin et al. 2008). Back and neck pain was fol-
lowed in frequency by sleep disorders (also increasing),
anxiety/depression, muscle spasms, and arthritis. Fully
half of this sample reported using MM as a substitute
Journal of Psychoactive Drugs 131 Volume 43 (2), April – June 2011
Reinarman et al. Who Are Medical Marijuana Patients?
TABLE 3
Conditions Most Frequently Recorded by
Physicians As Reasons for Approving Medical
Marijuana Patient Identification Cards
Percent ICD-9 Codes
Back/Spine/Neck Pain 30.6% [722.1–724.2]
Sleep Disorders 15.7% [307.42, 327.0]
Anxiety/Depression 13.0% [300.0, 311.0]
Muscle Spasms 9.5% [728.85]
Arthritis 8.5% [715.0, 721.2, 721.2]
Injuries (Knee, Ankle, Foot) 4.5% [959.7]
Joint Disease/Disorders 4.4% [716.1–719.49]
Narcolepsy 3.7% [347.0]
Nausea 3.4% [787.02]
Inflammation (Spine, Nerve) 2.9% [724.4]
Headaches/Migraines 2.7% [784.0, 346.0, 346.2]
Eating Disorders 1.1% [783.0]
N=1746; some patients reported multiple symptoms and/or
conditions.
TABLE 4
Other Treatment Modalities Tried for the Medical
Condition(s) for Which Patients Seek Medical
Marijuana
%N
Prescription Medication 79.3% 1383
Physical Therapy 48.7 850
Chiropractic 36.3 633
Surgery 22.3 389
Counseling 21.0 366
Acupuncture 19.4 338
Therapeutic Injection 15.4 269
Homeopathy 12.0 209
Other Types of Treatment 11.9 208
N=1746; patients could report multiple other treatments.
for prescription drugs, consistent with other studies (e.g.,
Reiman 2007a).
Table 4 indicates that the MM patients in the sample
had tried a variety of other treatments, conventional and
alternative, for the conditions for which they were seek-
ing a MM identification card. Four in five (79.3%) reported
having tried other medications prescribed by their physi-
cians (almost half were opiates); about half (48.7%) had
tried physical therapy; over a third (36.3%) had tried chi-
ropractic; nearly one-fourth (22.3%) reported having had
surgery for their condition.
Table 5 compares patient responses to the drug use
questions to those in the 2006 National Survey on Drug
Use and Health (SAMHSA 2007). Prevalence of tobacco
TABL E 5
Medical Marijuana Patients’ Self-Reported
Current Nonmedical Drug Use, Compared to 2006
National Survey on Drug Use And Health
(SAMHSA 2007)
MM Patients NSDUH
Tobacco 29.4% 25.0%
Alcohol 47.5 61.9
Cocaine 0.3 1.9
Methamphetamine 0.4 0.5
Heroin 0.1 0.3
Other Opiates 1.2 ∗∗
Note: Participants were asked “Do you currently use . . .”; answers
are percent responding “yes.” N =1745; patients could report more
than one drug. Of smokers, 65.5% used ten or less cigarettes/day; of
drinkers, 58.7% used</=one or less drinks/day.
NSDUH figures for “past month” prevalence used as a proxy for
“current use”.
∗∗Data not available in comparable form.
use was somewhat higher than in the general popula-
tion, but prevalence of alcohol use was significantly lower.
Many patients reported that they valued MM because it
allowed them to reduce their alcohol use. It is possible that
self-reports on a self-administered instrument will under-
estimate illicit drug use, particularly if patients felt that
admitting illicit drug use could reduce their chances of
obtaining a MM identification card. Rigorous assessments
of the reliability of such data must await further research,
but limitations aside, these data suggest low prevalence of
other illicit drug use among MM patients. While it is true
that the great majority of our respondents had used mari-
juana recreationally, in response to a separate question over
two-fifths (41.2%) reported that they had not been using it
recreationally prior to trying it for medicinal purposes.
Table 6 presents data on patients’ medical marijuana
use practices. Amounts used per week varied from three
grams or less (40.1%) to seven or more grams (23.3%).
Two-thirds (67%) reported using MM daily while one-
fourth (26%) reported using less than once a week. Half
(52.9%) reported using one or two times per day while one
in ten (10%) reported using three or more times per day.
Patients consumed MM primarily in the evenings (52.3%)
or prior to sleep (56.1%). More than two in five (42.3%)
reported that when they used depended on their medi-
cal symptoms. Patients ingested MM predominantly by
smoking (86.1%), although one-fourth (24.4%) reported
ingesting orally and nearly a fourth (21.8%) reported using
a vaporizer. These latter figures suggest that at least some of
the time, many MM patients are choosing modes of inges-
tion that reduce the perceived risk of harms from smoking
(Tan et al. 2009; Hashibe et al. 2006).
Journal of Psychoactive Drugs 132 Volume 43 (2), April – June 2011
Reinarman et al. Who Are Medical Marijuana Patients?
TABLE 6
Medical Marijuana Use Practices
Frequency of Medical Marijuana Use (N =1583)
Daily 67.0% (1065)
<Once A Week 26.0% (409)
<Once A Month 7.0% (109)
On Days Used, Frequency per Day (N =1574)
1 To 2 Times Per Day 52.9% (833)
2 To 3 Times Per Day 29.0% (457)
>3 Times Per Day 10.0% (284)
Time Of Day Typically Used (N =1745)
Prior To Sleep 56.1% (979)
Evenings 52.3% (913)
Depends on Symptoms 42.3% (739)
Mornings 25.7% (448)
Afternoons 20.1% (350)
After Work 12.4% (217)
Middle of the Night 6.5% (114)
All Day 5.3% (93)
Mode of Ingestion (N =1745)
Smoke 86.1% (1503)
Oral Ingestion 24.4% (426)
Vapor 21.8% (380)
Topical 2.8% (49)
Amount Used per Week (N =1431)
0–3 Grams 40.1% (574)
4–7 Grams 36.5% (523)
>7 Grams 23.3% (334)
Total n =1745, but N’s vary across questions because patients could
choose more than one response and because not all responded to each
question.
DISCUSSION
Rediscovery of Medicinal Utility and Diversifying
Patient Population
Compared to earlier studies of MM patients, these data
suggest that the patient population has evolved from mostly
HIV/AIDS and cancer patients to a significantly more
diverse array. The diffusion of marijuana as a medicine
may have been slower than that of other medicines in con-
ventional clinical practice because the flow of information
from physician to patient is impeded by MM’s ambiguous
legal status. Thus, information about the potential thera-
peutic utility of cannabis is spread mostly via word of
mouth and other informal means. This suggests that the
patient population is likely to continue evolving as new
patients and physicians discover the therapeutic uses of
cannabis. Ironically, this trend toward increasing thera-
peutic uses is bringing marijuana back to the position it
held in the U.S. Pharmacopeia prior to its prohibition in
1937.
Further Research
Like other medicines, marijuana’s therapeutic efficacy
varies across conditions and patient groups. This variation
seems more likely when supplies remain illicit because
standardized dosages or other quality controls are more dif-
ficult to achieve. To gain maximum therapeutic potential
across the growing range of conditions for which MM is
being recommended, more systematic research is needed.
Longitudinal, case control, and double-blind studies are
required to rigorously assess marijuana’s therapeutic effi-
cacy for specific patient groups, conditions, and diseases.
With regard to shifts in the patient population, it also would
be very useful to have follow-up studies of patients access-
ing the assessment clinics in our sample and others drawn
from similar assessment clinics.
Diversion
Critics have argued that some MM patients are “gam-
ing the system” to get marijuana for nonmedical use.
Neither our data nor any other data we are aware of allow
any clear-cut, empirical estimate of the scale of such diver-
sion. Given the widespread nonmedical use marijuana in
the general population (102,404,000 Americans report life-
time prevalence; see SAMHSA 2010) and the risk of arrest
(847,864 Americans were arrested for marijuana offenses
in 2008, 754,224 or 88.96% of them for possession alone;
FBI 2009), it seems likely that at least some MM patients
use MM dispensaries as sources of supply for nonmedical
use.
Defining and measuring such diversion, however, is
complicated at best. Given the high prevalence of nonmed-
ical use, it is not surprising that most MM patients in our
sample reported having used it recreationally before using
it therapeutically. But as noted above, two-fifths had not
been using marijuana recreationally prior to trying it for
medicinal purposes. Their self-reported rates of other illicit
drug use are slightly lower than those found among the gen-
eral population, and their levels of educational attainment
and rate of employment are comparable to the California
population. Our data have clear limitations, but they con-
tain no obvious signs that MM patients differ from the
general population.
Nor is drug diversion unique to medical marijuana.
A significant albeit unknown proportion of other patients
obtain prescriptions for numerous drugs through legal
medical channels that they then use for nonmedical pur-
poses, for example, Valium and other benzodiazepines
(Haafkens 1997), Ritalin and other stimulants prescribed
for ADHD, and Oxycontin and other opiates prescribed
for pain.
The diversion issue will likely become more impor-
tant as the line between medical and nonmedical drug
use is increasingly blurred (Murray, Gaylin & Macklin
1984). Beyond the spread of MM, Prozac and other SSRI-
type antidepressants, for example, are often prescribed
Journal of Psychoactive Drugs 133 Volume 43 (2), April – June 2011
Reinarman et al. Who Are Medical Marijuana Patients?
for patients who do not meet DSM criteria for clinical
depression but who simply feel better when taking it. Such
“cosmetic psychopharmacology” (Kramer 1993) is likely
to grow as new psychiatric medications come to market.
The line between medical and nonmedical drug use has
also been blurred by performance enhancing drugs such
as steroids, so-called “smart drugs” that combine vitamins
with psychoactive ingredients, and herbal remedies like ma
huang (ephedra) available in health food stores (Burros &
Jay 1996).
These examples suggest that despite the best intentions
of physicians and law makers, much drug use does not fit
into two neat boxes, medical and nonmedical, but rather
exists on a continuum where one shades into the other as
patients’ purposes shift to suit situational exigencies in
their health and their daily lives. It is not clear where a
border line between medical and nonmedical marijuana or
other drug use might be drawn nor how it might be effec-
tively policed (see Reinarman & Levine 1997: 334–44).
NOTE
1. We are grateful to one anonymous reviewer for
pointing out that the cost of these assessments may well
have prevented some potential MM patients—including
many impoverished HIV/AIDS patients—from obtaining
ID cards, which may have affected the demographics of this
sample.
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Journal of Psychoactive Drugs 135 Volume 43 (2), April – June 2011
... Although the UK has begun to develop a registry of medical cannabis patients (9), rigorous observational studies and prospective clinical trials have yet to be undertaken and most of the available data is derived from surveys of cooperating users. These surveys are usually limited in scope, retrospective, and rarely collect data on variables beyond basic demographic elements, comorbidities, modes of consumption, and overall satisfaction (2,(6)(7)(8)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). ...
... The demographic and medical characteristics of our cohort differ from most reported populations. The Israeli medical cannabis patients are on average (55 years old) two and a half-decade older than patients in comparable reports (2,8,10,(12)(13)(14)(15)(16)(18)(19)(20)(21), with a more balanced gender distribution (51.3% men compared to 60-80% in most studies) (2,11,(13)(14)(15)(16)(17)(18)(19)(21)(22)(23)(24). In the current cohort, the main indication for cannabis treatment was cancer (48.9%), while in other studies the main indications were pain (2, 10-12, 15, 18, 24, 25, 33-35), anxiety (13,14,36), and depression (19); cancer was diagnosed in only 7.4-11.4% of the patients (2, 10-12, 14, 15, 19, 24, 25). ...
... The demographic and medical characteristics of our cohort differ from most reported populations. The Israeli medical cannabis patients are on average (55 years old) two and a half-decade older than patients in comparable reports (2,8,10,(12)(13)(14)(15)(16)(18)(19)(20)(21), with a more balanced gender distribution (51.3% men compared to 60-80% in most studies) (2,11,(13)(14)(15)(16)(17)(18)(19)(21)(22)(23)(24). In the current cohort, the main indication for cannabis treatment was cancer (48.9%), while in other studies the main indications were pain (2, 10-12, 15, 18, 24, 25, 33-35), anxiety (13,14,36), and depression (19); cancer was diagnosed in only 7.4-11.4% of the patients (2, 10-12, 14, 15, 19, 24, 25). ...
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Background Despite the absence of rigorous prospective studies, there has been an increase in the use of cannabis-based medicinal products. During the study period, the use of medical cannabis in Israel was tightly regulated by national policy. Through a prospective study of approximately 10,000 patients, we aimed to characterize the medical cannabis patient population as well as to identify treatment adherence, safety, and effectiveness. Methods and Findings In this study of prescribed medical cannabis patients, adherence, safety, and effectiveness were assessed at 6 months. Treatment adherence was assessed by the proportion of patients purchasing the medication out of the total number of patients (excluding deceased cases and patients transferred to another cannabis clinic). Safety was assessed by the frequency of the side-effects, while effectiveness was defined as at least moderate improvement in the patient condition without treatment cessation or serious side-effects. The most frequent primary indications requiring therapy were cancer (49.1%), followed by non-specific pain (29.3%). The average age was 54.6 ± 20.9 years, 51.1% males; 30.2% of the patients reported prior experience with cannabis. During the study follow-up, 1,938 patients died (19.4%) and 1,735 stopped treatment (17.3%). Common side-effects, reported by 1,675 patients (34.2%), were: dizziness (8.2%), dry mouth (6.7%), increased appetite (4.7%), sleepiness (4.4%), and psychoactive effect (4.3%). Overall, 70.6% patients had treatment success at 6 months. Multivariable logistic regression analysis revealed that the following factors were associated with treatment success: cigarette smoking, prior experience with cannabis, active driving, working, and a young age. The main limitation of this study was the lack of data on safety and effectiveness of the treatment for patients who refused to undergo medical assessment even at baseline or died within the first 6 months. Conclusions We observed that supervised medical-cannabis treatment is associated with high adherence, improvement in quality of life, and a decrease in pain level with a low incidence of serious adverse events.
... Despite the burgeoning availability and use of MM, relatively little is known about the characteristics, healthrelated quality of life (HRQoL), and psychosocial functioning of MM patients. Studies of patients in Florida [8] and California [9] reported chronic pain, anxiety, stress, and insomnia to be the most common complaints or conditions prompting referrals for MM. Among chronic pain patients in Ohio considering MM, 67.6% wanted to reduce their use of opioid medications, and 93.6% were amenable to following physician recommendations regarding the use of opioids and MM concurrently [10]. ...
... Several findings are noteworthy. First, the most common referral conditions of participants in the sample were chronic pain and anxiety, which is consistent with findings from previous studies in this area [8,9]. Collectively, our findings suggest that patients with chronic pain or anxiety may pursue alternative therapies for symptom relief beyond prescription medications or psychotherapy. ...
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b> Introduction: Despite the rising availability and use of medical marijuana (MM) in the USA, little is known about the demographics, clinical characteristics, or quality of life of MM patients. This study describes the demographic characteristics and health-related quality of life (HRQoL) of MM patients who are initiating treatment in Pennsylvania. Methods: Two-hundred adults naive to MM and referred for any of the 23 state-approved qualifying conditions were recruited at three MM dispensaries in Pennsylvania between September 2020 and March 2021. All participants consented to the study; completed semi-structured interviews that included demographic questionnaires, the Short Form-36 (SF-36), and Generalized Anxiety Disorder-7 (GAD-7); provided height and weight measurements; and allowed access their dispensary medical records. Results: Participants had a mean age of 48.5 ± 15.6 years, predominantly identified as female (67.5%), and were most commonly referred for chronic pain (63.5%) and/or anxiety (58.5%). Additionally, 46.0% were living with obesity as determined by BMI. Relative to a normative sample, participants reported diminished HRQoL in several domains, most notably in role limitations due to physical health ( M = 46.0 ± 42.0), role limitations due to emotional problems ( M = 52.5 ± 42.3), energy and fatigue ( M = 39.8 ± 20.2), and pain ( M = 49.4 ± 26.0). Discussion/Conclusion: Patients initiating MM treatment experienced low HRQoL in multiple domains. Future studies could evaluate the relationship between HRQoL and patients’ decisions to pursue MM treatment, as well as changes in HRQoL with MM use over time.
... 5 Documentation of patients' medical cannabis use in the electronic health record (EHR) can support patient-clinician discussions of the risks of cannabis use and exploration of treatment alternatives. Patients use cannabis for a variety of health conditions, [6][7][8][9][10] and although evidence suggests potential benefit for neuropathic pain, appetite, nausea and vomiting, spasticity, and shortterm sleep outcomes, most health conditions for which patients use cannabis have insufficient or nonexistent evidence of benefit, potential contraindications, and more effective first-line treatment options. [11][12][13] Moreover, cannabis use has known risks, including increased risk of cannabis and other substance use disorders, mental health disorders, acute care utilization, and withdrawal. ...
Article
Importance: Patients who use cannabis for medical reasons may benefit from discussions with clinicians about health risks of cannabis and evidence-based treatment alternatives. However, little is known about the prevalence of medical cannabis use in primary care and how often it is documented in patient electronic health records (EHR). Objective: To estimate the primary care prevalence of medical cannabis use according to confidential patient survey and to compare the prevalence of medical cannabis use documented in the EHR with patient report. Design, setting, and participants: This study is a cross-sectional survey performed in a large health system that conducts routine cannabis screening in Washington state where medical and nonmedical cannabis use are legal. Among 108 950 patients who completed routine cannabis screening (between March 28, 2019, and September 12, 2019), 5000 were randomly selected for a confidential survey about cannabis use, using stratified random sampling for frequency of past-year use and patient race and ethnicity. Data were analyzed from November 2020 to December 2021. Exposures: Survey measures of patient-reported past-year cannabis use, medical cannabis use (ie, explicit medical use), and any health reason(s) for use (ie, implicit medical use). Main outcomes and measures: Survey data were linked to EHR data in the year before screening. EHR measures included documentation of explicit and/or implicit medical cannabis use. Analyses estimated the primary care prevalence of cannabis use and compared EHR-documented with patient-reported medical cannabis use, accounting for stratified sampling and nonresponse. Results: Overall, 1688 patients responded to the survey (34% response rate; mean [SD] age, 50.7 [17.5] years; 861 female [56%], 1184 White [74%], 1514 non-Hispanic [97%], and 1059 commercially insured [65%]). The primary care prevalence of any past-year patient-reported cannabis use on the survey was 38.8% (95% CI, 31.9%-46.1%), whereas the prevalence of explicit and implicit medical use were 26.5% (95% CI, 21.6%-31.3%) and 35.1% (95% CI, 29.3%-40.8%), respectively. The prevalence of EHR-documented medical cannabis use was 4.8% (95% CI, 3.45%-6.2%). Compared with patient-reported explicit medical use, the sensitivity and specificity of EHR-documented medical cannabis use were 10.0% (95% CI, 4.4%-15.6%) and 97.1% (95% CI, 94.4%-99.8%), respectively. Conclusions and relevance: These findings suggest that medical cannabis use is common among primary care patients in a state with legal use, and most use is not documented in the EHR. Patient report of health reasons for cannabis use identifies more medical use compared with explicit questions about medical use.
... In addition, our study is the first to examine medical cannabis services in New York, which has one of the most stringent medical cannabis policies in the US. In the only study that we are aware of that examined disparities in medical cannabis certification, only 14% of patients assessed for certification at nine medical cannabis clinics in California were Hispanic, while 32% of Californians were Hispanic [32]. Our study did not find a relationship between the percentage of Hispanic residents in a census tract and the availability of cannabis services. ...
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Background Within the United States (US), because racial/ethnic disparities in cannabis arrests continue, and cannabis legalization is expanding, understanding disparities in availability of legal cannabis services is important. Few studies report mixed findings regarding disparities in availability of legal cannabis services; none examined New York. We examined disparities in availability of medical cannabis services in New York. We hypothesized that New York census tracts with few Black or Hispanic residents, high incomes, high education levels, and greater urbanicity would have more medical cannabis services. Methods In this cross-sectional study, we used data from the 2018 US Census Bureau 5-year American Community Survey and New York Medical Marijuana Program. Main exposures were census tract characteristics, including urban–rural classification, percentage of Black and Hispanic residents, percentage of residents with bachelor’s degrees or higher, and median household income. Main outcomes were presence of at least one medical cannabis certifying provider and dispensary in each census tract. To compare census tracts’ characteristics with (vs. without) certifying providers and dispensaries, we used chi-square tests and t-tests. To examine characteristics independently associated with (vs. without) certifying providers, we used multivariable logistic regression. Results Of 4858 New York census tracts, 1073 (22.1%) had medical cannabis certifying providers and 37 (0.8%) had dispensaries. Compared to urban census tracts, suburban census tracts were 62% less likely to have at least one certifying provider (aOR = 0.38; 95% CI = 0.25–0.57). For every 10% increase in the proportion of Black residents, a census tract was 5% less likely to have at least one certifying provider (aOR = 0.95; 95% CI = 0.92–0.99). For every 10% increase in the proportion of residents with bachelor’s degrees or higher, a census tract was 30% more likely to have at least one certifying provider (aOR = 1.30; 95% CI = 1.21–1.38). Census tracts with (vs. without) dispensaries were more likely to have a higher percentage of residents with bachelor’s degrees or higher (43.7% vs. 34.1%, p < 0.005). Conclusions In New York, medical cannabis services are least available in neighborhoods with Black residents and most available in urban neighborhoods with highly educated residents. Benefits of legal cannabis must be shared by communities disproportionately harmed by illegal cannabis.
Article
This was a retrospective study of patients utilizing medical cannabis who received their medical cannabis documentation and allotment from a Harvest Medicine clinic in Canada to determine the impact of medical cannabis on anxiety and depression outcomes. Patients included in the study were at least 18 years of age with completed validated questionnaires for anxiety (GAD-7) and depression (PHQ-9) at their initial evaluation and at least one follow-up visit. There were 7,362 patients included in the sample, of which the average age was 49.8 years, and 53.1% were female. There were statistically significant improvements between baseline and follow-up scores for both the GAD-7 and PHQ-9, with larger improvements seen for patients who were actively seeking medical cannabis to treat anxiety or depression. From 12 months on, those reporting anxiety had an average decrease in GAD-7 scores that was greater than the minimum clinically important difference of 4, and the same was seen for patients reporting depression from 18 months on, with the average decrease in PHQ-9 scores more than the MCID minimum clinically important difference of 5. This study provides some evidence to support the effectiveness of medical cannabis as a treatment for anxiety and depression.
Article
Given the rapid change in legal status and rise in cannabis use within the United States (U.S.), pharmacists will increasingly require competence in issues related to cannabis, especially for medical use. Pharmacy students and professionals in other health fields report low levels of cannabis knowledge, and medical cannabis users report that their knowledge is mostly from their own experiences and the internet. Several pharmacy organizations have advocated for pharmacists' education on therapeutic and legal issues related to medical cannabis. To determine the extent to which cannabis and its medical use are covered in the educational curricula of U.S. schools and colleges of pharmacy, plans for future coverage of medical cannabis, and differences by the state‐level legal status of cannabis. Pharmacy schools and colleges located within the U.S. were identified via the Accreditation Council for Pharmacy Education website. A 19‐item survey was developed by researchers with experience in curriculum development and pharmaceutical issues related to cannabis. One individual from each school provided detailed information on the inclusion of medical cannabis/marijuana topics in their Doctor of Pharmacy program. Two‐thirds (67%) of programs responded to the survey. Most programs (85.4%) had content on medical cannabis available in their curriculum, 53.1% in their required curriculum, 65.6% in their elective curriculum, and 33.0% in both their required and elective curricula. A small proportion (16.7%) had a stand‐alone medical cannabis elective course. Stand‐alone electives had the most comprehensive coverage of cannabis topics. General required and elective courses had minor differences in comprehensiveness. Results demonstrate a moderately rapid expansion in cannabis coverage in pharmacy curricula, although coverage of cannabis topics is rarely comprehensive. Additional efforts are needed to integrate cannabis into coursework and experiential learning experiences.
Article
Objectives: To examine the proportion of individuals using cannabis for medical purposes who reported nonmedical use of cannabis after it became legal to do so. Materials and Methods: We acquired data from the Population Assessment for Tomorrow's Health, the Cannabis Legalization Surveillance Study on a subpopulation of participants residing in Hamilton, Ontario, Canada, who reported using cannabis for medical purposes. Specifically, we acquired data 6 months before, and again 6 months after, legalization of cannabis for nonmedical purposes. We constructed a logistic regression model to explore the association between potential explanatory factors and endorsing exclusively nonmedical use after legalization and reported associations as odds ratios and 95% confidence intervals. Results: Our sample included 254 respondents (mean age 33±13; 61% female), of which 208 (82%) reported both medical and nonmedical use of cannabis (dual motives) before legalization for nonmedical purposes, and 46 (18%) reported cannabis use exclusively for medical purposes. Twenty-five percent (n=63) indicated they had medical authorization to use medical cannabis, of which 37 (59%) also endorsed nonmedical use. After legalization of nonmedical cannabis, ∼1 in 4 previously exclusive cannabis users for medical purposes declared dual use (medical and nonmedical), and ∼1 in 4 previously dual users declared exclusively nonmedical use of cannabis. No individual with medical authorization reported a change to exclusively nonmedical use after legalization. Our adjusted regression analysis found that younger age, male sex, and lacking authorization for cannabis use were associated with declaring exclusively nonmedical use of cannabis after legalization. Anxiety, depression, impaired sleep, pain, and headaches were among the most common complaints for which respondents used cannabis therapeutically. Most respondents reported using cannabis as a substitute for prescription medication at least some of the time, and approximately half reported using cannabis as a substitute for alcohol at least some of the time. Conclusions: In a community sample of Canadian adults reporting use of cannabis for medical purposes, legalization of nonmedical cannabis was associated with a substantial proportion changing to either dual use (using cannabis for both medical and nonmedical purposes) or exclusively nonmedical use. Younger men without medical authorization for cannabis use were more likely to declare exclusively nonmedical use after legalization.
Article
Importance: Despite the legalization and widespread use of cannabis products for a variety of medical concerns in the US, there is not yet a strong clinical literature to support such use. The risks and benefits of obtaining a medical marijuana card for common clinical outcomes are largely unknown. Objective: To evaluate the effect of obtaining a medical marijuana card on target clinical and cannabis use disorder (CUD) symptoms in adults with a chief concern of chronic pain, insomnia, or anxiety or depressive symptoms. Design, setting, and participants: This pragmatic, single-site, single-blind randomized clinical trial was conducted in the Greater Boston area from July 1, 2017, to July 31, 2020. Participants were adults aged 18 to 65 years with a chief concern of pain, insomnia, or anxiety or depressive symptoms. Participants were randomized 2:1 to either the immediate card acquisition group (n = 105) or the delayed card acquisition group (n = 81). Randomization was stratified by chief concern, age, and sex. The statistical analysis followed an evaluable population approach. Interventions: The immediate card acquisition group was allowed to obtain a medical marijuana card immediately after randomization. The delayed card acquisition group was asked to wait 12 weeks before obtaining a medical marijuana card. All participants could choose cannabis products from a dispensary, the dose, and the frequency of use. Participants could continue their usual medical or psychiatric care. Main outcomes and measures: Primary outcomes were changes in CUD symptoms, anxiety and depressive symptoms, pain severity, and insomnia symptoms during the trial. A logistic regression model was used to estimate the odds ratio (OR) for CUD diagnosis, and linear models were used for continuous outcomes to estimate the mean difference (MD) in symptom scores. Results: A total of 186 participants (mean [SD] age 37.2 [14.4] years; 122 women [65.6%]) were randomized and included in the analyses. Compared with the delayed card acquisition group, the immediate card acquisition group had more CUD symptoms (MD, 0.28; 95% CI, 0.15-0.40; P < .001); fewer self-rated insomnia symptoms (MD, -2.90; 95% CI, -4.31 to -1.51; P < .001); and reported no significant changes in pain severity or anxiety or depressive symptoms. Participants in the immediate card acquisition group also had a higher incidence of CUD during the intervention (17.1% [n = 18] in the immediate card acquisition group vs 8.6% [n = 7] in the delayed card acquisition group; adjusted odds ratio, 2.88; 95% CI, 1.17-7.07; P = .02), particularly those with a chief concern of anxiety or depressive symptoms. Conclusions and relevance: This randomized clinical trial found that immediate acquisition of a medical marijuana card led to a higher incidence and severity of CUD; resulted in no significant improvement in pain, anxiety, or depressive symptoms; and improved self-rating of insomnia symptoms. Further investigation of the benefits of medical marijuana card ownership for insomnia and the risk of CUD are needed, particularly for individuals with anxiety or depressive symptoms. Trial registration: ClinicalTrials.gov Identifier: NCT03224468.
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Rationale Adolescent cannabinoid exposure has been shown to alter cognitive, reward-related, and motor behaviors as well as mesocorticolimbic dopamine (DA) function in adult animals. Pain is also influenced by mesocorticolimbic DA function, but it is not known whether pain or cannabinoid analgesia in adults is altered by early exposure to cannabinoids. Objective To determine whether adolescent Δ⁹-tetrahydrocannabinol (THC) exposure alters pain-related behaviors before and after induction of persistent inflammatory pain, and whether it influences antinociceptive of THC, in adult rats, and to compare the impact of adolescent THC exposure on pain to its effects on known DA-dependent behaviors such as exploration and consumption of a sweet solution. Methods Vehicle or THC (2.5 to 10 mg/kg s.c.) was administered daily to male and female rats on post-natal day (PND) 30–43. In adulthood (PND 80–88), sensitivity to mechanical and thermal stimuli before and after intraplantar injection of complete Freund’s adjuvant (CFA) was determined. Antinociceptive, exploratory, and consummatory effects of 2.0 mg/kg THC were then examined. Results Adolescent THC exposure did not significantly alter adult sensitivity to non-noxious or noxious stimuli either before or after CFA injection, nor did it alter the antinociceptive effect of THC. In contrast, adolescent THC exposure altered adult exploratory and consummatory behaviors in a sex-dependent manner: when tested as adults, adolescent THC-treated males showed less hedonic drinking than adolescent vehicle-treated males, and females but not males that had been THC-exposed as adolescents showed reduced sensitivity to THC-induced suppression of activity and THC-induced hedonic drinking as adults. Conclusions Adolescent THC exposure that altered both exploratory and consummatory behaviors in adults did not alter pain-related behaviors either before or after induction of inflammatory pain, suggesting that cannabinoid exposure during adolescence is not likely to substantially alter pain or cannabinoid analgesia in adulthood.
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