Cannabis For Therapeutic Purposes Research Articles

Therapeutic cannabis use by patients with cancer in Canada: A national survey of the experiences, opinions and information needs of Radiation Therapists

PurposeTo understand the experiences, opinions and information needs of Canadian Radiation Therapists when caring for cancer patients who are taking cannabis for therapeutic purposes (CTP). MethodsThe study employed prospective data collection, via a single cross-sectional web-based questionnaire. After REB approval, the questionnaire was distributed electronically to all Radiation Therapists across Canada. The questionnaire was open for a one month accrual, with reminders sent at two and four weeks. The raw data was aggregated using standard descriptive statistics. The response differences between naturally occurring demographic cohorts was determined using inferential statistics. ResultsTwo hundred and eighty two Therapists completed the questionnaire (25.6%), of which 19.1% reported being approached by patients to talk about cannabis more than once per month and 4.4% reported initiating a conversation with patients about cannabis. There were no differences between the provinces or catchment areas regarding how common or socially acceptable cannabis use by patients was. Confidence in discussing cannabis was strongly positively correlated with ratings of current knowledge (r² 0.77). Of the respondents, 99.9% believed that their radiation therapy training did not prepare them to support patients using cannabis. ConclusionsThe data revealed that patients more frequently seek out guidance for CTP than Therapists initiate those discussions. This lack of Therapist willingness to begin cannabis conversations was associated with the low levels of knowledge. Almost all Therapists recognized the limitations of their knowledge and expressed interest in receiving further information about cannabis. The findings of this study strongly advocate for the development of educational tools to meet Therapists clinical needs.

Patients experiences of therapeutic cannabis consumption in New Zealand

PurposeThis study aims to explore people’s experiences of taking cannabis therapeutically and to gather some real-world evidence (RWE) about the products they were using, their efficacy and what kinds of positive or negative effect/s patients experienced. The focus of this discussion is the efficacy of cannabis for the participants in this study.Design/methodology/approachThis was an exploratory study that used a mixed methods approach: a survey and semi-structured interviews. The data presented here focus on thematic analysis of five of the open-ended survey questions. Results from a purposive survey sample are also briefly reported. Interview data are not reported on here.FindingsAcross the sample (n = 213), 95.6% of participants reported that taking cannabis helped them with a number of conditions. The most common three themes across the thematic analysis were that cannabis helped with pain relief, sleep and anxiety. Negative effects, some of which related to having to source cannabis from the illicit market, were relatively minor and experienced by 28% (n = 58) of participants. An important finding was that 49% (n = 76) of those who said their use of prescribed medicines had decreased (n = 155), significantly decreased and in some cases stopped their use of prescribed medications.Originality/valueThis study reports on a sample of participants with clinically diagnosed conditions and adds to the RWE base about the efficacy of using cannabis for therapeutic purposes in the New Zealand context.

Tobacco/nicotine use among individuals using cannabis for therapeutic purposes.

While the relationship between recreational cannabis and nicotine use is well established, little is known about nicotine use among users of cannabis for therapeutic purposes (CTP). Patients attending a medical marijuana dispensary (N = 697; 75.3% White; 60.0% male) completed a survey examining nicotine use, motivation to quit cigarette smoking, routes of administration of nicotine and cannabis, and CTP qualifying conditions. More than one-third (39.3%) of participants reported current nicotine use. Compared to exclusive cigarette smokers, e-cigarette users and non-users of nicotine were approximately four times more likely to vape, rather than to smoke, cannabis. Furthermore, 46.8% of cigarette smokers reported plans to quit smoking in the next 6 months (but not in the next month) and an additional 31.6% planned to quit in the next month. Having a psychiatric condition was associated with nicotine use and higher motivation to quit smoking. Users of CTP are more likely to use nicotine products than the general population and the route of administration of nicotine products is related to the route of administration of CTP. If aerosolized CTP is a less harmful route of administration than smoked CTP, dispensary staff should be aware of this relationship and take this into account when recommending a noncombustible route. This study further characterizes nicotine use behaviors and motivation to quit smoking among users of CTP and may be among the first to examine nicotine use among patients of a medical marijuana dispensary.

Higher Risk, Higher Reward? Self-Reported Effects of Real-World Cannabis Use in Parkinson's Disease.

BackgroundDespite limited evidence, people with Parkinson's disease (PD) use cannabis for therapeutic purposes. Given barriers to performing randomized trials, exploring real‐world experiences with cannabis in PD is valuable.ObjectiveInvestigate the frequency and magnitude of symptomatic effects reported with cannabis use in PD.MethodsAn anonymous, 15‐question, web‐based survey was deployed on Fox Insight. Cannabis product types were defined (by relative tetrahydrocannabinol [THC] and cannabidiol [CBD] content) and respondents were asked to reference product labels. Questions focused on use patterns and subjective effects on 36 predefined symptoms (rated −2‐markedly worse to +2‐markedly better).Results1,881 people with PD responded (58.5% men; mean age 66.5; 50.5% <3 years of PD). 73.0% of respondents reported medicinal use, though 30.8% did not inform their doctor. 86.7% knew their type of cannabis product: 54.6% took higher CBD, 30.2% higher THC, and 15.2% took similar amounts of THC and CBD products. Most common use was oral administration, once daily, for less than six months. Frequent improvements were reported for pain, anxiety, agitation, and sleep (>50% of respondents, mean magnitude 1.28–1.51). Dry mouth, dizziness, and cognitive changes were common adverse effects (20.9%–30.8%, mean −1.13 to −1.21). Higher THC users reported more frequent improvements in depression, anxiety, and tremor, and more frequent worsening in dry mouth and bradykinesia than other product types.ConclusionsRespondents with PD reported using more CBD products, via oral administration, with mild subjective benefits primarily for sleep, pain, and mood. Higher THC products may be higher risk/higher reward for PD‐related symptoms.

Perceptions of Medical Cannabis Packaging and Labeling among Middle-Aged and Older Canadians

The use of cannabis for therapeutic purposes is becoming more popular in many countries, including the United States and Canada. In Canada, middle-aged and older adults make up the largest proportion of medical cannabis users. Canadian legislation mandates that medical cannabis be packaged in plain-looking containers with small labels, childproof caps, and required health warnings. This is meant to standardize the way cannabis products are distributed, as well as protect children from accidental ingestion. However, there is limited research on how these regulations affect cannabis users over age 45. In the present study, residents of Winnipeg, Manitoba, Canada aged 45 and older (n=40) were surveyed regarding their experiences with medical cannabis packaging and labeling. Half of the participants (50%) felt they had a hard time opening their medical cannabis container. A majority (60%) thought having an easy-open lid would be helpful. Most participants (78%) reported experiencing difficulties reading the label on their container, and 75% thought it would be helpful to have a printout of the label in a larger font. In addition, 89% of participants who took more than one kind of medical cannabis favored a symbol on their medication bottle that would indicate the type of medical cannabis contained inside. Implications for policy makers and future research are discussed.

A qualitative study of VHA clinicians' knowledge and perspectives on cannabis for medical purposes.

The legalization of cannabis is expanding across the USA, and its use has increased significantly, including among Veterans. Although the Veterans Health Administration (VHA) abides by the classification of cannabis as a Schedule I substance, it recently recommended that clinicians discuss cannabis with their patients. Little is known about VHA clinicians' perspectives on and knowledge of cannabis. We sought to better understand clinicians' attitudes, beliefs, knowledge and communication with patients regarding cannabis. We conducted semi-structured phone interviews with 14 VHA clinicians. Interviews were audio-recorded, transcribed verbatim and analysed using qualitative thematic analysis. VA clinicians described ambivalence towards cannabis for therapeutic purposes and identified several factors that inhibit conversations about cannabis use with their patients including discomfort with the lack of product standardization; lack of research examining the effectiveness and risks of cannabis use; unfamiliarity with pharmacology, formulations, and dosing of cannabis; and uncertainty regarding VHA policy. Clinicians had differing views on cannabis in the context of the opioid crisis. VA clinicians face challenges in navigating the topic of medical cannabis. Educational materials about cannabis products, dose and harms would be helpful to clinicians.

Quality of Life, Mental Health, Personality and Patterns of Use in Self-Medicated Cannabis Users with Chronic Diseases: A 12-Month Longitudinal Study.

The number of patients using cannabis for therapeutic purposes is growing worldwide. While research regarding the treatment of certain diseases/disorders with cannabis and cannabinoids is also expanding, only a few longitudinal studies have assessed the mid-term impacts of medical cannabis use on psychological variables and quality of life (QoL). The aim of the study was to assess the psychological safety and QoL of patients with chronic diseases who self-medicate with cannabis over time. We recruited patients with various chronic diseases who use cannabis and collected data regarding patterns of cannabis use as well as mental health, personality and QoL. Participants were followed-up at baseline, 4, 8 and 12 months. Hair analysis was conducted to confirm the presence of cannabinoids. Personality assessment showed a consistent decrease in self-transcendence and self-directedness scores. Neither cognitive nor psychopathological deterioration was found. There were also no variations in QoL. Mid-term use of medical cannabis seems to show adequate tolerability regarding cognitive and psychopathological abilities, and it may help patients with chronic diseases to maintain an acceptable QoL.

Cannabis education needs assessment among Canadian physicians-in-training

BackgroundSince 1999, the Canadian courts have recognized the rights of patients to access cannabis for therapeutic purposes (CTP). Due to the increasing interest in the use of CTP, competency with the topic among health care providers is essential. As concerns mount around the role of industry involvement in cannabis education, it has become increasingly important for medical schools to provide physicians-in-training balanced evidence regarding the harms and benefits of CTP. In the present study, we surveyed Canadian physicians-in-training regarding their knowledge, experience, attitudes, and barriers surrounding CTP. MethodsSurvey questions were adapted from extant physician and nurse practitioner education needs assessments. We invited representatives from all 17 Canadian universities with a Faculty of Medicine to electronically distribute the survey to physicians-in-training. ResultsThe survey was accessed by 93 physicians-in-training of whom 76 provided responses (46 % female; Mage = 28, SD = 3.03). Physicians-in-training reported receiving significantly less instruction on CTP than they desired. Responses demonstrated differences between current and desired knowledge across all domains queried. More education was the factor identified as most likely to increase comfort authorizing and discussing CTP with patients. ConclusionsFindings from this study demonstrate an expressed desire for more education surrounding CTP among a self-selected sample of Canadian physicians-in-training. There was a substantial divergence between current and desired levels of knowledge, and the largest gaps related to creating effective treatment plans and understanding the risks and benefits of CTP. Improving the educational opportunities of students will improve standard-of-care for patients.

The Canna(business) of Higher Education

While the idea of legalizing cannabis for adult use is gaining on acceptance among the public, the past and current policies on both, the state and federal level, have resulted in dearth of research on the efficacy of cannabis for therapeutic purposes as well as possible societal and health consequences of recreational use. Institutes of higher education are best positioned to not only reform research on the substance, but to train a generation of cultivators, distributors, and healthcare professionals, and while doing so address some of the historical harms perpetrated by the policies of the War on Drugs. Students are seeking out ways to capitalize on a growing market and remedying past discrimination should be a top priority. This paper first provides an overview of cannabis legalization as it stands today, the political efforts that got it here, and those that will move it forward. It then discusses institutes of higher education and the efforts to bring cannabis into the classroom. Lastly, this paper argues that Historically Black Colleges and Universities can provide education, training, and a foot in the door for Black individuals who have suffered harsher criminal penalties in the name of the war on crime.

New Perspectives on the Use of Cannabis in the Treatment of Psychiatric Disorders.

Following the discovery of the endocannabinoid system and its potential as a therapeutic target for various pathological conditions, growing interest led researchers to investigate the role of cannabis and its derivatives for medical purposes. The compounds Δ9-tetrahydrocannabinol and cannabidiol are the most abundant phytocannabinoids found in cannabis extracts, as well as the most studied. The present review aims to provide an overview of the current evidence for their beneficial effects in treating psychiatric disorders, including schizophrenia, anxiety, and depression. Nevertheless, further investigations are required to clarify many pending issues, especially those relative to the assessment of benefits and risks when using cannabis for therapeutic purposes, thereby also helping national and federal jurisdictions to remain updated.

A National Needs Assessment of Canadian Nurse Practitioners Regarding Cannabis for Therapeutic Purposes.

Introduction: In Canada, the Access to Cannabis for Medical Purposes Regulations (ACMPR) has given nurse practitioners (NPs) the power to authorize cannabis for therapeutic purposes (CTP) to eligible patients. This expansion in NPs' scope of practice underscores the importance of delivering balanced, evidence-based education on cannabis to NPs. The aim of this national study was to assess NPs' knowledge and practice gaps related to CTP to inform the development of future education resources that increase NPs' clinical competence and improve patient care related to medical cannabis.Methods: This is a quantitative, descriptive exploratory design study. A national online survey of NPs was conducted from August 2013 to June 2014. NPs were recruited through email lists held by numerous Canadian nursing organizations. The survey was adapted from a previous national survey that assessed CTP educational needs among Canadian physicians. The survey assessed NPs' knowledge, experience, barriers, and attitudes related to CTP as well as preferred format for future CTP education.Results: The sample consisted of 182 NPs from across Canada. The largest knowledge gap was related to dosing and creating effective treatment plans for patients using CTP. The majority of respondents (76.3%) ranked the need for education on CTP to be either strong or very strong. Over half (57%) reported that they would be comfortable authorizing medical cannabis through the ACMPR; this number increased to 64% if they were to receive appropriate education.Conclusion: Nursing regulatory organizations, in partnership with academic institutions and government agencies, must work toward the development of educational and clinical competencies specific to CTP. Tailored education programs are needed to address the knowledge gaps held by NPs and the clinical barriers they face to including CTP as part of their care.

Are dispensaries indispensable? Patient experiences of access to cannabis from medical cannabis dispensaries in Canada

BackgroundIn 2001, Canada established a federal program for cannabis for therapeutic purposes (CTP). Medical cannabis dispensaries (dispensaries) are widely accessed as a source of CTP despite storefront sales of cannabis being illegal. The discrepancy between legal status and social practice has fuelled active debate regarding the role of dispensaries. The present study aims to inform this debate by analysing CTP user experiences with different CTP sources, and comparing dispensary users to those accessing CTP from other sources. MethodsWe compared sociodemographic characteristics, health related factors and patterns of cannabis use of 445 respondents, 215 who accessed CTP from dispensaries with 230 who accessed other sources. We compared patients’ ratings of CTP sources (dispensaries, Health Canada's supplier, self-production, other producer, friend or acquaintance, street dealer) for quality and availability of product, safety and efficiency of access, cost, and feeling respected while accessing. ResultsPatients using dispensaries were older, more likely to have arthritis and HIV/AIDS, and less likely to have mental health conditions than those not using dispensaries. Those accessing dispensaries used larger quantities of cannabis, placed greater value on access to specific strains, and were more likely to have legal authorization for CTP. Dispensaries were rated equally to or more favourably than other sources of CTP for quality, safety, availability, efficiency and feeling respected, and less favourably than self-production and other producer for cost. ConclusionGiven the high endorsement of dispensaries by patients, future regulations should consider including dispensaries as a source of CTP and address known barriers to access such as cost and health care provider support. Further research should assess the impact of the addition of licensed producers on the role and perceived value of dispensaries within the Canadian medical cannabis system.

Therapeutic use of cannabis: Prevalence and characteristics among adults in Ontario, Canada

To investigate the prevalence of therapeutic cannabis use within a general population sample of adults and to describe various characteristics associated with use. Data were derived from the 2013 and 2014 CAMH Monitor Survey of adults in Ontario, Canada. This repeated cross-sectional survey employed a regionally stratified design and utilized computer-assisted telephone interviewing. Analyses were based on 401 respondents who reported using cannabis. The data indicated that 28.8% of those who used cannabis in the past year self-reported using cannabis for therapeutic purposes. Of therapeutic users, 15.2% reported having medical approval to use cannabis for therapeutic purposes. Cannabis use for therapeutic purposes was associated with more frequent use of cannabis, a moderate to high risk of problematic cannabis use, and a greater likelihood of using prescription opioids for medical purposes. There was little difference in cannabis use for therapeutic purposes according to sex, age, and marital status after adjusting for opioid use and problematic cannabis use. Findings suggest some potential negative consequences of cannabis use for therapeutic purposes; however, further research is needed to better understand the range and patterns of use and their corresponding vulnerabilities.

Irish general practitioner attitudes toward decriminalisation and medical use of cannabis: results from a national survey

BackgroundGovernmental debate in Ireland on the de facto decriminalisation of cannabis and legalisation for medical use is ongoing. A cannabis-based medicinal product (Sativex®) has recently been granted market authorisation in Ireland. This unique study aimed to investigate Irish general practitioner (GP) attitudes toward decriminalisation of cannabis and assess levels of support for use of cannabis for therapeutic purposes (CTP).MethodsGeneral practitioners in the Irish College of General Practitioner (ICGP) database were invited to complete an online survey. Anonymous data yielded descriptive statistics (frequencies, percentages) to summarise participant demographic information and agreement with attitudinal statements. Chi-square tests and multi-nominal logistic regression were included.ResultsThe response rate was 15% (n = 565) which is similar to other Irish national GP attitudinal surveys. Over half of Irish GPs did not support the decriminalisation of cannabis (56.8%). In terms of gender, a significantly higher proportion of males compared with females (40.6 vs. 15%; p < 0.0001) agreed or strongly agreed with this drug policy approach. A higher percentage of GPs with advanced addiction specialist training (level 2) agreed/strongly agreed that cannabis should be decriminalised (54.1 vs. 31.5%; p = 0.021). Over 80% of both genders supported the view that cannabis use has a significant effect on patients’ mental health and increases the risk of schizophrenia (77.3%). Over half of Irish GPs supported the legalisation of cannabis for medical use (58.6%). A higher percentage of those who were level 1-trained (trained in addiction treatment but not to an advanced level) agreed/strongly agreed cannabis should be legalised for medical use (p = 0.003). Over 60% agreed that cannabis can have a role in palliative care, pain management and treatment of multiple sclerosis (MS). In the regression response predicator analysis, females were 66.2% less likely to agree that cannabis should be decriminalised, 42.5% less likely to agree that cannabis should be legalised for medical use and 59.8 and 37.6% less likely to agree that cannabis has a role in palliative care and in the treatment of multiple sclerosis (respectively) than males.ConclusionsThe majority of Irish GPs do not support the present Irish governmental drug policy of decriminalisation of cannabis but do support the legalisation of cannabis for therapeutic purposes. Male GPs and those with higher levels of addiction training are more likely to support a more liberal drug policy approach to cannabis for personal use. A clear majority of GPs expressed significant concerns regarding both the mental and physical health risks of cannabis use. Ongoing research into the health and other effects of drug policy changes on cannabis use is required.

Characteristics of Individuals with Spinal Cord Injury Who Use Cannabis for Therapeutic Purposes.

Background: People with spinal cord injury (SCI) are accessing cannabis for therapeutic purposes (CTP), the use of which has been legalized in more than 20 states. In the past, illicit marijuana use had positive correlations with other health risk behaviors. It is not known whether access to CTP has shifted patterns of use and altered health outcomes. Objective: To describe the self-reported patterns of CTP use among individuals with SCI and correlations with health behaviors and health indicators. Method: Secondary analysis of data from a cross-sectional study involving community-dwelling individuals with chronic SCI and neurogenic bladder and bowel, at least 5 years post injury. Data were collected via structured interviews. Results: 92.2% of the current sample (n = 244) lived in states that, at the time of the study, permitted the use of CTP. 22.5% reported using CTP at least monthly to relieve pain (70.4%) and spasticity (46.3%). Of those 54 participants, 52.7% were daily users. Whereas 23.0% of non-CTP users endorsed having prescriptions for at least one opioid-based medication, 38.1% of CTP users did so, suggesting that CTP use does not mitigate opioid use. Users were more likely to be single and live alone, report more bladder complications, and perceive their psychosocial functioning as more compromised than non-users. Conclusion: A relatively large percentage of individuals with chronic SCI appear to use CTP on a regular basis. Results suggest that they may be more vulnerable to complications and to risk factors for substance use disorders in SCI, such as social isolation. Although the generalizability of these findings is limited by the sampling strategies and the eligibility criteria of the larger study, CTP use should be assessed and considered when planning health interventions.

Cannabis in medicine: a national educational needs assessment among Canadian physicians.

BackgroundThere is increasing global awareness and interest in the use of cannabis for therapeutic purposes (CTP). It is clear that health care professionals need to be involved in these decisions, but often lack the education needed to engage in informed discussions with patients. This study was conducted to determine the educational needs of Canadian physicians regarding CTP.MethodsA national needs assessment survey was developed based on previous survey tools. The survey was approved by the Research Ethics Board of the McGill University Health Centre Research Institute and was provided online using LimeSurvey®. Several national physician organizations and medical education organizations informed their members of the survey. The target audience was Canadian physicians. We sought to identify and rank using 5-point Likert scales the most common factors involved in decision making about using CTP in the following categories: knowledge, experience, attitudes, and barriers. Preferred educational approaches and physician demographics were collected. Gap analysis was conducted to determine the magnitude and importance of differences between perceived and desired knowledge on all decision factors.ResultsFour hundred and twenty six responses were received, and physician responses were distributed across Canada consistent with national physician distribution. The most desired knowledge concerned “potential risks of using CTP” and “safety, warning signs and precautions for patients using CTP”. The largest gap between perceived current and desired knowledge levels was “dosing” and “the development of treatment plans”.ConclusionsWe have identified several key educational needs among Canadian physicians regarding CTP. These data can be used to develop resources and educational programs to support clinicians in this area, as well as to guide further research to inform these gaps.

Is cannabis an illicit drug or a medicine? A quantitative framing analysis of Israeli newspaper coverage

BackgroundVarious countries and states, including Israel, have recently legalized cannabis for therapeutic purposes (CTP). These changes have received mass media coverage and prompted national and international dialogue about the status of cannabis and whether or not it can be defined as a (legitimate) medicine, illicit and harmful drug, or both. News media framing may influence, and be influenced by, public opinion regarding CTP and support for CTP license provisions for patients. This study examines the framing of CTP in Israeli media coverage and the association between media coverage and trends in the provision of CTP licenses in Israel over time. MethodsAll published news articles relevant to CTP and the framing of cannabis (N=214) from the three highest circulation newspapers in Israel were content analyzed. Articles were published between January 2007 and June 2013, a period in which CTP licenses granted by the Ministry of Health increased substantially. ResultsIn the majority of CTP news articles (69%), cannabis was framed as a medicine, although in almost one third of articles (31%) cannabis was framed as an illicit drug. The relative proportion of news items in which cannabis was framed as an illicit drug fluctuated during the study period, but was unrelated to linear or curvilinear trends in CTP licensing. ConclusionThe relatively large proportion of news items framing cannabis as a medicine is consistent with growing support for the expansion of the Israel's CTP program.

PC-FACS

PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at [email protected] PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at [email protected] Pavisian B, MacIntosh BJ, Szilagyi G, et al. Effects of cannabis on cognition in patients with MS: a psychometric and MRI study. Neurology 2014;82:1879-1887. Rahn EJ, Deng L, Thakur GA, et al. Prophylactic cannabinoid administration blocks the development of paclitaxel-induced neuropathic nociception during analgesic treatment and following cessation of drug delivery. Mol Pain 2014;10:27. Gates PJ, Albertella L, Copeland J. The effects of cannabinoid administration on sleep: a systematic review of human studies Sleep Med Rev 2014 March 7. [Epub ahead of print]. Lutge EE, Gray A, Siegfried N. The medical use of cannabis for reducing morbidity and mortality in patients with HIV/AIDS. Cochrane Database Syst Rev 2013;4:CD005175. Koppel BS, Brust JC, Fife T, et al. Systematic review: efficacy and safety of medical marijuana in selected neurologic disorders: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2014;82:1556-1563. Van den Elsen GAH, Ahmed AIA, Lammers M, et al. Efficacy and safety of medical cannabinoids in older subjects: a systematic review. Ageing Res Rev 2014;14:56-64. Bottorff JL, Bissell LJ, Balneaves LG, et al. Perceptions of cannabis as a stigmatized medicine: a qualitative descriptive study. Harm Reduct J 2013;10:2. Salomonsen-Sautel S, Min SJ, Sakai JT, Thurstone C, Hopfer C. Trends in fatal motor vehicle crashes before and after marijuana commercialization in Colorado. Drug Alcohol Depend 2014;140:137-144. Wang GS, Roosevelt G, Heard K. Pediatric marijuana exposures in a medical marijuana state. JAMA Pediatr 2013;167:630-633. Ache K, Harrold J, Harris P, Dougherty M, Casarett D. Are advance directives associated with better hospice care? J Am Geriat Soc 2014;62:1091-1096. Wolfe J, Orellana L, Cook EF, et al. Improving the care of children with advanced cancer by using an electronic patient-reported feedback intervention: results from the PediQUEST randomized controlled trial. J Clin Oncol 2014;32:1119-1126. Huffman JC, Mastromauro CA, Beach SR, et al. Collaborative care for depression and anxiety disorders in patients with recent cardiac events: the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized clinical trial. JAMA Intern Med 2014;174:927-935. Dev R, Hui D, Del Fabbro E, et al. Association between hypogonadism, symptom burden, and survival in male patients with advanced cancer. Cancer 2014;120:1586-1593. Sinha M, Jang YC, Oh J, et al. Restoring systemic GDF11 levels reverses age-related dysfunction in mouse skeletal muscle. Science 2014;344:649-652. Xafis V, Wilkinson D, Gillam L, Sullivan J. Balancing obligations: should written information about life-sustaining treatment be neutral? J Med Ethics 2014 Apr 24. [Epub ahead of print]. Payot A, Gendron S, Lefebvre F, Doucet H. Deciding to resuscitate extremely premature babies: how do parents and neonatologists engage in the decision? Soc Sci Med 2007;64 When we began planning this issue on cannabinoids, we didn't know how timely it would be. Yet recent events remind us that medicine has a sociocultural context: the August 3rd New York Times featured a full-page advertisement congratulating New York State on passing the Compassionate Care Act and advocating for the use of marijuana varietals for multiple sclerosis (MS) and cancer symptoms. Cannabinoids may be helpful analgesics for neuropathic pain in HIV, diminish symptoms of MS, and help manage chemotherapy-associated nausea. However, there is no clinical evidence that cannabinoids (in whole leaf or any pharmaceutical formulation) are superior to available treatments. I've seen them work, whatever that means. However, cannabinoids are not risk-free,1 and although these risks may be less important to palliative care patients than to others, they are significant for a society contemplating widespread access. It's also possible that “Big Marijuana” would promote as recklessly in the 21st century as “Big Tobacco” did in the 20th.2 In the United States, we have two U.S. Food and Drug Administration–approved cannabinoid drugs—dronabinol and nabilone—and may soon have a third—nabiximols, which is already available in Canada and England. But the uncertain chemical composition of whole-leaf marijuana limits meaningful discussions. Perhaps greater use of pharmaceutical cannabinoids will allow us to figure out what we're talking about. Sincerely, Thomas B. Strouse, MD, Senior Section Editor, Psychosocial 1.Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med 2014;370:2219-2227.2.Richter KP, Levy S. Big marijuana—lessons from big tobacco. N Engl J Med 2014;371:399-401. In patients with multiple sclerosis (MS), cannabis exacerbates problems with working memory,1 information processing speed, and executive dysfunction.2 Are there neural correlates of these effects? This was a cross-sectional imaging study of cognition among MS patients who smoke cannabis. Eligible individuals had an MS diagnosis; regularly used cannabis (positive urine test for metabolites); and had no history of brain injury, illicit drug use (excluding cannabis), alcohol abuse, concurrent neurologic or psychiatric diseases, or steroid use within 3 months. Controls (nonusers) were group-matched on demographic and disease-related variables. Participants abstained from cannabis for 12 hours before testing. Imaging data collected were an fMRI performed during completion of a working memory test (N-Back), resting-state fMRI, and structural MRI (lesion and normal-appearing brain tissue volumes, diffusion tensor imaging). Neuro-psychological data collected were verbal memory (Selective Reminding Test Revised), visual memory (10/36 Spatial Recall Test), information processing speed (Paced Auditory Serial Addition Test [PASAT], Symbol Digit Modalities Test), and attention (Word List Generation). Participants (N = 39) were mean age 42 years and 31% female. No between-group differences in resting-state networks or structural MRI variables were found. Cannabis users had more diffuse cerebral activation across all N-Back trials. They made more errors on the 2-Back task (P = 0.006), displaying greater activation than controls in working memory regions (parietal [P = 0.007] and anterior cingulate [P =0.001]). The cannabis group performed worse on the 2-second PASAT (P < 0.02) and 10/36 test (P < 0.03). Global cognitive impairment did not correlate with frequency of cannabis use or urine concentration of cannabis metabolites (both r = 0.32; both P = 0.17). The key finding in this well-designed trial in patients with MS is that marijuana, used primarily for spasticity, exacerbated baseline difficulties with some elements of cognition. Verbal memory and attention were unimpaired, but increasing task complexity demonstrated deficits that correlated with marijuana use. As with all other agents, the use of cannabinoids for symptom management in hospice and palliative medicine patients should be based on patients' goals of care, the efficacy of the drug's use (not explored in this article), and potential side effects that may limit the ability to work or complete complex tasks as shown in this study. Marijuana, like most of our interventions, is not an entirely benign drug. Chronic marijuana use causes functional changes in the brains of patients with MS that correlate with impaired cognition, most noticeably as task complexity increases. Tommie W. Farrell, MD, Texas Tech University Health and Science Center School of Medicine, Lubbock, TX. Pavisian B, MacIntosh BJ, Szilagyi G, et al. Effects of cannabis on cognition in patients with MS: a psychometric and MRI study. Neurology 2014;82:1879-1887. 1.Ghaffar O, Feinstein A. Multiple sclerosis and cannabis: a cognitive and psychiatric study. Neurology 2008;71: 164-169.2.Honarmand K, Tierney MC, O'Connor P, Feinstein A. Effects of cannabis on cognitive function in patients with multiple sclerosis. Neurology 2011;76:1153-1160. Neuropathic pain is a dose-limiting chemotherapy side effect and a major factor in treatment discontinuation.1,2 Can prophylactic cannabinoids help prevent paclitaxel-induced nociception? This preclinical study built on prior findings that cannabinoid agonists suppress paclitaxel-induced neuropathic nociception in animal models through activation of both CB1 and CB2 cannabinoid receptor subtypes.3,4 The investigators administered to rats WIN55,212-2 (a CB1 and CB2 agonist) and AM1710 (a CB2-preferring agonist) before, during, and after paclitaxel treatment, continuously infusing these cannabinoids subcutaneously via osmotic mini-pumps. Development of mechanical and cold allodynia (common clinical manifestations of paclitaxel-induced neuropathy) was then evaluated. Pharmacological specificity was assessed using CB1 and CB2 antagonists. Impact on transcriptional regulation of mRNA markers of astrocytes (GPAF), microglia (CD11b), and cannabinoid receptors (CB1, CB2) was assessed in lumbar spinal cords of paclitaxel- and vehicle-treated rats. Both WIN55,212-2 and AM1710 blocked the development of paclitaxel-induced mechanical and cold allodynia; effects persisted for 2-3 weeks following drug cessation. WIN55,212-2 suppressed development of both mechanical and cold allodynia. CB1 activation dominated the suppression of mechanical hypersensitivity; blockade by either CB1 or CB2 antagonists did not significantly alter cold allodynia. AM1710 suppressed mechanical allodynia but only suppressed cold allodynia at the highest dose. CB2 mediated the anti-allodynic effects of AM1710; the duration of efficacy was longer than that induced by WIN55,212-2. mRNA expression of GFAP was marginally increased by paclitaxel treatment; expression of CD11b was unchanged. Both WIN55,212-2 and AM1710 increased CB1 and CB2 mRNA expression in lumbar spinal cords; AM630 (a CB2 antagonist) blocked this effect. This preclinical study using an animal model for paclitaxel-induced mechanical and cold allodynia showed cannabinoids prevent the development of neuropathy and continue to protect against neuropathy even after discontinued. The contribution of the CB1 and CB2 receptors to antinociception varied, with CB1 being more important in preventing mechanical allodynia, and the selective CB2 agonist produced a longer duration of benefit. Other than up-regulation of cannabinoid receptors, the mechanism of the antinociceptive action remains unclear because microglia or astrocyte mRNA expression was not significantly increased. Although prior preclinical studies3,4 have shown that CB1 and CB2 receptors mediate antinoceptive effects, a randomized, controlled trial showed no statistical difference between cannabinoids and placebo in treating patients with established chemotherapy-induced peripheral neuropathy.5 Cannabinoids prevent paclitaxel-induced peripheral neuropathic pain in an animal model but need to be evaluated in controlled human studies before their prophylactic use can be recommended. Egidio Del Fabbro, MD, Virginia Commonwealth University, Richmond, VA. Rahn EJ, Deng L, Thakur GA, et al. Prophylactic cannabinoid administration blocks the development of paclitaxel-induced neuropathic nociception during analgesic treatment and following cessation of drug delivery. Mol Pain 2014;10:27. 1.Wolf S, Barton D, Kottschade L, Grothey A, Loprinzi C. Chemotherapy-induced peripheral neuropathy: prevention and treatment strategies. Eur J Cancer. 2008;44(11):1507-1515.2.Kannarkat G, Lasher EE, Schiff D: Neurologic complications of chemotherapy agents. Curr Opin Neurol 2007;20:719-725.3.Pascual D, Goicoechea C, Suardíaz M, Martín MI. A cannabinoid agonist, WIN55,212-2, reduces neuropathic nociception induced by paclitaxel in rats. Pain 2005;118:23-34.4.Rahn EJ, Zvonok AM, Thakur GA, et al. Selective activation of cannabinoid CB2 receptors suppresses neuropathic nociception induced by treatment with the chemotherapeutic agent paclitaxel in rats. J Pharmacol Exp Ther 2008;327: 584-591.5.Lynch ME, Cesar-Rittenberg P, Hohmann AG. A double-blind, placebo controlled, crossover pilot trial with extension using an oral mucosal cannabinoid extract for treatment of chemotherapy-induced neuropathic pain. J Pain Symptom Manage 2014;47:166-173. Use of cannabis for medical purposes remains contested. This literature review searched eight electronic databases for clinical studies that included cannabinoid administration and one or more quantitative measures of sleep. A custom-built assessment of article quality and risk of bias was applied. Thirty-nine articles met the inclusion criteria. Many studies were old; sample sizes were often small. Studies overwhelmingly contained a substantial risk of bias, often not controlling for other substance use, using measures without psychometric validation, and failing to blind participants. Conclusions cannot be drawn, but evidence suggests that cannabis use may cause a decrease in slow wave sleep time, and correspondingly more time spent in stage 2 sleep, but no consistent effect on total sleep time. There may be a small dose effect. Medicinal cannabis users with preexisting sleep-interrupting symptoms (e.g., pain) may benefit. This Cochrane review searched CENTRAL/CCTR; MEDLINE; Embase; and journals, reference lists, and conference proceedings for quasirandomized/randomized, controlled trials of cannabis, smoked or ingested, versus placebo or other treatment. Primary outcomes were mortality and morbidity (frequency, type, duration of episodes of infection; malignancies; AIDS incidence; hospital admissions; other illnesses). Secondary outcomes included weight, appetite, pain, mood, and quality of life. Eight articles (seven studies) were included. Studies had short durations (21-84 days). Insufficient information and bias risk prevent conclusions; evidence for substantial effects was slim. Data from one study (N = 139) could be analyzed. Participants who received dronabinol were more likely to gain 2 kg or more than participants receiving placebo (RR, 2.1; 95% CI, 0.7-6.1). Mean weight gain among dronabinol recipients was 0.1 kg, versus -0.4 kg (placebo). This systematic review searched MEDLINE, Embase, PsycINFO, Web of Science, and Scopus for studies evaluating cannabis for symptoms of multiple sclerosis (MS), epilepsy, and movement disorders. Effectiveness varied with different formulations (oral cannabis extract, nabiximols, tetrahydrocannabinol). In patients with MS, some benefit was reported for spasticity, central pain/painful spasms, and urinary dysfunction. Little evidence of effectiveness was found for other neurologic conditions. Risk of serious adverse psychopathologic effects was nearly 1%. Most commercially available cannabinoids target CB1 receptors, except nabiximols, which also contain cannabidiol which targets nonclassic (CB1, CB2) receptors There is conflicting data concerning cannabinoids' effects on sleep architecture. Cannabidiol may actually be activating. The most consistent finding is subjective sleep improvement for those in pain. Cannabinoids increased weight (predominantly fat), reduced nausea and peripheral neuropathic pain (numbers needed to treat [NNT], 5), and minimally reduced protease inhibitor levels in HIV-infected individuals. Weight gain was only 0.1 kg on average, which may not be clinically relevant. HIV-infected individuals treated with cannabinoids experience more severe adverse events (8.3%) relative to placebo. For patients with MS, subjective but not objective spasticity is reduced, central pain improves (NNT, 5-8), and bladder spasms improve only with nabiximols, suggesting that cannabidiol is the important cannabinoid. Posture and balance worsen with cannabinoids. The data do not justify the widespread use of “medicinal cannabis” and self-prescribing. The development of cannabinoids selective for CB2 receptors, “orphan receptors,” and transient potential receptors will have a greater therapeutic index and safety margin and should be pursued in clinical trials. My fear is that widespread public use of “medicinal cannabis” will contaminate these trials. Commercially available cannabinoids improve sleep in individuals with pain and improve several other symptoms in patients with HIV and MS. Mellar P. Davis, MD, FCCP, FAAHPM, Taussig Cancer Institute, The Cleveland Clinic, Cleveland, OH. Gates PJ, Albertella L, Copeland J. The effects of cannabinoid administration on sleep: a systematic review of human studies Sleep Med Rev 2014 March 7. [Epub ahead of print]. Lutge EE, Gray A, Siegfried N. The medical use of cannabis for reducing morbidity and mortality in patients with HIV/AIDS. Cochrane Database Syst Rev 2013;4:CD005175. Koppel BS, Brust JC, Fife T, et al. Systematic review: efficacy and safety of medical marijuana in selected neurologic disorders: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2014;82:1556-1563. International Web-based surveys show a low percentage of older users of medical cannabis, but in the Netherlands, more than 33% of prescription users are older than 60 years.1,2 Is medical marijuana safe and effective for older people? This Dutch systematic review searched PubMed, Embase, CINAHL, and Cochrane Library databases for therapeutic studies of cannabis for older patients. Eligible studies were prospective, controlled, intervention trials that included exclusively older participants (age 65 years or older) or provided separate results for this subgroup and that studied and reported the efficacy, safety, or pharmacokinetics of medical cannabinoids. Quality assessment was conducted using a modified Effective Practice and Organization of Care form. A consensus-based risk of bias table was constructed. Five studies met the inclusion criteria (N = 267); all were randomized, controlled trials with crossover design. Interventions studied were oral tetrahydro-cannabinol (THC; three studies) and oral THC combined with cannabidiol (two studies). Meta-analysis was infeasible because of the great clinical and methodological diversity across studies; four of five studies showed a moderate to high risk of bias in several domains. Results were analyzed through qualitative, descriptive summarization. No evidence of efficacy was found to support the use of medical cannabis to improve dyskinesia, breathlessness, and chemotherapy-induced nausea and vomiting. Two studies showed THC to be beneficial in treating anorexia and behavioral symptoms in dementia; small sample sizes and low/moderate methodological quality prevented definitive conclusions. Despite the relatively low doses used, adverse events were more frequently reported with cannabinoids versus control; most adverse events concerned neuropsychiatric symptoms (e.g., drowsiness, tiredness, somnolence). American society is increasingly open to the potential therapeutic uses of marijuana and cannabinoid pharmaceuticals. Twenty-three states and the District of Columbia have legalized medical cannabis, and two have legalized recreational use (Colorado and Washington). Medical marijuana may provide symptom relief for some acute and chronic medical conditions, particularly in our aging population. In this review, adverse effects deterred treatment, with improvement seen only in anorexia and dementia. Palliative medicine providers, who often care for elderly patients with multiple comorbidities, may benefit from recognizing the potential palliative value of cannabinoids. Cannabis has shown potential benefit as an appetite stimulant, antiemetic, antispasmodic, and analgesic but has been inadequately studied in the elderly.3 Better studies are needed to evaluate the safety and efficacy of cannabinoids in the geriatric population. The potential value of medical cannabis in elderly patients will hopefully drive more research on its safety and effectiveness in this vulnerable population. David B. Brecher, MD, FAAFP, FAAHPM, Tacoma General Hospital, MultiCare Health System, Tacoma, WA. Van den Elsen GAH, Ahmed AIA, Lammers M, et al. Efficacy and safety of medical cannabinoids in older subjects: a systematic review. Ageing Res Rev 2014;14:56-64. 1.Hazekamp A, Heerdink ER. The prevalence and incidence of medicinal cannabis on prescription in the Netherlands. Eur J Clin Pharmacol 2013;69:1575-1580.2.Hazekamp A, Ware MA, Muller-Vahl KR. The medicinal use of cannabis and cannabinoids—an international cross-sectional survey on administration forms. J Psychoactive Drugs 2013;45:199-210.3.Ben Amar M. Cannabinoids in medicine: a review of their therapeutic potential. J Ethnopharmacol 2006;105: 1-25. Despite changes in public attitudes toward marijuana, users of cannabis for therapeutic purposes (CTP) continue to experience stigma and risk related to CTP use, particularly in interactions with authorities including employers, landlords, and law enforcement.1,2 How do users perceive and respond to the stigma associated with CTP? This Canadian, qualitative, descriptive study utilized qualitative methods, inductive analysis, and purposive sampling to develop an in-depth understanding of the experiences of CTP users. Participants were recruited through four community-based cannabis dispensaries in British Columbia and an online forum (2007-2008). Eligible individuals were age 19 years or older and reported using CTP in the last 30 days and for more than six consecutive months. Data were collected in semistructured, individual face-to-face or telephone interviews lasting 1-3 hours. Interview transcripts were analyzed using an inductive thematic approach. Participants (N = 23) were mean age 45 years (range, 25-66) and 57% female with an average annual income of $21,000. Participants described many experiences of stigma associated with their CTP use, arising in interactions with family, close friends, and others. Three dimensions of stigma were identified: others' negative views of cannabis as a recreational drug, others' assumption of or perspective on illegal activity surrounding cannabis use, and participants' vulnerabilities related to poverty and particular illnesses/disabilities. Most participant experiences touched on one or more dimensions. Participants described efforts to negotiate social censorship, disapproval, threats, and isolation. Principal coping strategies were keeping CTP use undercover, convincing others of CTP benefits, being responsible in their use of CTP, and actively defending their right to choose their medication. More than 80% of Americans favor legalizing medical cannabis, and 23 states and the District of Columbia have already done so.3 The number of patients using medical cannabis ranges from 1% of the population in Vermont to 21% in Colorado, with a national average of 7%.4 There is data supporting medical cannabis for HIV neuropathy and wasting, chemotherapy-related nausea, and multiple sclerosis-related spasticity,5 although many websites promote its use for diverse diseases ranging from Alzheimer's to arthritis.6 What this study showed is that even where medical cannabis is legal, patients feel stigmatized by health care professionals, workers, and family for using it. They react by becoming socially withdrawn, not telling others and limiting their interactions with health care providers. Even when medicines are legal, patients may feel stigmatized by their use and respond by withdrawing; therefore, asking about this issue is important. Robert M. Arnold, MD, FAAHPM, University of Pittsburgh Palliative and Supportive Institute, UPMC Health System, Pittsburgh, PA. Bottorff JL, Bissell LJ, Balneaves LG, et al. Perceptions of cannabis as a stigmatized medicine: a qualitative descriptive study. Harm Reduct J 2013;10:2. 1.Hathaway AD. Cannabis users' informal rules for managing stigma and risk. Deviant Behav 2004;25:559-577.2.Johnson BD, Ream GL, Dunlap E, Sifaneck SJ. Civic norms and etiquettes regarding marijuana use in public settings in New York City. Subst Use Misuse 2008;43:895-918.3.Wikipedia website. Medical cannabis in the United States. Wikipedia website. Available from http://en.wikipedia.org/wiki/Medical_cannabis_in_the_United_States. Accessed July 19, 2014.4.ProCon.org. How many people in the United States use medical marijuana? Available from http://medicalmarijuana.procon.org/view.answers.php?questionID=001199. Accessed July 19, 2014.5.Grant I, Hampton Atkinson J, Gouax B, Wilsey B. Medical marijuana: clearing away the smoke. Open Neurol J 2012;6: 18-25.6.ProCon.org. Disease/conditions. Available from http://medicalmarijuana.procon.org/view.subissues.php?issueID=000029. Accessed July 19, 2014. Medical marijuana became legal and commercially available in Colorado mid-2009. This retrospective data analysis utilized records from the Fatality Analysis Reporting System from 1994-2011. Analyses were completed for Colorado and all 34 states that did not have medical marijuana laws through 2011. Colorado's post-commercialization period for marijuana was defined as July 2009-2011. Temporal changes in proportions of drivers in a fatal motor vehicle crash (MVC) who were alcohol-impaired (≥ 0.08 g/dl) or marijuana-positive were examined. In Colorado, the trend in proportion of drivers in fatal MVCs who were marijuana-positive was negative before mid-2009 (t = -2.4; P = 0.02), and positive after mid-2009 (t = 4.8; P = 0.0001). This proportion was erratic over the precommercialization period, then climbed sharply from 5.9% in the first half of 2009 to 10% in late 2011. No significant changes were seen in states without legalized marijuana, or in proportions of drivers in fatal MVCs who were alcohol-impaired in Colorado or other states. This retrospective cohort study was conducted in a tertiary-care children's hospital emergency department (ED) in Colorado. Eligible individuals were age 12 years or younger and evaluated for toxic ingestion from 2005-2011. The proportion of marijuana ingestions before/after modification of relevant Colorado drug enforcement laws (before/after October 2009) was compared. Participants (N = 1378) were 790 before and 588 after; median age (IQR) 2.6 years (1.6-3.0) and 2.3 years (1.5-3.6), respectively; and 57% male. From 2005 to September 30, 2009, no patients age 12 years or younger presented at the ED with marijuana ingestion. From October 1, 2009, through 2011, 14 patients in this age bracket had confirmed marijuana ingestion (urine toxicology screen). The age of exposed patients ranged from 8 months to 12 years; 64% were male. Most had central nervous system effects (e.g., lethargy, somnolence); respiratory insufficiency was the most serious symptom. These two studies demonstrate that there are hidden costs to medical marijuana use. Although the overall car crash fatality did not increase in Colorado after 2009, marijuana's role in these deaths doubled after legalization. Tests are currently not quantitative and it is not known whether there is a safe threshold. In the pediatric intoxication study, important takeaways are that the “medications” were often in candy, baked goods, or soft drinks; that ingestions were not acknowledged, whether unobserved or socially embarrassing, leading to invasive and expensive work-ups; and that most of these “medications” belonged to grandparents, who are potentially hospice and palliative care patients. There is no child-proofing or warning required at present for medical marijuana. Patients and families should be made aware of impaired driving concerns and alerted to keep “medications” in any form, including food substances, out of the reach of children. Medical marijuana poses an increased risk of vehicular death and child injury. Marcia Levetown, MD, FAAHPM, HealthCare Communication Associates, Houston, TX. Salomonsen-Sautel S, Min SJ, Sakai JT, Thurstone C, Hopfer C. Trends in fatal motor vehicle crashes before and after marijuana commercialization in Colorado. Drug Alcohol Depend 2014;140:137-144. Wang GS, Roosevelt G, Heard K. Pediatric marijuana exposures in a medical marijuana state. JAMA Pediatr 2013;167:630-633. Growing evidence suggests that advance directives (ADs) are associated with less aggressive treatments and better patient outcomes in various health care settings.1-3 Do patients with versus without ADs at hospice enrollment have different patterns of care and outcomes? This retrospective cohort study used electronic health records from three hospices participating in the Coalition of Hospices Organized to Investigate Comparative Effectiveness (CHOICE) network. Eligible individuals were admitted to hospice between 2008 and 2012. Extracted data included documentation of AD at time of admission, demographic and clinical data, site of care, and Palliative Performance Status score. Propensity score was used to create a logistic regression model that accommodated nonrandom assignment between groups (AD, no AD). Outcomes of interest were timing of enrollment in hospice relative to death, rates of voluntary withdrawal from hospice, and site of death. Of the total participants (N = 49,370), participants with ADs (n = 35,968) were mean age 81 years (IQR, 75-90), 42% male, and 91% white; part

Cannabis for Therapeutic Purposes and public health and safety: A systematic and critical review

BackgroundThe use of Cannabis for Therapeutic Purposes (CTP) has recently become legal in many places. These policy and legal modifications may be related to changes in cannabis perceptions, availability and use and in the way cannabis is grown and sold. This may in turn have effects on public health and safety. To better understand the potential effects of CTP legalization on public health and safety, the current paper synthesizes and critically discusses the relevant literature. MethodsTwenty-eight studies were identified by a comprehensive search strategy, and their characteristics and main findings were systematically reviewed according to the following content themes: CTP and illegal cannabis use; CTP and other public health issues; CTP, crime and neighbourhood disadvantage. ResultsThe research field is currently limited by a lack of theoretical and methodological rigorous studies. The review shows that the most prevalent theme of investigation so far has been the relation between CTP and illegal cannabis use. In addition, the literature review shows that there is an absence of evidence to support many common concerns related to detrimental public health and safety effects of CTP legalization. ConclusionAlthough lack of evidence provides some reassurance that CTP legalization may not have posed a substantial threat to public health and safety, this conclusion needs to be examined in light of the limitations of studies conducted so far. Furthermore, as CTP policy continues to evolve, including incorporation of greater commercialization, it is possible that the full effects of CTP legalization have yet to take place. Ensuring study quality will allow future research to better investigate the complex role that CTP plays in relation to society at large, and public health and safety in particular.

Barriers to access for Canadians who use cannabis for therapeutic purposes

BackgroundThere is increased interest in the therapeutic potential of cannabis in recent decades. Canada, the Netherlands, Israel and some states in the United States have developed programs to allow access to cannabis for therapeutic purposes (CTP). In Canada, enrollment in the federal CTP program represents fewer than 5% of the estimated users of CTP. The discrepancy between the number of Canadians who report using CTP and the rate of utilization of the federal CTP program suggests the existence of barriers to access to this program. MethodsIn the present study we employ a health services analytical framework to examine barriers to access to CTP among 628 current CTP users. We define barriers to access as areas of poor fit between clients and services. We use five dimensions of accommodation, accessibility, availability, affordability, and acceptability to examine access to CTP. ResultsOur findings reveal that it is difficult for Canadians to find a physician to support their application to access CTP. Accessing CTP from unauthorized sources was common; only 7% of respondents accessed CTP exclusively from authorized sources. Access to CTP was positively associated with the presence of medical cannabis dispensaries, which were not included in the regulatory regime. Access to CTP varied by medical condition and general quality of health. Affordability of CTP was a substantial barrier to access. ConclusionsStrategies need to be developed to encourage scientific inquiry into CTP and address the barriers to access to CTP and the stigma and controversy that surround CTP and strain patient–physician relationships.