Similar to the overall sample, frequency of past-week cannabis use in these groups returned to levels comparable to baseline for the remainder of the study period. Collectively, these findings offer new insight into patterns of cannabis use over time throughout the pandemic among U.S. adults. Our findings are broadly consistent with studies from other countries, including some European countries and Canada . In a study of adults who use cannabis in the European Union, self-reported cannabis use remained stable overall, with 42% of participants reporting no change in use between April 8 and May 25, 2020. Increases in frequency and quantity of cannabis use were larger among those who used cannabis regularly rather than occasionally . Another repeated cross-sectional study of Canadian adults showed cannabis use in the overall population remained unchanged during the pandemic between May and June 2020. Though about 50% of the individuals who reported using cannabis stated that their cannabis use had increased, the reported number of days cannabis was used in the last seven days remained stable over the study period . Other cross-sectional studies from France and Belgium at the start of national lockdowns further reported findings of overall cannabis use remaining stable . Though these findings are generally consistent with ours, comparison is limited due to the non-representative and cross-sectional nature of these studies that report changes only in the first wave of lockdowns between March and June 2020. The U.S. context of cannabis policies and access is important to consider when reflecting on factors that may have influenced these trends. The marginal changes in cannabis use among some groups early on in the pandemic may have been influenced by public health measures implemented to reduce the spread of COVID-19.
One such consideration is the role of stay-at-home orders and social distancing measures indirectly impacting behaviors among those who obtain cannabis drying racks through illicit markets or peers. For example, our data show that in states where cannabis is prohibited, days of cannabis use had a decreasing trend, although not statistically significant, over the course of the COVID-19 pandemic, with November having the greatest decrease compared to March. The study from the European Union notes that Ireland, Italy, Poland, and Portugal were the countries with the largest proportions of cannabis use reduction or stopped use, citing Italy’s restrictions on movement within regions and Portugal’s reported decrease in availability as factors in impeding access to cannabis . On the other hand, in states where medical cannabis was legally available, the level of cannabis use across the first 8 months of the pandemic was either similar to or modestly greater than baseline. Increased use in states that allow medical cannabis use may be an indicator of an exacerbation of common conditions treated with medical cannabis, including anxiety and insomnia. A prior study of US adults who use cannabis medicinally found that those with anxiety or depression reported increased use during the pandemic . Though the current study does not indicate that cannabis use increased significantly during the pandemic, there is a need to continue public health surveillance to monitor changes in cannabis use. As states expand efforts to vaccinate the larger US population and social distancing measures begin to be lifted in parts of the US, cannabis availability may return to normal for portions of the population that may have had limited access to cannabis during earlier phases of the pandemic. In the interest of further understanding the long-term effects of the pandemic on cannabis use, monitoring and further studies are needed. Future research should also explore associations between changes in cannabis use and mental health status before, during, and following the pandemic. This study has several limitations that should be considered when interpreting findings. First, the survey only included measures of quantity, contents, or mode of cannabis consumption at two time points,Waves 4 and 5.
Therefore, we are not able to understand changes in cannabis use that may be more clinically meaningful over time, such as quantity and mode of consumption. Second, there are sociodemographic characteristics known to be associated with cannabis use behaviors, such as education and sexual or gender identity , that were not examined in this study. In addition, although most states with operational dispensaries deemed them “essential services”, there were some time-variant changes in guidelines, including capacity limits, operating curbside pick-up, and delivery, that we were not able to account for in our analyses. These quickly evolving guidelines may have impacted individual access to cannabis and potentially cannabis use behaviors within certain populations. Further, due to small sample size, some sociodemographic groups were combined in our analyses; for example, Native Hawaiian/Pacific Islanders, American Indian/Alaskan Natives, and those reporting more than one race were categorized as “Other.” It is also noted that some categories consisted of small sample sizes that may lack the statistical power to capture differences in trends across subgroups. These groups should be considered for future research to understand trends of cannabis use among these populations. Third, the analyses were conducted among individuals who ever used cannabis during the study period and may not be representative of all adults who use cannabis. Fourth, this panel did not have data on cannabis use prior to March 10th, and therefore we were not able to identify initiators of cannabis use or capture changes in cannabis use that may have occurred before the start of lockdown measures. Fourth, although our survey weights were adjusted for non-response using baseline characteristics, they were not post stratified to account for non-response at each follow-up wave, which may have affected the representativeness of our sample and the generalizability of our findings.The therapeutic use of cannabis dates back several thousands of years, however, during the early 20th century a global trend of cannabis prohibition emerged, resulting in an almost 100 year gap in clinical use and research advancement.
Therapeutic use among patients has continued despite legal status and recent introduction of medical cannabis regulations in more than 30 countries has permitted millions of patients to legally access medical cannabis and has revived the production of medical cannabis research. There has been growing evidence of the therapeutic effects of cannabinoid-based treatments in several conditions including chemotherapy-induced nausea and vomiting, chronic pain, drug resistant epilepsy, spasticity associated to multiple sclerosis and insomnia.2 Yet access to cannabinoid-based products and clinical knowledge of effective initiation and monitoring is still poor, partly because of a lack of proper integration of healthcare settings or formal medical education. Dedicated medical cannabis facilities can provide innovative care and education, based on and for patient’s needs. They may also assist and train physicians in prescribing personalized treatments and navigating through the complex administrative and regulatory framework of medical cannabis. Various settings have been employed over time, from buyer’s or compassion clubs to dispensaries to, more recently, private medical clinics. However, there has been virtually no literature on medical cannabis care services which has also increased barriers to the production of evidence-based policies and clinic models.3,4 Canada has long been on the frontier of medical cannabis access, with the enactment of legislation in 2001 following a Supreme Court challenge to the Charter of Rights and Freedoms.5 The regulatory system has evolved over time, most recently with the legalization of non-medical or ‘recreational’ cannabis under the Cannabis Act in October 2018. However, despite this long history of medical cannabis access, significant medical stigma and persistent barriers to prescription remain. In 2014, approximately 40,000 Canadians were authorized for medical cannabis use, however an estimated 1 million were using cannabis therapeutically via illicit sources.6,7 The aim of this article is to present the care model of a successful clinic dedicated to medical cannabis treatments. The key elements related to the clinic organization and the clinical team as well as clinic statistics and critical patients’ data are described and discussed in detail. This paper also aims to inform health care providers and other medical cannabis stakeholders on the considerations of effective medical cannabis practice that can be adapted to different clinical settings and various regulatory frameworks. The main objective of any medical cannabis treatment is to provide a complementary option to traditional treatments in order to alleviate persistent symptoms and suffering associated with the patient’s condition. This is achieved through the following sub-objectives: give the patient a sense of control over their condition; improve the symptoms experienced by each patient; and improve the patient’s health-related quality of life with a minimum of treatment related adverse effects. Moreover, as a complementary or adjunctive treatment, medical cannabis treatment must be integrated with primary and speciality care to support best outcomes.
The medical cannabis grow tray clinic model was developed by the co-founding team of medical cannabis advocates, researchers and physicians to meet the needs of patients and the medical community. In early years, the stigma of being classified as a ‘pot doctor’ required peer support among the medical team and resulted in the establishment of initiatives to support clinic credibility, including rigorous clinical practice guidelines, a strict referral model, and the initiation of a research program to collect real-world evidence about patient treatment outcomes. Maintaining the credibility of medical cannabis treatments and separating myths from realities remains a core function of the clinic as a resource centre for evidence-based medical cannabis information. Each country may have specific considerations and requirements for a clinic implementation. It may be required to develop specific protocol or reporting for each patient that is prescribed medical cannabis. Developing such protocols in a peer-reviewed environment to meet the needs of common patient diagnoses and symptom expression is important to ensure compliance and clinical efficiency. Different healthcare environments may present challenges as well as sociological impacts; integration with private health insurance providers may be necessary initially to support patients who are unable to pay for clinic visits or medical cannabis treatments.A dedicated, attentive and diverse team of experts is a key aspect to medical cannabis care. The clinic has expanded from a small team of five practicing part-time physicians and one medical cannabis educator in one location to a network of four clinics across Quebec and a team of twelve consulting physicians and fifteen nurses as part of a complete staff of fifty employees. The current core clinical team consists of clinic coordinators who supervise research assistants and administrative needs, nurse coordinators and a team of nurses with both research and patient education experience and physicians from various specialities, including family physicians and specialists in pain, palliative care, endocrinology and gastroenterology.The team provides specific, comprehensive counseling to patients taking into account their individual medical condition, lifestyle and accessibility needs. In the early years of clinic development, medical cannabis advocates or educators played a critical role to support cannabis knowledge transfer and personnel training, bridging medical cannabis and healthcare experiences. To provide sufficient support and education, patients are followed by the same physician, though nursing and education support may rotate, and all notes are documented on an electronic medical record . Such a multidisciplinary approach between healthcare professionals provides for personalized, effective and efficient recommendations and the appropriate, supportive follow-up required by most patients, as it occurs in other clinical settings.9 Peer support among healthcare providers, especially physicians, across various specialities, facilitates support and mentorship within an otherwise stigmatized and controversial treatment. The initial clinic visit is an opportunity to meet the patient, confirm eligibility for cannabinoid-based treatments and provide patient education on medical cannabis. Baseline clinical data and validated questionnaires are collected and may be used for further analysis. A complete medical history is obtained by a registered and trained nurse with a focus on factors that will determine treatment recommendations including a patient’s previous cannabis experience. Consulting physicians confirm patient eligibility and treatment decisions and determine a follow-up and monitoring schedule according to a clinic-wide protocol. A medical cannabis authorization is written in accordance with federal regulations, the authorization is akin to a prescription in practice. Patient education is led by the nurse and includes discussion of treatment objectives with the patient and family, review and management of treatment expectations, careful explanation of the individualized treatment plan, titration instructions and an original patient daily diary and education booklet that cover all general information. Furthermore, a patient treatment agreement is an indispensable tool to confirm treatment objective and clinical program limitations.