Negative experiences of patients using medicinal cannabis : A systematic review of qualitative studies
Or Gliksberg, P Talma Kushnir, Sharon R. Sznitman, Shaul Lev-Ran, Silviu Brill, Ben H. Amit, Daniel Feingold PhD,
Journal of Clinical Nursing, 2023, 1-12.
doi : 10.1111/jocn.16653
Aims and Objectives : In this study, we systematically reviewed qualitative studies concerning patients’ experience with medicinal cannabis (MC) use, to gain insight into the negative effects of MC.
Background : Over the past decades, the use of MC for therapeutic purposes has increased. However, there is conflicting and insufficient data on possible negative physiological and psychological effects of MC treatment.
Design : A systematic review was conducted and the PRISMA guidelines were adopted. Literature searches were conducted using PubMed, PsycINFO and EMBASE. Critical Appraisal Skills Programme (CASP) qualitative checklist used to assess risk of bias in the included studies.
Methods : We included studies focusing on conventional medical treatment using cannabis-based products, approved by a physician for a particular health issue.
Results : Of the 1230 articles identified in the initial search, eight articles were in- cluded in the review. Following the compilation of themes in the eligible studies, six themes were identified: (1) MC approval; (2) administrative barriers; (3) social percep- tion; (4) MC misuse/widespread effect; (5) adverse effects; and (6) dependence or addiction. These were grouped into two meta-themes: (1) administrative and social aspects of MC use; and (2) experiences of the effects of medicinal cannabis.
Conclusions : Our findings call for specific attention to unique consequences associated with MC use. Further research is needed in order to assess the degree to which nega- tive experiences associated with MC use may affect various aspects of patients’ medical condition.
Relevance to clinical practice : Describing the complex experience of MC treatment and its spectrum of consequences for patients may enable physicians, therapists and researchers to provide more attentive and accurate MC treatment to their patients. Patient or public contribution: In this review, patients’ narratives were explored, yet the research methods did not directly involve patients or the public.
KEYWORDS : barriers to treatment, medical marijuana, medicinal cannabis, misuse, qualitative research, stigma, systematic review
What does this paper contribute to the wider global clinical community ?
• There seems to be several barriers to the process of receiving medicinal cannabis approval, as well financial burden associated with this treatment.
• Medicinal cannabis treatment is associated with per- ceived stigma.
• Patients tend to describe patterns of misuse, not addiction.
• Medicaladministrationsshouldconsidershorteningand streamlining the process of receiving medicinal cannabis approval, taking actions to reduce the stigma and closely monitor harms associated with medicinal cannabis use.
1 | AIMS AND OBJECTIVES
In light of the increasing use of medicinal cannabis (MC) and the la- cuna in conceptual understanding of negative physical and psycho- logical consequences associated with its use, the aims of this review are (a) to identify existing qualitative studies focusing on patients who use MC; (b) to identify patients’ reported negative experiences associated with MC use; and (c) to characterise these negative ex- periences. A preliminary search through Medline and Prospero da- tabases did not yield any systematic reviews, which were published on patients’ experiences with MC use. Clinical trials registries were not included in this preliminary search due to their irrelevance to our methodological focus (i.e. qualitative research). Therefore, we per- formed this systematic review, which refines the missing information on this subject. Negative experiences may differ in MC use when compared to recreational cannabis use, due to patient-related fac- tors (e.g. co-occurring physical and mental diagnoses) and context- related factors such as norms, regulations, culture, values, attitudes, etc. (Borodovsky et al., 2021). Exploring subjective experiences may also be important due to the fact that some MC effects are hard to quantify, given the lack of standardization of potency, chemical com- position, route of administration, etc. (Schlag et al., 2021). Therefore, focusing on MC patients’ experiences permits gaining meaningful in- sights into the unique effects of MC.
2 | BACKGROUND
Cannabis is the most commonly used psychoactive substance in the world, followed by tobacco and alcohol (United Nations Office on Drugs and Crime, 2021). There are several medical conditions which are approved for treatment using MC for either palliative or thera- peutic benefit, depending on the country or state-level legislation (Bramness et al., 2018; Sarvet et al., 2018). Notably, there are pro- cedural variations in the process of obtaining MC from a physician, internationally. For example, in the United States, a physician recom- mends the use of MC, which may subsequently prescribed and pro- vided elsewhere. Contrarily, MC is directly prescribed by physicians in the Netherlands, while physicians in Canada may approve a MC licences. Due to these variations, we used the general term ‘MC ap- proval’ in our review. In the United States, the most frequently cited reason for approving MC for adult patients is pain, primarily chronic pain, followed by arthritis and cancer (Park & Wu, 2017). In recent years, several concerns have been raised as to the efficacy of MC in treating medical conditions (Hill et al., 2022). For example, a system- atic review and meta-analysis of randomised clinical trials indicated that compared to placebos, the use of MC was associated with only a small to very small improvement in pain relief, physical functioning and sleep quality among cancer- and non-cancer related chronic pain patients (Wang et al., 2021).
In addition to efficacy, safety of MC treatment has also been ques- tioned. A number of adverse effects of MC have been documented, including short-term physical effects (e.g. dizziness, dry mouth and nausea; Briscoe & Casarett, 2018) and long-term physical effects (e.g. cardiovascular rhythm abnormalities; Pasha et al., 2021). Short-term cognitive deficits were also reported following MC treatment, in- cluding impaired executive function and short-term memory (Saulino et al., 2021). Finally, concerns have been raised regarding possible psy- chological effects, including the risk of developing dependence and addiction (Maharajan et al., 2020). However, despite these concerns only few randomised control trials assessed abuse liability (Cooper & Abrams, 2019). Approximately 27% of lifetime recreational cannabis users will qualify for a diagnosis of DSM-5 cannabis use disorder (CUD; Feingold et al., 2020). However, diagnosing substance use disorders (SUDs) in a medical context may differ fundamentally from diagnosing SUDs in a non-medical context. Using addictive substances for medi- cal purposes (e.g. prescription opioids or neuro-stimulants) commonly entails physical dependence, which is one of the common domains of SUD in a non-medical context, yet does not necessarily imply pa- thology among medical patients (Sznitman & Room, 2018; Tetrault & Butner, 2015). To date, there is insufficient conceptual understanding of CUD in medical contexts, and accordingly, no epidemiological data or clinical diagnostic tools are available for assessing CUD.