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Medical Cannabis Use: Exploring the Perceptions and Experiences of Older Adults with Chronic Conditions Lydia Manning PhD and Lauren Bouchard MS

College of Graduate and Studies/Center for Gerontology, Concordia University-Chicago, River Forest, Illinois, USA

ABSTRACT Objectives: Although the rate of cannabis use by older adults is increasing more quickly than all other age groups, little is known about the reasons older adults use cannabis and the outcomes they experience. With this research, we investigated older adults’ perceptions and experiences of medical cannabis use to treat and/or manage chronic conditions, specifically as a substitute for prescription drugs. Methods: Researchers relied on qualitative inquiry in the form of semi-structured, one-on-one interviewing to investigate the phenomenon of medical cannabis use for the management of chronic conditions. Results: Our findings suggest that older adults are open to medical cannabis as an alternative to pharmaceutical drugs, hopeful with regard to the management of symptoms and pain, and aware of and astute at managing issues related to stigma both from their physicians and family and friends. Furthermore, older adults describe the frustrations with education, awareness, and lack of support with dosing. Conclusions: Participations found medical cannabis use to be beneficial in managing chronic conditions and alleviating symptoms such as chronic pain. Findings are presented as an interpreta- tion of the participants’ perceptions of their medical cannabis use. Implications for putting medical cannabis use into everyday practice as well as policy implications are considered.

Clinical Implications: This information will help clinicians better support older adults desiring to use medical cannabis. This research will help clinicians learn more about factors impacting medical cannabis use, and the types of information and assistance that may aid older adults in their health and well-being with the use of medical cannabis to treat chronic conditions.

KEYWORDS Aging; health; medical cannabis; qualitative methods

Introduction

Due to recent changes in state laws, more chroni- cally ill and disabled adults have access to medical cannabis as a treatment option. Medical cannabis is now available in 33 states–almost three quarters of the United States–yet questions remain about the use, scope, and experience of utilization. Older adults may be drawn to medical cannabis for a myriad of reasons, but some researchers suggest older adults may be using primarily for medical use rather than for any recreational purposes (Haug et al., 2017), and they may also have a lower perception of risk in general cannabis use (Black & Joseph, 2014; Choi, Marti, DiNitto, & Choi, 2018).

Older adults have a higher rate of chronic health conditions, and so it is increasingly attractive to

supplement treatment in order to cope with symp- toms that affect their daily lives (Briscoe & Casarett, 2018). Many adults opt to use medical cannabis to treat long-term pain, loss of appetite/nausea, and other neurological or psychiatric symptoms that are common with conditions that impact daily life (Briscoe & Casarett, 2018). Trends across adult- hood show older adults are more likely than middle or younger age adults to use cannabis for condi- tions such as cancer, glaucoma, and HIV/AIDS (Haug et al., 2017). Other researchers purport cau- tion as medical cannabis may impact older adults differently due to metabolic, cognitive, and psycho- motor function (Minerbi, Häuser, & Fitzcharles, 2019), and a smaller minority of older users may be at risk for mental health and substance use con- cerns (Choi et al., 2018).

CONTACT Lydia Manning lydia.manning@cuchicago.edu College of Graduate and Studies/Center for Gerontology, Concordia University-Chicago, , River Forest, IL 60305.

CLINICAL GERONTOLOGIST 2021, VOL. 44, NO. 1, 32–41 https://doi.org/10.1080/07317115.2020.1853299

© 2020 Taylor & Francis Group, LLC

Brief history of medical cannabis in IL

In 2013, Illinois passed the Compassionate use of Medical Cannabis Pilot Program and patients with a qualifying condition and a medical cannabis card issued by the Illinois Department of Public Health were permitted to begin purchasing medical cannabis at a local and approved dispensary beginning in January, 2016. Despite cannabis’s federal status as a Schedule I drug, Illinoisans could access medical cannabis after applying in conjunction with a physician. This “pilot” status of the program has now been removed and several more qualifying con- ditions have been added. The state also implemented specific protocol for a short-term opioid alternative option, which is valid for 90 days in lieu of opioid medications after accidents, surgeries, or acute health events, which may also disproportionately affect older people. In January of 2020, Illinois also legalized recreational cannabis for the general population.

Older adults and cannabis outcomes

The scientific literature regarding medical cannabis usage in the older adult population is often mixed and limited in its findings. Briscoe & Casarrett’s (2018) review of the literature in regards to palliative care indicated many of the studies investigating adverse side effects for older adults are based upon recreational use rather than medical use. This dis- tinction is increasingly important for the research across states where both types of usage are legal and common across generations. These researchers reported some potential side effects in older adults such as acute psychosis, impaired cognition, and dizziness, depending on the routes of administration (e.g. inhalation vs. edibles; Briscoe & Casarett, 2018).

There may also be increased risk for depression, anxiety, and suicidality, yet “questions remain about the cause and effect,” of these symptoms (Briscoe & Casarett, 2018, p. 862). Additionally, little research exists regarding how these side effects compared to other prescription medications older adults may take for their chronic conditions. There is also some evidence regarding efficacy of medical cannabis for nausea and vomiting (especially related to cancer patients) as well as some evidence for sleep-related concerns such as obstructive sleep apnea, fibromyalgia, multiple sclerosis, and general

chronic pain related to other conditions (Briscoe & Casarett, 2018). Although dementia-related agita- tion is listed as a qualifying condition in the state of Illinois, Weier and Hall (2017) reported limited results in the benefits of use for dementia condi- tions in their randomized controlled trial.

Lum et al. (2019) surveyed community-dwelling adults 60 and older in Colorado who reported using cannabis for medical reasons such as arthritis, chronic pain, and anxiety and depression. Those who used medical cannabis in the last year reported better overall health including better quality of life, well-being, and day-to-day functioning (Lum et al., 2019). Notably, these respondents also did not report greater incidence of falls, accidents, or injuries related to medical cannabis use (Lum et al., 2019).

Abuhasira, Schleider, Mechoulam, and Novack (2018) explored the older adult medical cannabis users in Israel. Each participant was fully educated via a physician regarding types of administration, product ingredients, and potential options based on condition. Participants reported a decrease in pain symptoms and increase in quality of life measures. Common adverse side effects were dizziness and dry mouth. A small portion of study participants also discontinued due to ineffectiveness. 18% of partici- pants reduced their opioid usage due to the medical cannabis regimen. Generally, these researchers reported very few adverse events and general efficacy across their sample. Their approach regarding sup- portive education by a registered nurse is also notable.

Caution and risks

A general cultural shift related to cannabis may muddy the risks associated with both recreational and medical cannabis use across generations (Han et al., 2017). Adults in states with medical cannabis legalization are more likely to perceive any use as acceptable. Based on recreational usage, Choi et al. (2018) reported older adults who frequently use can- nabis (to the extent of Cannabis Use Disorder per the DSM-5), have increased perceptions of risk, while older adults with less frequent use may perceive lower or moderate risk. It is unclear if these percep- tions are related to those using cannabis for medical use (e.g. aiding in disabling symptoms with help from a physician) or those who simply use it for recrea- tional purposes.

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As many researchers have noted, it is paramount to thoroughly explore the risk and benefits of med- ical cannabis in order to better treat older adults with chronic conditions.

(Ahmed, van den Elsen, van der Marck, & Olde Rikkert, 2014; Marcum, Tu, Crawford, & Hirano, 2019; Minerbi et al., 2019). Medical researchers also indicate a strong patient doctor decision-making model may affect success of medical cannabis in symptom management (Ahmed & van den Elsen, 2014; Choi et al., 2018; Minerbi et al., 2019). However, it is also unclear how many older adults are advised with such a model (Bobitt et al., 2019). While epidemiological, randomized controlled trials, and longitudinal studies are distinctly impor- tant to researchers and clinicians, we also need to hear directly from older adults regarding their experiences and desires for the future of medical cannabis use. As noted by Briscoe and Casarett (2018), medical cannabis research infrequently focuses upon older adults directly. Given the poten- tial for differences in this group, older adult’s nar- ratives may be beneficial to the formulation of a strong patient-doctor decision-making model.

The study presented here explored the nature of medical cannabis use by older adults in Illinois. We wanted to understand the motives, perceptions, and barriers of older adults who utilize this as a medical treatment. We also wanted to explore frequently cited qualifying conditions, symptoms, and experi- ences related to utilizing medical cannabis through a dispensary with the documentation of a physician. We specifically asked questions about dosage, frequency of use, and concurrent use with other pharmaceuticals such as opiates and related medications. Finally, we asked participants about how those around them understood their use, including physicians, in order to understand how stigma and/or acceptance might affect usage or access to medical cannabis.

In this study we sought to answer the following research questions:

(1) What are the perceptions and experiences of older adults who are using medical cannabis to treat chronic conditions? a. What are the motivators for older adults

to use medical cannabis in lieu of pre- scription drugs?

(2) How does medical cannabis use shape experiences of health and wellness for indi- viduals 65 years of age and older?

(3) How do individuals age 65 and older seek information or assistance for medical canna- bis use? Who are the various agents and resources (e.g., family, service organizations, advocacy groups, etc.) they seek out as they address their health-related needs related to chronic conditions?

Methods

The central research question and related sub- questions were explored using a basic qualitative study. A basic qualitative study focuses on the meaning people assign to a particular topic, how people interpret their experiences with the topic, and how they behave based on their understanding of the topic (Creswell, 2015; Merriam & Tisdell, 2016). This study was well suited for a qualitative design because we wanted to capture the lived experience of medical cannabis use from the per- spective of older adults who are actually using medical cannabis and also to explore a rather recent and unexplored phenomenon. We sought to unearth the opinions, thoughts, and feelings of participants.

Sample

Once IRB approval was obtained, participants and sites for the study were selected from the population using a purposeful sampling model for the identifi- cation and selection of information-rich cases related to the older adults using medical cannabis to manage chronic conditions. Sampling for this research aligns with the basic tenets and assump- tions of basic qualitative inquiry. Participants were not randomly selected or predetermined during the initial planning stages of the project. Individuals were selected to participate in this study based on their firsthand experience with the phenomenon of interest – using medical cannabis to manage chronic conditions in later life. This study used a purposeful sampling approach, common in qualitative design (Strauss & Corbin, 1997).

We used a purposive sample of people ages 60 and older who were willing and able to discuss their

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experiences of utilizing medical cannabis who resided in Illinois. The researchers reside in Illinois and had access to the medical cannabis community in the state. Recruitment flyers were placed in the lobby areas of three dispensary loca- tions in the Chicagoland area. Additionally, the flyer was shared with a private Medical Cannabis of Illinois Facebook group. Respondents emailed and expressed interest in participating in the study. Participants were selected to participate if they were over the age of 60, had a medical canna- bis card, and were using medical cannabis to treat their chronic and comorbid conditions. A one-on- one, semi-structured interview with each partici- pant was conducted in person or over the phone. The interview guide consisted of 12 questions with additional prompts. Each interview began with the researcher asking the participant to “tell me about how you discovered medical cannabis as a treatment option”. Participants were additionally asked about their experiences with their physicians, the dispensary, dosing protocols as well as to describe barriers and motivators regarding use. The interview guide was created based on identifi- able gaps in the literature on medical cannabis use among older adults. Interviews lasted between 45 minutes to an hour and half. Each interview was audiotaped and transcribed verbatim. The two researchers on this project collected, analyzed, and interpreted the data.

Data analysis

Analysis of these data involved thematic analysis (Braun & Clark, 2006). The focus of this analysis was on the perceptions and experiences of the par- ticipants who were using medical cannabis to man- age chronic health conditions. The data from the 10 participants were transcribed and de-identified prior to the analysis process. The data were then organized according to participants’ responses to each question in the interview guide. For example, all the participants’ responses to question one were placed together and so on. The data presented in the section below provide a summary of the inter- view questions.

Two researchers read through the transcripts multiple times to become familiar with the dataset as a whole. This was followed by initial coding of

discrete phrases, sentences, and/or responses using a coding scheme aimed at focusing later coding on data that was relevant to the research question. Next, these codes were collapsed into larger codes surrounding similar ideas. Finally, these larger codes were evaluated as to their relevance to the research question (Emerson, Fretz, & Shaw, 1995). The two researchers met regularly to compare cod- ing and larger themes. The end result was the identification of three overarching themes related to participants’ experiences and perceptions of medical cannabis use.

Using Dedoose (2018) (https://app.dedoose. com/App/?Version=8.0.35), the authors analyzed the data and explored how the participants dis- cussed their perceptions of and experiences with medical cannabis use. Findings generated from this thematic analysis are presented here. To arrive at the emergent and major findings, the authors relied on thematic analysis, interpretations of meaning statements, and syntheses of the emergent themes as well as taking into consideration the existing literature on medical cannabis use, aging, and health.

Results

Upon completion of the data analysis process, rich descriptions related to the research questions were developed. Those findings are organized by theme and sorted by the corresponding research question that relates to each particular theme. Select quotes from the participants are provided as support for each finding. These quotes are not intended to be exhaustive, but representative of the various parti- cipant perspectives. The quotes also serve to enhance the trustworthiness of the study. The codes that emerged in the data analysis of this study were perceptions and experiences of using medical cannabis to manage chronic conditions, key motivators and barriers shaping use, treatment- seeking behaviors, and experiences of stigma related to medical cannabis use.

The sample consisted of 10 participants, all individuals aged 64 and older who were using medical cannabis legally and with a state-issued medical cannabis card in Illinois. Participants ran- ged in age from 64 to 83. All but one participant was white, and eight of the ten were women. Seven

CLINICAL GERONTOLOGIST 35

of the 10 participants had at least a college degree and all had annual household incomes over 40,000 USD. The state of Illinois identifies over 50 chronic conditions that qualify a person to receive a medical cannabis card (a comprehensive list can be found here: https://www.dph.illinois.gov/ topics-services/prevention-wellness/medical-can nabis/debilitating-conditions). For the participants in this study, qualifying conditions included Fibromyalgia, Parkinson’s Disease, Cancer, Post- Traumatic Stress disorder, and Rheumatoid Arthritis with some participants having additional comorbidities. Participants whose data were ana- lyzed here illustrate three overarching themes in their interviews as they described the adversities, hardships, challenges, and in some cases opportu- nities of living with a chronic condition that qua- lified them to use medical cannabis as a treatment option: 1) appreciation for and reliance on medi- cal cannabis as a means of alternative treatment for chronic conditions, 2) frustration with costs and the process of obtaining a medical cannabis card from the state, and 3) issues with stigma associated with using medical cannabis. Participants were intentional about the way in which they used medical cannabis to enhance their quality of life while finding peace, comfort, and symptom management as they navigated the less than ideal terrain of living with chronic and/ or comorbid conditions.

Perceptions

Participants were asked to describe their overall perceptions of medical cannabis use. Overwhelmingly, people expressed being satisfied with medical cannabis as a treatment option and reported perceiving the treatment option as legit- imate, beneficial, and reliable as a tool to manage symptoms. When asked about her overall percep- tions of medical cannabis and related experiences, Mia (72) who was using medical cannabis to man- age her Fibromyalgia, explained:

There’s definitely an overwhelming sense of satisfaction, um, and gratefulness that this is an option. I’ve been using recreationally since I was 20 since college or you know, around about there and now it’s just nice to be able to, to be able to utilize it in a way that is consistent

and safe and quality. I know what I’m getting and it mitigates my condition. It really helps me.

Individuals in this study did not credit medical cannabis use as a means of curing their condition but rather as a modality for management. Only one of the 10 participants explained how medical can- nabis did not help them manage their chronic con- ditions. Half of the participants in this study had never used cannabis prior to receiving their medical cannabis clearance and card.

Furthermore, all participants described feeling grateful for being able to use medical cannabis. For some, this meant recognition that medical can- nabis use reflected a place of privilege in terms of being able to afford the treatment as well as being socially sanctioned to seek out the treatment. Several participants described their discomfort that while they were benefiting from medical can- nabis, other people were being imprisoned and treated as criminals for cannabis distribution and use and recognized the societal double standard associated with criminalization. Regarding percep- tions and experiences of use, participants expressed frustration with the marketing and naming of pro- ducts. Several people described that the packaging of the products was not user friendly and many expressed being unable to open various packages and had to patiently wait for a loved one to help them open products for use.

Additionally, some participants expressed frus- tration with the lack of educational support regard- ing product use. For example, when asked about her experiences with medical cannabis use, Laurel (69) explained that she spent almost 100 USD on “some type of vaping thing” that she was unable to use because she did not understand how to operate the product. She had to wait for a family member who understood vaping technologies and the use of cartridges to assist her. Other participants expressed annoyance with the branding and nam- ing of the products. John, age 81 and managing Parkison’s Disease, found it odd to have his desig- nated caregiver request products called “Baba Koush,” “Sour Diesel,” and “Red Headed Stranger” for him to utilize, feeling that these “sounded more fun than medical.” Ellie, 72 and managing glaucoma, described that she felt “ridi- culous walking into a dispensary and asking for DJ

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Short Flo” as a form of medicine. All participants discussed high costs associated with the use of medical cannabis as an alternative treatment option along with the extensive sale taxes. Individuals described being grateful for being able to afford the products for continued use.

Motivators

Participants were asked about the main aspects and conditions that motivated them to use medical cannabis to manage their chronic conditions. Most of individuals identified pain management associated with their qualifying conditions as the main motivation for seeking out and utilizing med- ical cannabis. Additionally, people described using medical cannabis to manage other issues that caused discomfort, i.e., insomnia, nausea, and lack of appetite related to chemotherapy and radiation. For the one participant who reported medical can- nabis not being effective, the inability for the alter- native therapy to not mitigate insomnia was the main reason for discontinued use. Jo Anne, age 71, explained how medical cannabis use was helpful for her pain management:

I needed to manage my pain and I decided I couldn’t take opiates four times a day and enjoy it. My pain is really hard to manage and medical cannabis is a non- opiate solution that allows me to have comfort.

Older adults in this study frequently discussed that other forms of pharmaceutical treatments were sim- ply ineffective as being a motivator for seeking out medical cannabis use as an alternative form of treat- ment. As a result, many of these participants decided to try medical cannabis with high levels of satisfac- tion. Half of participants were motivated to use it due to previous relief while using recreationally and all participants, while frustrated with the high costs, were motivated to use because they could afford to do so.

Treatment-seeking behaviors

Healthcare treatment-seeking behavior exhibited by individuals living with chronic and co-morbid con- ditions varies and is often modified by socioeco- nomic status, demographic, and physical factors as well as relationships with providers, access, and edu- cation levels regarding treatment options. Several of

these trends were reflected in the treatment-seeking behaviors of participants in this study. The relation- ship with their physician played an important role in how participants decided to use medical cannabis. The majority of participants, seven out of ten came to treatment on their own and sought the advice of their current primary physician. Three were encour- aged by their primary physician to try medical can- nabis as a treatment option while the other seven participants were either deterred or informed they needed to find another referring physician. One individual was told they would no longer be seen as a patient because of their decision to use medical cannabis to manage their condition against their physician’s advice.

Understanding the benefits and receiving educa- tion on how to use medical cannabis was also pivotal. Many participants reported doing their own research on the risks and benefits and weigh- ing options. Access to information and education was important to treatment-seeking behavior. For example, four participants described wanting to use medical cannabis in lieu of using opioids to manage pain after doing extensive investigation on the ben- efits of opting to not use opioids and working to understand the Alternative to Opioids Act of 2018 law in Illinois which affords people who would be prescribed opiates but are given the option to use medical cannabis as an alternative for a six-month time period. Other participants expressed that being able to use the designated caregiver option was a vehicle that enabled them to seek out treat- ment and was instrumental in their ability to use access and utilize medical cannabis.

Using-related experiences of disease management

Participants were asked to describe their experi- ences with the actual everyday use of medical can- nabis and overall with understanding how best to use the treatment related to their qualifying condi- tion. Most of the participants all described frustra- tion with the “trial and error” process related to “micro dosing” and finding the right combination of product use. Individuals are told to “go low and slow” when first starting to use. There are many options in terms of types of products (edibles, flow- ers, vaping cartridges, oils, RSOs (Rick Simpson Oil, or RSO, is a full extract cannabis oil meant to

CLINICAL GERONTOLOGIST 37

be taken orally or applied topically), tinctures, creams, patches, and suppositories) and partici- pants consistently reported feeling confused and overwhelmed when first attempting to identify the appropriate product for their need and their symp- toms. For example, Marge age 74, when asked about her treatment protocol reported:

I use RSO with high CBD with very little THC. So, I try to do that once or twice a day. And then at night I use higher THC. It’s like 600 and something milligrams. I can’t remember. It took me time to figure out what works. The CBD helps me sleep. You really have to do your research and try different products and different, what do they call it? – dosing protocols until you figure it out. People at the dispensary don’t seem to know and my provider is of no help. It’s such science and chemistry.

Additionally, there was variation in what medical cannabis products older adults used. Four of the participants used only flower (smokable cannabis leaves) and the remainder used other medical deliv- ery options (i.e., edibles, RS0, or tinctures). Regardless of the product choice or dosing proto- cols, all participants were frustrated with inaccessi- bility and lack of user and age-friendly design. Many of the products and related packaging are simply not user friendly.

Furthermore, all participants all described frus- tration with the “trial and error” process related to “micro dosing”, finding the right combination of product use, and having to become an overnight expert on medical cannabis as a treatment option.

Stigma

While the enactment of the Illinois Compassionate Use of Medical Cannabis Pilot Program Act allows patients to use cannabis for medical reasons, pro- vided that it is recommended by a physician and that the user has a state-issued medical cannabis card, many patients are at risk of being stigmatized for this practice. This was the case for half the participants in this study. Several of the participants described reluctance to disclose their use of medical cannabis to friends, families, and in some cases other providers because of issues related to stigma. For example, John, age 66, was worried about stigma and discrimination from his employer. He explained:

My family knows, but I don’t want my friends and other people to know. I don’t tell a lot of people because many people still see cannabis as criminal or a taboo recrea- tional and gateway drug. We also have this issue at the state and the federal level and that cannabis is still a level-1 controlled substance. I have a government job and I don’t want to be fired.

Conversely, rather than expressing concerns about stigma, there were a few participants who were openly communicative about their medical canna- bis use and saw themselves as advocates for the use of medical cannabis as an option for older adults to manage chronic and co-morbid conditions asso- ciated with aging. These participants felt strongly that healthcare providers and physicians needed more education about medical cannabis in terms of both how to refer patients for use and how best to direct patients to utilize products and the various treatment options.

In sum, participants in this study expressed an overall appreciation, despite various frustrations, for the ability to use medical cannabis to help manage their chronic conditions. The older adults were about to manage issues with stigma associated with using medical cannabis and benefited in terms of an enhanced quality of life with regard to utiliz- ing medical cannabis to ameliorate negative out- comes associated with chronic and/or comorbid conditions.

Discussion

The findings presented in this article offer insight into how some people over the age of 60 are using medical cannabis to manage their chronic condi- tions. In particular, the authors identified that all but one of the participants reported satisfaction with being able to use medical cannabis to manage symptoms, get relief from pain, and have an improved quality of life all while lessening their dependence on pharmaceutical drugs. Additionally, we explored the nature of older adult’s medical cannabis use and have argued it serves as a useful and effective treatment option for managing chronic and in some cases comorbid conditions for the participants in this study. Older adults in this study reported relying on their med- ical cannabis to manage their chronic conditions and to also lessen their dependence on

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pharmaceutical drugs.Our qualitative investigation explored the multifaceted experiences of older adult medical cannabis users in Illinois. Most described a desire to reduce their everyday symptoms while relying less on pharmaceutical medications such as opioids. Despite their gratitude for medical canna- bis as a treatment option, many of the participants described barriers regarding physician support and knowledge, age-friendly design in dispensaries (e.g. product terms, staff support, etc.), and the financial burden even in situations where they could afford it due to economic security.

These older adults also consistently discussed the difficulty of the trial/error dosing methods regard- ing administration and product ingredients. A disproportionate number of the participants described their own motivation was the primary factor in their use of medical cannabis rather than guidance or support from a physician. Indeed, seven of the ten participants had to seek out differ- ent physicians in order to complete mandatory paperwork. Some of the older adults described themselves as “advocates” due to the general inac- cessibility of products they found helpful for themselves.

Practice implications

Gerontologists, medical providers, and social ser- vice professionals must account for these barriers in their education and guidance. Dispensaries also may need to consider their approach toward med- ical cannabis users, especially older adults who may need more support in dosing and products in rela- tion to their current conditions. The vast majority of participants want to utilize medical cannabis responsibly with the help of their primary physi- cians, yet physicians are often unsupportive despite the patient’s motivations and plans for their own symptom management. Physicians cannot delay cannabis-related education any longer due to the reality of medical cannabis as a treatment option. Earlier qualitative research in Colorado noted simi- lar themes: lack of education and research regard- ing cannabis, lack of provider communication, and general access to medical cannabis (e.g. cost, authorization, and recreational atmosphere; Bobitt et al., 2019). Our findings echo these barriers, con- cerns, and difficulties. It is important to address the

difficulty in accessing medical cannabis from an economic standpoint. The majority of our partici- pants were economically stable and able to pay out- of-pocket cash costs, yet they noted this barrier for others as well.

Bobitt et al. (2019) also described older adults’ reticence in states where both recreational cannabis and medical cannabis are legal. Although at the time of our data collection recreational cannabis was not yet legal in Illinois, several older adults voiced con- cerns about the overlap between recreational and medical access. This overlap caused considerable confusion for both patients and providers, especially given the differences in administration, ingredients, and pharmaceutical interactions. Due to the diffi- culty of regulation in Illinois, medical users may be having more difficulty after the legalization of recrea- tional cannabis. Most of our participants simulta- neously voiced concerns regarding their ability to access cannabis with an influx of recreational users. Additionally, many noted the disparity in access due to race, economic status, and/or other justice issues in the prosecution of cannabis use in the past.

Policy implications

Medical cannabis-related policy is increasingly complex due to differences in state laws and diffi- culty in regulation across regions (Nicholas & Maclean, 2019). Most of our participants were retired, unemployed, or receiving disability benefits due to a chronic condition, yet they did note improvements in their ability to manage symptoms and productivity. Pain control was consistently described as one of the most important outcomes of medical cannabis use, and this must be consid- ered in relation to public policy, medical symptom management, and long-term care regulations.

Limitations and future directions

Our participant demographics were largely white, upper middle class, suburban dwelling women with chronic pain conditions. The Illinois Department of Public Health (Illinois Department of Public Health (IDPH), 2019) estimated that roughly the same percentage of men (49.68%) and women (50.32%) applied for medical cannabis registry. The IDPH (2019) also reported that roughly 30%

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of registered card holders were over the age of 60. Unfortunately, these reports only document age and gender and do not report registrants by racial/ethnic group.

A limitation of our qualitative study is a lack of gender, racial/ethnic, and geographic diversity. More research should be conducted in multiple Cook County neighborhoods (including southside neighborhoods) as well as communities outside of the Chicagoland area (e.g., southern and central IL) as there may be additional barriers in these loca- tions. Our results are qualitative and not causal and do not specifically note the efficacy of medical can- nabis across the population of older adults. The participants’ narratives are rooted in their contex- tual experiences and future research should explore other experiences especially related to barriers in access to healthcare.

Clinical implications

● Older adults need better information and assistance from clinicians about the use of medical cannabis (including products, packaging, use of dispensary).

● Physicians must be prepared to understand how medical cannabis use impacts current treatment protocols and document use accordingly in the medical record.

● Physicians should counsel on variability of quality and concentration of medical cannabis and related dosing and potential drug interactions (e.g., delayed time to effect after ingestion of oral cannabis).

Disclosure statement

No potential conflict of interest was reported by the authors.

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