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J Clin Nurs. 2022;00:1–12. wileyonlinelibrary.com/journal/jocn  | 1

Received: 23 December 2021  | Revised: 29 March 2022  | Accepted: 1 April 2022

DOI: 10.1111/jocn.16340

O R I G I N A L A R T I C L E

Medical cannabis and stigma: A qualitative study with patients living with chronic pain

Amany Hulaihel MD, MHA, Medical Doctor1  | Or Gliksberg Doctoral Student2 | Daniel Feingold PhD, Senior Lecturer2 | Silviu Brill MD, Medical Doctor3 | Ben H. Amit MD, MSc, Medical Doctor4,5 | Shaul Lev- ran MD, MHA, Associate Professor5,6,7 | Sharon R. Sznitman PhD, Associate Professor1

1School of Public Health, University of Haifa, Haifa, Israel 2Department of Psychology, Ariel University, Ariel, Israel 3Institute of Pain Medicine, Tel Aviv Medical Center, Tel Aviv, Israel 4Cannabis Clinic, Reuth Rehabilitation Center, Tel Aviv, Israel 5Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 6Israel Center on Addiction, Netanya, Israel 7Lev Hasharon Medical Center, Netanya, Israel

Correspondence Amany Hulaihel, School of Public Health, University of Haifa, Room 430, Mt. Carmel, 31905 Haifa, Israel. Email: [email protected]

Funding information This research received no specific grant from any funding agency in the public, commercial or not- for- profit sectors

Abstract Aims and Objectives: To explore the ways in which stigma is experienced, and what strategies are used to manage stigma among patients using medical cannabis to ease suffering from chronic pain. Background: Various jurisdictions have legalised medical cannabis in recent decades. Despite increasing prevalence and more liberal attitudes towards medical cannabis, it is possible that patients who use medical cannabis experience stigma. Design: A phenomenological qualitative study. Methods: Fifteen patients living with chronic pain and licensed by the Israeli Ministry of Health to use medical cannabis to treat pain symptoms for at least 1 year partici- pated in semi- structured interviews. Transcribed data were analysed using thematic analysis to identify themes related to stigma. The manuscript is in correspondence to SRQR EQUATOR checklist. Results: Expressions of stigma were more related to ‘felt’ than ‘enacted’ stigma. Stigma related to decisions to delay onset of medical cannabis treatment and the ways in which participants managed medical cannabis use during their everyday lives. Participants dissociated themselves from recreational cannabis users, by presenting themselves as responsible normative individuals and engaging in a form of normalisa- tion known as ‘normification’, emphasising their own discrete and controlled medical cannabis use and cannabis' benefits. Conclusions: Patients experienced ‘felt’ stigma which had consequences for their self- presentations and medical cannabis use. This suggests that medical cannabis is not normalised in Israel and interventions may be needed to handle stigma related to medical cannabis. Relevance to clinical practice: The findings emphasise the effects of ‘felt’ stigma on patients. Aiming to increase the effectiveness of medical cannabis treatment and re- ducing harms, we suggest that particular focus should be placed on managing stigma

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

© 2022 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.

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1  |  INTRODUC TION

Cannabis is the most widely used illicit drug in the western world (United Nations Office on Drugs and Crime, 2020). In recent years, there has been a shift towards medical cannabis (MC) legalisation, and jurisdictions in many countries have developed and implemented MC programmes (Perlmutter, 2019). Despite increasing cannabis use worldwide, and more liberal policies and attitudes, cannabis users are considered to be a stigmatised group (Bottorff et al., 2013; Ryan & Sharts- Hopko, 2017; Satterlund et al., 2015). Moreover, according to the few studies conducted regarding people who use MC, patients using cannabis for medical purposes report experiencing stigma de- spite the fact that MC is legalised in several countries including Israel (Bottorff et al., 2013; Ryan & Sharts- Hopko, 2017). Research shows that stigma plays a crucial role in patients' decisions on whether or not to start MC treatment (Ryan & Sharts- Hopko, 2017).

This study aims to examine the meaning of stigma in the con- text of MC use and how it is experienced by patients living with chronic pain who are using MC. As MC use is becoming increas- ingly common, it is imperative to better understand how patients experience and deal with stigma associated with their MC use. Knowledge about stigma may help develop new approaches to reduce stigma and help patients cope with potential MC related stigma. Recent qualitative research based on interviews regard- ing people who use MC has been done in several countries (e.g. Norway, Canada, the United States and England) (Bottorff et al., 2013; Ryan & Sharts- Hopko, 2017; Satterlund et al., 2015). Yet, as far as we are aware, no research has examined stigma experiences in Israeli patients living with chronic pain and who are licensed to use MC. Israel is a world leader when it comes to regulating and providing MC to patients (Sznitman, 2020; Zarhin et al., 2018). Furthermore, MC use has increased in recent years (Sznitman, 2020) and illegal use of cannabis for non- medical purposes has also increased and the prevalence of cannabis use in Israel is among the highest in the world (Harel- Fisch, 2017). For all these reasons, Israel provides an informative case study for a better un- derstanding of how MC may relate to stigma.

2  |  BACKGROUND

Following alcohol and tobacco, cannabis continues to be the most widely used psychoactive drug in the western world, and it is increas- ingly being used for therapeutic purposes (United Nations Office on Drugs and Crime, 2020). Policies regarding MC vary across differ- ent countries. Most countries including Israel, follow the UN Single Convention on narcotic drugs and classifies cannabis as an illicit drug

with no medicinal use (Ministry of Health Israel, 2019; UN, 1961). Nevertheless, many jurisdictions still allow cannabis use for medi- cal purposes under specific conditions. The use of MC has increased in recent decades (Sznitman, 2020) due to shifting public attitudes, new legislation, increased availability and aggressive marketing of MC products. The increase in use has occurred despite the fact that meta- analyses of randomised- controlled trials (RCT) have reached inconsist- ent conclusions regarding the effectiveness of MC, and some studies have failed to demonstrate effectiveness (Stockings et al., 2018).

Israel has been running a MC program since 1990s, in which the Israeli Medical Cannabis Agency (IMCA), established by the ministry of health, is responsible for authorising licenses for patients (Zarhin et al., 2018). To receive a MC license, Israeli patients need to prove that they have tried other conventional medications without symp- tom relief for at least 1 year. Treating specialist physicians make recommendations for MC on behalf of their patients, and recom- mendations are sent to the Ministry of Health for approval. In Israel, more than half of MC licenses are granted for different chronic pain indications (Sznitman, 2020).

at the intrapersonal level. In addition, there may be a need to address stigma at the societal level including social interactions with friends, family and medical personnel.

K E Y W O R D S medical cannabis, normification, othering, patients living with chronic pain, qualitative research, stigma

What does this paper contribute to the wider global community?

The results of the current study show that there may be a need to develop strategies aimed at reducing stigma related to MC treatment. Some of this may relate to how MC use is talked about and handled in social encounters with people who do not use MC and thus focus on en- acted stigma. Yet, the current study suggests that more focus should be on addressing felt stigma and thus focus is needed on the intrapersonal level in addition to the inter- personal, organizational/institutional, community and gov- ernmental/structural level (Clinton & Pollini, 2021; Luoma et al., 2008). While there has been a great deal of work related to understanding stigma and its consequences, far less attention has been placed on assessing effective- ness of stigma reduction interventions (Committee on the Science of Changing Behavioral Health Social Norms Board on Behavioral, 2016). Livingston (Livingston et al., 2012) notes a few promising interventions that can reduce stigma related to substance use disorders (e.g. Acceptance and Commitment Therapy). As far as we are aware, there has been no attempt to develop stigma reducing interven- tions related to MC in particular, but this is clearly an area in need of further research.

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Despite the fact that MC is legal in Israel and elsewhere, it is pos- sible that stigma associated with this relatively new and controversial treatment influence patients using MC in their use and decision- making related to their course of treatment. Stigma is defined as ‘the phenomenon whereby an individual with an attribute which is deeply discredited by his or her society, is rejected as a result of the attribute’ (Goffman, 1963, p. 3). According to Ahern and colleagues, ‘Stigma is both a social process perpetuated by non- marginalized groups to achieve goals of exclusion and conformity, and a psychosocial pro- cess that marginalized groups must navigate and contend with’ (Ahern et al., 2007, p. 189). Another definition of stigma is ‘a social process or related personal experience characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable an- ticipation of an adverse social judgment about a person or group iden- tified with a particular health problem’ (Weiss et al., 2006, p. 536).

Research investigating how stigma relates to cannabis use and cannabis users mostly focus on recreational and illicit use of cannabis. Research has concluded that cannabis users experience stigma, with some studies indicates that only heavy, chronic and problematic use is stigmatised, while others suggest that cannabis users experience stigma regardless of pattern and motivation for use (Duff et al., 2012; Hathaway et al., 2011; Lau et al., 2015; Livingston et al., 2012; Reid, 2020). Research shows that not all people using cannabis experience the same level of stigma (Duff et al., 2012; Liebregts, 2015; Miles, 2014; Skliamis et al., 2020). Stigma- related experiences may be affected by cannabis policies and whether or not cannabis is prohibited or normalised (Reid, 2020). In fact, stigma has been found to be more prominent in countries with more punitive cannabis policies (Skliamis et al., 2020).

Compared to research on stigma and illicit recreational canna- bis use, far less work has been conducted on MC use and stigma. Notwithstanding the current legal status of MC in different coun- tries, people who use MC may still report experiences of stigma related to their use of the substance (Bottorff et al., 2013; Ryan & Sharts- Hopko, 2017). In fact, in a study that reviewed the qual- itative literature on MC found that stigma was a common theme across studies (Ryan & Sharts- Hopko, 2017). Bottorff et al.'s qualita- tive research found that patients using MC reported being labelled as ‘potheads’ by their families and society at large (Bottorff et al., 2013). They also reported being accused of unjustified (e.g. non- medical) use of cannabis. Similar findings were also noted elsewhere (Satterlund et al., 2015).

Examining how stigma relates to MC is important because stigma may have detrimental effects on patients' health in different ways (Knaak et al., 2017; Koschorke et al., 2021; Luoma et al., 2014; Ryan & Sharts- Hopko, 2017). Specifically related to MC use, stigma may lead to feelings of stress and social isolation (Bottorff et al., 2013; Satterlund et al., 2015). In addition, patients may circumvent their physician's medical advice and delay MC treatment which may in turn increase or prolong suffering (Ryan & Sharts- Hopko, 2017).

Theoretically, patients using MC may experience stigma as felt and/ or enacted. Enacted stigma, which is also referred to as external stigma, relates to stigma expressed by the public towards individuals. This might have varying degrees of severity, from indirect behaviours such

as being avoided or treated less seriously, to outright social discrimina- tion (Boyle, 2018; Scambler, 2009). Felt stigma, on the contrary, relates to an internal experience of expectation, or to the individual's belief that she/he will encounter enacted stigma in certain social situations. In other words, felt stigma is related to an awareness or expectation that enacted stigma might occur (Boyle, 2018; Reid, 2020).

Patients using MC may adapt different patterns of behaviour when dealing with stigma (Bottorff et al., 2013; Satterlund et al., 2015). ‘Normification’ is the presentation of self as ordinary by performing expected normative behaviours in order to reduce or deal with stigma (Goffman, 1963; Hathaway et al., 2011; Reid, 2020). For example, the decision of avoiding MC use at the workplace can be considered a process of normification. An additional way of dealing with stigma is the process of othering, by which the participants emphasise negative characteristics of an outgroup (e.g. recreational cannabis users) and how this group differs from their own behaviours. By contrasting one's own behaviour to a negative outgroup, othering enables positive self- representation (Bore´us, 2004; Rødner, 2005).

2.1  |  The study

As of today, little is known about the stigma experiences of licensed Israeli patients using MC for chronic pain. This is despite the fact that Israel has a relatively long experience with MC policy development and implementation (Sznitman, 2020; Zarhin et al., 2018). Examining potential stigma experiences of patients using MC, who are licensed to do so and who are living in a country with long- standing liberal attitudes towards MC treatment (as reflected in formal policies) is important as it may give insight into experiences of patients in other places that are in the process of, or have already, legalised cannabis for medical and/or recreational purposes. At the practical level, find- ings may contribute to improving existing treatment.

2.1.1  |  Research objectives

The aim of this study was to explore the ways in which stigma is experienced, and what strategies are used to manage stigma among patients using MC to ease suffering from chronic pain. We focus on patients living with chronic pain because they constitute the major- ity of patients using MC in Israel (Sznitman, 2020).

3  |  METHODS

3.1  |  Design of the study

We used a phenomenological qualitative research strategy (Alase, 2017). This approach is an effective way to learn and explore a con- troversial and complex issue as it shows sensitivity and respect to- wards the interviewees' stories in a way that focuses on the meaning and lived experiences individuals ascribe to the phenomenon (Alase,

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2017). The Standards for Reporting Qualitative Research (SRQR) was used in this study (O'Brien et al., 2014).

3.2  |  Recruitment and sampling

The participants were recruited based on their use of MC without any limitation of specific administration mode. Inclusion criteria were Israeli MC license- holders, male and female, older than 17 years of age, and treated for chronic pain for at least 1 year. Exclusion criteria were pa- tients treated with MC for any diagnosis other than chronic pain.

3.3  |  Procedure

Patients living with chronic pain who use MC were recruited through convenience sampling. Specifically, patients were recruited through the pain clinic of Ichilov hospital, Tel Aviv. During regular clinic vis- its, patients using MC were asked if they would be interested in being contacted for the purpose of participating in a qualitative re- search project related to MC treatment among patients living with chronic pain. Patients who agreed and signed the informed consent form were contacted later by phone by a trained research assistant. During the phone conversation the patients were given detailed in- formation of what participation in the study would imply, they gave oral consent to participate in the study and a time for the inter- view was set. The interviews were conducted via online video apps (‘Zoom’ and ‘WhatsApp’).

3.4  |  Ethics considerations

The study protocol was granted Helsinki approval (0675- 20- TLV) and university ethical approval (approval no. 507/20). The partici- pants were asked to sign an informed consent form after receiving full explanation regarding the study and were informed that they were free to stop participating whenever they wanted.

The participants' privacy and confidentiality were kept, and during the interview, the researcher attitude was pleasant, respect- ing and not judgmental. The research team had prepared to give patients advice on potential concerns regarding problematic MC use, but none of the participants expressed experiences of concern during the interviews. The documents and records were kept safe in password protected computers that only the researchers had access to, and the data will be saved for a maximum of 5 years after the research is completed.

3.5  |  Data collection

A semi- structured interview protocol based on open- ended ques- tions was used (see File S1). The interview questions were devel- oped in order to ensure that specific topics were discussed (personal

experience of MC use and related benefits and problems) but at the same time allowing participants to express their own view (Alase, 2017). Interviews lasted for 45– 90 min. Interviews were video re- corded, de- identified and transcribed verbatim. The sample size was determined according to the theoretical saturation point, which meant we stopped recruiting participants after 15 interviews when it became clear that interviewees' responses become redundant and no unique information was achieved (Saunders et al., 2018; Vasileiou et al., 2018). Data collection and interviews were conducted in the time period from February 2021 to August 2021.

3.6  |  Data analysis

The transcripts were analysed according to the thematic analysis model in which the participant's description of his/her experience and the words used are perceived to reflect his/her beliefs and inner world (Alase, 2017). The thematic model included open coding, axial coding and integration (Strauss & Corbin, 1998; Williams & Moser, 2019). The transcripts were read and re- read separately. Primary sub- themes were extracted from every transcript, using Atlas.ti software (Smit, 2018; Smit & Scherman, 2021). The next step was the axial coding, which is the process of relating codes (categories and concepts) to each other. Lastly, sub- theme extraction was con- ducted jointly by the research team members and when there was disagreement about result interpretation and coding, this was dis- cussed until consensus was met. Themes were integrated into pri- mary and secondary themes.

3.7  |  Rigour

Lincoln and Guba (Lincoln & Guba, 1985) suggest several concepts that relate to assessing the quality of qualitative research. Credibility relates to the correspondence between the participants' worldview, and how it is represented by researchers. Conducting the interviews and analys- ing the data by one person might affect the result of the study. In order to decrease the researcher's effect on the results, results and interpre- tations of data were discussed between the research team members. Elaborated and detailed transcripts, in addition to writing field notes increased dependability, or in other words, whether or not the conclu- sions of the study would persist if the interviews were analysed by other researchers, or in a potential replication study. Reliability in data analysis was achieved through extensive training of research assis- tants in coding and working with ATLAS.ti software. When writing the results and findings, each finding was authenticated by quotes from the original interview, this step may increase confirmability, which re- lates to how much the study's conclusions correspond to the collected data, and not affected by the researcher's points of view. Determining the sample size according to a ‘saturation point’ assured not dismiss- ing new ideas or themes, and lastly, saving all the relevant documents, including records and transcripts are additional steps that served the quality control of the study.

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4  |  FINDINGS

4.1  |  Sample characteristics

The sample included 15 participants (21 participants were ap- proached but 6 did not fulfil inclusion criteria or refused participa- tion), including 10 men (66%) and 5 women (33%). One participant had missing data on age, religiousness and monthly dosage. Ages ranged from 30 to 79 years (mean 54.85, SD = 11.89). Participants' marital status were as follows: 6% (n=1) single, 20% (n = 3) divorced, 66% (n = 10) married and 6% (n = 1) widow. All participants were Jewish, 53% (n = 8) were secular and 6 religious. In terms of educa- tion, 2 participants had completed less than 12 years of studies, 7 had completed high school, 3 had completed Diploma- studies, and 3 have a BA degree.

The duration of MC use ranged from 4 to 14 years (mean 7.53, median 7, SD = 3.02). All participants reported using MC daily. The monthly dosage ranged from 20 to 80 grams. In terms of mode of use, 80% (n = 12) of the participants reported administrating MC through smoking and 20% (n = 3) through a vaporiser. In terms of other substance use, 53% (n=8) smoked tobacco cigarettes and 3 participants reported occasional alcohol consumption. Four partic- ipants reported use of prescription opioids (when needed), and 3 participants reported using sleeping pills and anxiety medications.

The following five themes were extracted from the interviews: Pre- existing stigma, stigma after onset of treatment, othering: rec- reational vs. medical use of cannabis, othering: MC vs. pharmaceu- tical medications and self- control. Each theme is described in detail below.

4.2  |  Pre- existing stigma

Participants' narratives included a discourse of stigma that tran- scended their experiences, attitudes and feelings even before onset of MC treatment. Indeed, one of the most striking observations was that the participants stated that they had stigma towards cannabis in one way or another before starting treatment with MC.

Five years ago, one doctor named **, suggested that I should start treatment with MC. I replied to her: “please do me a favor, it's not appropriate”. I grew up in a place where we knew that cannabis is used only by criminals. I told her that with all due respect I'm not interested. Even when she tried to convince me it would help me, I explained that I'm not interested.

(Interviewee no. 05)

Stigma prior to onset of MC treatment led to apprehension and scepticism regarding whether or not to start MC treatment. One in- terviewee noted that, despite the medical recommendations from her physicians, and her severe physical health condition, she refused the

proposal from the treating physician to start MC treatment at the out- set, and she continued suffering from pain for an additional 2 years.

After this, at some point they started talking to me about taking it [MC]. At first, I had a very strong op- position to it, because this is how I perceived it, its drugs and so on. I don't take it, I don't mess with it at all. It's like .. I had a strong resistance to it, it took me about 2 years until I was able to accept that it was my last resort and that I had no choice, and that if I want to help myself there is no other way. I had lots of conversations with Dr. ***, I had lots of conversations with other doctors. I was very hesitant whether or not to take it. In the end my physical condition was over- whelming and there was no more deliberation. I had nothing else left. So that's it, I started using cannabis.

(Interviewee no.016)

The above quote exemplifies an established route for overcom- ing initial scepticism emphasised in the interviews, namely acquiring knowledge. The participants emphasised that stigma at the outset was due to lack of knowledge and by acquiring knowledge and be- coming educated they also could overcome the barrier of starting MC treatment.

I didn't know what this drug would do. I didn't know its long- term effects, I didn't read any research about this, I did nothing. You know I was just anti at first, and today…I look back and I don't understand why. I think I should have jumped on it, from the first moment they offered it, I should have said: yes, I want to start. I guess at that time I was young and stupid. It took me 2 years, 2 years of suffering, crying, and shouting and I couldn't sleep and lay down, couldn't walk and sit down, I couldn't do anything. And I was really on hard drugs, I had to take Morphine and Targin, I got to the hospital and had injections, they [hospital staff] told me: we can't help anymore because it is already an overdose, and this can kill you, and I continued like this for 2 years. And when I finally took the cannabis, I realized I was an idiot.

(Interviewee no. 20)

4.3  |  Stigma after onset of treatment

A few participants spoke explicitly about concrete experiences of stigma after onset of MC use, or in other words, experiences in which they felt that members of society judged them negatively due to their MC use.

Interviewer: What bothers you when you smoke?

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Interviewee: I told you, every time I smoke, my neigh- bor closes her curtains. She acts like I do it on pur- pose, I really don't. It's just that sometimes I don't feel like I want to smoke inside the house, so I go outside. …. My brothers accept this [use of MC], they know I use it as a medicine, but my neighbors got irritated when they smelt it, then one of them asked if I really smoke cannabis. I told him this is my medication, but he didn't believe it's licensed and called the police. I'm not kidding, the police was here, they had a search warrant for my cannabis.

(Interviewee no. 015)

Stigma was not only part of personal experiences of social interac- tions with secondary socialisation groups such as neighbours. Indeed, participants also noted that stigma experiences came from interac- tions with family members.

I will not smoke this when they [participant's children] are nearby. Also, not when my wife is near, she sends me to smoke out there by the kitchen balcony, in the open air so there will be no celebrations in the house.

(Interviewee no. 017)

It should be noted that only two out of the 15 participants recalled concrete and lived experiences of stigmatisation. In other words, nar- ratives of ‘enacted stigma’ (Scambler, 2004) were rare in the inter- views. As shown below, much more evident in the interview data was ‘felt stigma’ (Scambler, 2004) or in other words expressed shame or fear of encountering potential stigmatisation.

I'm not going to smoke at work either. Because I don't want to be considered a criminal or something like that, so I will not smoke there. If I feel a little pain at work, I'll take a little more Optalgin [pharmaceutical pain reliever], I'll tolerate a little more until I will be done with work. No matter what, you will adjust it to fit into your society, it's not that you don't care for others' thoughts.

(Interviewee no. 018)

Discrete use of MC was a common way of dealing with felt stigma as it was used by participants to protect themselves from negative social criticism. In fact, a substantial proportion of the participants use their MC discretely, and some even noted that they preferred not telling their family and friends (besides select members of the nuclear family) about their use.

They [friends] don't have to know I smoke. I'm not interested in telling them. When I'm surrounded by people, if I'm in pain, I will search for a private place just to relieve the pain, then I will go back like nothing happened. But I will not do anything that ruins this.

Cannabis has become part of my life, it's not that I'm going to have fun.

(Interviewee no. 18)

It is important to note that participants also concealed their MC use to protect their children (e.g. discrete use was not only to protect themselves from stigma). Participants noted they did not want to ex- pose their children to MC, or to the knowledge that their parent use it.

See the house out there? That is the house where I live, and my children. Here is their pool, and here we sit and watch television, and here is also their play- room. So usually, I sit here and smoke only when they don't see me.

(Interviewee no. 01)

4.4  |  Othering: recreational vs. medical use of cannabis

A common strategy to deal with, or manage stigma is othering (Brons, 2015; Newhart & Dolphin, 2018; Reid, 2020). In the inter- views, it became clear that the participants were involved in various forms of othering. The most common type of othering was making a distinction between themselves and recreational users, or between MC use and recreational cannabis use. Throughout the interviews, the participants emphasised their negative attitude, even opposition towards recreational use of cannabis and other illicit drugs.

I'm very strict, I'm against drug use, I don't do drugs. Not at parties, and I didn't try any sort of drug in my whole life.

(Interviewee no. 01)

Emphasising their opposition to recreational use of cannabis and other drugs enabled the participants to make a distinction between this type of substance use and medical use of cannabis. In making this distinction, participants were engaged in a process of othering in which recreational cannabis users were constructed as a ‘negative out group’ very different from themselves. This process was in various ways achieved through polarisation in which the participants emphasise ‘our’ [e.g. patients using MC'] or ‘my’ good intentions and properties and actions and at the same time emphasising ‘their’ [recreational can- nabis users'] bad or deviant behaviour and intention.

I have proven myself, I'm 51 years old, I am not a small child who, for example, will go and smoke and go travelling for no reason. I do not smoke to be “high”. I smoke approximately half a cigarette a day when it hurts and there is no medication that can relieve it, and there is nothing that can make me forget what happened, this is the only reason [to smoke].

(Interviewee no. 01)

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In this interview extract, the informant emphasises his responsible actions (I am not a child and will use MC for pain relief, not to get high) at the same time as the informant emphasise recreational use as irre- sponsible (travelling for no reason). As such the distinction is clearly made that medical use is functional and socially acceptable and in con- trast to recreational use which is for having fun, which implicitly is not a socially acceptable reason for use.

For me cannabis is not for fun, cannabis is a medica- tion. It is something I need daily in order to function. I need it for activities of daily living, to wash the dishes, to get up and wash my face, to walk, to go out, to function. I don't take it for fun.

(Interviewee no. 016)

Clear from the above interview excerpt, the distinction made be- tween recreational and medical use enabled the participants to be engaged in normification, in which they emphasise their normative be- haviours. The participants emphasised that, as opposed to using can- nabis for recreational purposes, they used MC for the simplest daily functions of everyday life. The normification process that the partic- ipants were involved in was partly achieved by emphasising that the acute effect of cannabis is different for recreational and medical users. While recreational user feel ‘high’, people who use MC feel only pain relief.

When a normal person smokes cannabis, he may feel “high”, but when an injured person or a person in pain smokes cannabis, he just gets to be like a normal per- son, he doesn't feel anything beyond this. We get to be “normal” [when we smoke]. Generally, in our daily lives we are less than others, less than normal, it's hard to get up in the morning, the daily activities, ev- erything is hard.

(interviewer no. 01)

4.5  |  Othering: MC vs. pharmaceutical medications

Another form of othering evident in the interview material was that the participants made a distinction between MC and pharmaceutical medications. By painting a picture of pharmaceutical medication being either inadequate, or dangerous to their health, respondents made the case for how MC was a superior treatment and thus acceptable.

Look, the medical cannabis… saved me from being dependent on … addictive chemicals. These chemi- cals help on the one hand, but produce other things, things that you are not even aware of… you take it since others say it's good for you, you see it really helps you, so you continue to take it [pharmaceuti- cal medications]. You don't understand it can affect your stomach and kidney negatively, and besides that

it causes addiction. I've been addicted to Morphin. In that sense cannabis saved me, also mentally since it improved my mood.

(Interviewee no. 011)

The respondents referred to pharmaceutical treatment as a ‘chem- ical treatment’ that has several severe negative side effects. At the same time, they refer and contrast this to cannabis, which was descried as a natural plant that has less side effects and better therapeutic effi- ciency than the pharmaceutical medicine.

Cannabis is a plant, a plant of god. (Interviewee no. 01)

4.6  |  Self- control

The participants spent time and effort during the interviews to de- scribe rules of conduct that they follow in relationship with their MC use. Creating and obeying rules of using MC was a way for the par- ticipants to exemplify their self- discipline and demonstrate their re- sponsibility. One example of this was that participants made it clear that they safeguard their stored MC.

They know I have it [MC]. It's locked in my safe box. (Interviewee no. 020)

The participants also achieved normification by emphasising that they do not share their MC, despite being asked to share.

Everybody wants me to leave them a little bit of my [MC] cigarette but I don't have enough so I can't share it with them. Everyone asks me for it, but I'm not al- lowed to give.

(Interviewee no. 01)

Another guideline emphasised in the interviews was to avoid driv- ing under the influence of cannabis.

I know it's forbidden to drive under the influence of cannabis. Basically, I have a driver's license… but I'm a very focused person, I make an effort not to vaporize before driving. If I have to go out, I will not vaporize, I'll vaporize when I get back home.

(Interviewee no. 02)

Self- control and the ability to be in control over MC use was a re- current theme during the interviews. This is a form of normification as self- control is what is expected of normal adults. When asked how a person can control MC use, one interviewee replied that only if he is strong enough, he can be in control.

Interviewer: how can he do this control?

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Interviewee: if he is strong enough, he will be in con- trol. He has to be in control, this is what he needs.

Interviewer: doesn't he need any external help?

Interviewee: no no no, nothing external, how can this help him? What can someone external say? Don't take it now? The patient who uses MC needs to be strong enough, he can decide by himself when he needs to take it.

(Interviewee no. 019)

This interview excerpt makes it clear that the participant perceived control of MC use as important and that this control was an effect of a person's self- discipline, or a trait inherited in one's personality.

5  |  DISCUSSION

Our analysis suggests that participants experienced sigma in various ways. Before onset of MC treatment, the participants had stigma towards MC and they expressed hesitation and scepticisms regard- ing starting MC treatment, despite physician recommendation. In certain cases, this delayed treatment and led to unnecessary and continued suffering. This corresponds to the findings in Satterlund's et al. study (2015). Similarly, other studies have indicated that pa- tients suffering from physical and mental health problems sometime postpone treatment due to felt stigma (Frank et al., 2018; Hamilton et al., 2017; Knaak et al., 2017; Koschorke et al., 2021; Nyblade et al., 2019).

In addition, patients expressed stigma experiences after onset of MC treatment. A few of the informants noted incidences of enacted stigma. Yet, in most instances, stigma was not talked about in rela- tion to actual experiences of discrimination, but rather as felt stigma and participants had various ways of dealing with this type of stigma.

Felt stigma occurs when social and cultural negative messages penetrate one's beliefs, and the individual starts to acknowledge his identity as stigmatised (Livingston et al., 2012; Reid, 2020). As Reid states in his article ‘Felt stigma results from the awareness that an identity is culturally devalued and can result in anticipatory behavior to avoid negative interactions’ (Reid, 2020). In other words, when the individual starts to accept the problematised socially negative assumptions regarding MC, he will underestimate and de- evaluate himself (Frank et al., 2018; Hathaway et al., 2011). The current study indicates that felt stigma is evident among this convenience sample of people who use MC and that it likely precedes any experiences of enacted stigma.

Despite the fact that these participants are using MC accord- ing to legal guidelines, and even though actual experiences of stigmatisation were not a substantial part of these patients' self- presentation during the interviews, the analyses show that stigma was part of their internalised experiences. Participants felt that they would be judged if people knew about their MC use and this felt

stigma had real consequences in that it made participants choose carefully when to use MC, in front of whom, and whom to share the knowledge about their use to. These results are similar to other study findings (Reid, 2020; Ryan & Sharts- Hopko, 2017; Satterlund et al., 2015). It seems then that the deep- rooted stigma that these participants had towards cannabis before onset of use do not neces- sarily disappear after onset of MC use and new positive experiences of use. One consequence of this felt stigma was non- disclosure and concealment of MC treatment. As such it is possible that felt stigma actually reduces the chances of enacted stigma which in turn may explain why experiences of enacted stigma was not very prevalent in the interview data.

The fear of being stigmatised by others causes the individual to adjust their behaviour in various ways, and a common way to do this is through othering (Brons, 2015; Newhart & Dolphin, 2018; Reid, 2020). Othering is the process of identification of the self as member of a positive in- group which is partly achieved by identifying and emphasising a contrasting ‘negative’ out group (Brons, 2015). This study found that people who use MC deal with stigma by dissoci- ating themselves from the negative stereotypical identity of recre- ational users, that was described as socially deviant. Furthermore, the participants compared and contrasted this identity to their own identity, which was characterised as being in control, self- disciplining and MC use was a means to achieve a normal lifestyle not possible without. In this regard, the othering of recreational cannabis users was part of a processes of normification and assisted in creating an image of people who use MC as normative and as being integral part of normative society.

Previous studies conducted among mental health patients, in- cluding different diagnostic groups such as people suffering from depression, substance use disorder, schizophrenia and bipolar disor- ders, have found that felt stigma is associated with discontinuation of medications and treatment (Cinculova et al., 2017; Kamaradova et al., 2016). In the current study, felt stigma was not described as a reason to stop MC use. This may, however, be a function of the study's methodological design in which all recruited participants were current, as opposed to former, patients using MC. In order to reach an understanding of whether or not felt stigma relates to dis- continuation of MC treatment, there is a need for future studies to recruit patients who used MC in the past or follow- up patients over a longer study period.

5.1  |  Limitations

Several study limitations need to be recognised. First, most of the participants had been using MC for extended periods, and their experiences may be significantly affected by how they remember their reactions, and how they may have changed since the onset of MC treatment. Future research should include patients who are just about to start MC use or who have recently started MC treat- ment and contrast the different groups to examine whether expe- riences of stigma differ according to MC treatment experiences.

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In addition, a saturation point was reached after 15 interviews, which may be considered a small sample size, and may affect the reliability of the results. Yet, the saturation point was carefully as- sessed before we stopped recruitment and it is thus unlikely that more interviews would greatly affect the conclusions of the study. Furthermore, the sample is a convenience sample including Jewish people and all research participants were treated in the pain clinic of Ichilov hospital in Tel- Aviv city, which is known to be a par- ticularly liberal area of Israel (Israel Hofsheet, 2020). As such the findings may not be representative of the experiences of patients using MC in Israel from other cultural backgrounds (e.g. Arabs) and from other geographical locations. It is also possible that patients who use MC for other medical conditions have different experi- ences of stigma. This should be explored in future research. It is also difficult to determine the effects that the interview setting, and interviewer had on the material analysed found this study (Merriam, 1994). Nevertheless, the interview material and re- sponses of the participants give indication of how the participants view their social world and how they would like themselves to be perceived by others.

6  |  CONCLUSIONS

Despite the fact that participants of this sample are authorised to use MC, and despite the fact that they live in a social and cultural context of liberal attitudes towards MC, stigma, and especially felt stigma, is part of the participants MC experiences. The findings thus suggest that despite a long history of MC legalisation and con- tinuous development of MC policies, MC is not (yet) normalised in Israel. Indeed, similarly to recreational use of cannabis, MC use is associated with stigma. Stigma has the potential to have tremendous effect on patients, from the basic decision to start MC treatment through the rest of their treatment journey and how they decide to integrate this treatment into their daily lives. This might hold con- sequences affecting patients' identity, and relationship with friends and family members.

7  |  RELE VANCE TO CLINIC AL PR AC TICE

The results of the current study show that there may be a need to develop strategies aimed at reducing stigma related to MC treat- ment. Some of this may relate to how MC use is talked about and handled in social encounters with people who do not use MC and thus focus on enacted stigma. Yet, the current study suggests that more focus should be on addressing felt stigma and thus focus is needed on the intrapersonal level in addition to the interper- sonal, organisational/institutional, community and governmen- tal/structural level (Clinton & Pollini, 2021; Luoma et al., 2008). While there has been a great deal of work related to understand- ing stigma and its consequences, far less attention has been

placed on assessing effectiveness of stigma reduction interven- tions (National Academies of Sciences, Engineering, and Medicine, 2016). Livingston (Livingston et al., 2012) notes a few promising interventions that can reduce stigma related to substance use dis- orders (e.g. Acceptance and Commitment Therapy). As far as we are aware, there has been no attempt to develop stigma reducing interventions related to MC in particular, but this is clearly an area in need of further research.

7.1  |  Impact

• Despite a long history of MC policies in Israel, the current study indicates that MC is not normalised in Israel and that patients struggle with stigma related to MC use. It is important to examine and compare the extent to which stigma influences patients using MC in other jurisdictions.

• We suggest that addressing ‘felt’ stigma by focusing on the intra- personal level may be a particularly promising step that may assist patients using MC through the process of navigating MC treat- ment. This may in turn reduce harm and increase effectiveness of MC treatment.

• Addressing stigma related to MC treatment may improve the communication between nurses, doctors and their patients.

CONFLIC T OF INTERE S T The authors state no conflict of interest.

AUTHOR CONTRIBUTIONS Amany Hulaihel participated in the conceptualization and design of the study as well as the analysis and interpretation of data. Hulaihel drafted the article. Or Gliksberg substantially contributed to the acquisition of data and drafting the paper. Daniel Feingold partici- pated in the conceptualization and design of the study as well as the analysis and interpretation of data. He substantially contributed to the acquisition of data and drafting the paper. Silviu Brill, Ben Amit and Shaul Lev- ran substantially contributed to the acquisition of data and drafting the paper. Sharon Sznitman participated in the conceptualization and design of the study as well as the analysis and interpretation of data. Sznitman drafted the article. All authors read and approved the final manuscript.

ORCID Amany Hulaihel https://orcid.org/0000-0002-7194-2455

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How to cite this article: Hulaihel, A., Gliksberg, O., Feingold, D., Brill, S., Amit, B. H., Lev- ran, S., & Sznitman, S. R. (2022). Medical cannabis and stigma: A qualitative study with patients living with chronic pain. Journal of Clinical Nursing, 00, 1– 12. https://doi.org/10.1111/jocn.16340

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APPENDIX 1

INTERVIE W PROTOCOL

Opening conversation • Tell me a little about yourself. • Can you think back to the first time you used cannabis, please tell

me about that experience • Can you remember how it felt when you first used cannabis? • Do you feel that the use of medical cannabis is effective? How

does it help with your symptoms? Please specify. • How has your life changed since the beginning of your medical

cannabis use? Can you elaborate? • Are there any challenges that a patient using medical cannabis has

to deal with? That you had to deal with? Please elaborate.

Cannabis use routine • What is your daily routine in relation to your medical cannabis

use? Please describe… Do you use daily? When? • What made you decide on this routine…? • Are there days when you deviate from this routine? • Do you know other people who use medical cannabis? • Are there people who know/do not know about your use of med-

ical cannabis? If so, who?

Problematic use of medical cannabis • Do you have any concerns regarding your use of medical canna-

bis? If so, please specify… • Have certain concerns developed over time? Or vice versa? Were

there fears at first that dissipated over time? • Do you think prolonged use of medical cannabis can cause certain

problems? Can you give examples? • Do you think prolonged use of medical cannabis can lead to

addiction/dependence?

• Do you feel a ‘high’ (feeling of transcendence) after use? Please specify…

• Apart from pain relief, do you feel that medical cannabis alleviates / helps in other aspects? how? Please specify.

• Have you experienced any problems with the use of medical can- nabis? If so, please specify.

• Have you experienced that a friend or relative was bothered by your use of medical cannabis?

• Do you think there is a tolerance towards the therapeutic ef- fects of cannabis, meaning that you need to take higher dosage to achieve the same effects? Has this phenomenon happened to other people you know?

• If a renewal of your medical cannabis license will be rejected, how would this affect you? What would you do?

• If the doctor decides to reduce the dose of medical cannabis, how will you proceed? And how will you feel?

• Have you experienced a disturbance in daily functioning or in per- forming essential tasks due to your use of medical cannabis? Do you know people who have had this happen to them?

• Have you experienced an urge to consume medical cannabis? Do you know people who have had this happen to them?

• Have you ever felt that you needed to use more than the pre- scribed dose of medical cannabis? Do you know people who have had this happen to them?

• What do you think can help patients using medical cannabis so that they do not exceed their usual dose?

Concluding remarks Thank you for the time and cooperation.

• Do you want to add anything? • May I contact you, if I have any further questions?

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