Bio 22

Open camera or QR reader and scan code to access this article

and other resources online.

Medical Marijuana Use for Cancer-Related Symptoms among Floridians: A Descriptive Study

Cindy Tofthagen, PhD,1 Adam Perlman, MD,2 Pooja Advani, MD,3 Brenda Ernst, MD,4

Judith Kaur, MD,3 Winston Tan, MD,3 Katharine Sheffield, MA,1 John Crump, MD,5

Joshua Henry, MD,6 and Jason Starr, DO3

Abstract

Background: Thirty-six states, including Florida, have legalized marijuana for medical and/or recreational use, yet how it is used and perceived by persons with cancer is not well understood. Objectives: The purpose of this study was to identify patterns of use, perceived benefits, and side effects of medical marijuana (MMJ) among cancer patients in Florida. Methods: For this descriptive, cross-sectional study, anyone residing within the state of Florida who was diag- nosed or treated for a malignancy within the last five years and had used MMJ was eligible. An online survey containing questions about dosing, side effects, perceived benefits, and barriers to use was used. Descriptive statistics including frequencies, percentages, means, and standard deviations were used to analyze quantitative data. Responses to open-ended questions were coded and categorized. Results: Sleep (n = 112), pain (n = 96), and anxiety (n = 82) were the most common symptoms participants used MMJ to relieve and overall felt it was highly effective. MMJ was well tolerated with a minority (10.3%) reporting any adverse effects. Cost was the most frequent barrier reported by participants (42.8%). A variety of legal, bureaucratic, and system-related barriers were described. Conclusion: Participants perceived MMJ to be helpful in alleviating cancer symptoms. They held negative perceptions of the way MMJ is implemented and integrated into their oncology treatment plan. Enhanced communication and patient/provider education on MMJ are needed to inform patient decision making.

Keywords: cancer; cannabis; symptoms; tetrahydrocannabinol

Introduction

Thirty-six states and four territories in the United States have legalized marijuana for medical and/or rec-

reational use, although it remains a U.S. Drug Enforcement Agency Schedule 1 drug.1 As of March 25, 2022, there were >699,000 individuals in Florida who are approved by the state to use medical marijuana (MMJ).2 Cancer is one of

the approved indications for obtaining MMJ. Approxi- mately 15% of persons approved for MMJ use in Florida have a cancer diagnosis.3 To be able to certify patients as eligible, licensed physicians must complete an eight-hour course.4

The certifying physician is usually not the patient’s oncologist, and communication between the oncologist and the physician making the recommendation for MMJ

1Division of Nursing Research, 2Division of General Internal Medicine, 3Division of Hematology/Oncology, Mayo Clinic, Jacksonville, Florida, USA.

4Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona, USA. 5ReLeafe Now, Jacksonville, Florida, USA. 6North Florida Sports and Spine Center, Jacksonville, Florida, USA. Accepted June 13, 2022.

JOURNAL OF PALLIATIVE MEDICINE Volume 25, Number 10, 2022 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2022.0100

1563

D ow

nl oa

de d

by 7

4. 68

.1 30

.1 95

f ro

m w

w w

.li eb

er tp

ub .c

om a

t 1 0/

12 /2

2. F

or p

er so

na l u

se o

nl y.

is not required. Once an individual is certified as eligible, they must apply for an identification card from the state to then obtain marijuana products from a licensed dispensary. Anyone who wished to obtain MMJ must pay out-of-pocket for the doctor’s visits, licensing fees, and marijuana prod- ucts as these are not covered by insurance.

In oncology and palliative care settings where other con- trolled substances are being prescribed, open and forthright conversations about MMJ use are essential.5 Yet, there can be social stigma associated with its use,6 and patients with cancer may be reluctant to disclose use of marijuana to their oncology team. Further, oncology professionals may not feel comfortable talking with patients about use of MMJ. A University of Colorado Cancer Center study showed that while 73% of surveyed oncology providers believed that MMJ was beneficial for cancer patients, only 46% were comfortable recommending it. Major concerns cited included uncertain dosing, limited knowledge of available products and where to get them, and possible interactions with other medications.7

With the growing number of states legalizing MMJ for recreational and medical purposes, it is increasingly impor- tant for health care professionals to gain a better under- standing of MMJ use among oncology patients. Several studies inform knowledge of MMJ use among persons with cancer in Florida. A retrospective review of 816 cancer pati- ents in a palliative care program in Florida found that tetra- hydrocannabinol (THC) was present in the urine of *20% of patients during routine urine drug screens. THC in the urine was associated with moderate-to-severe symptoms, includ- ing lack of appetite, shortness of breath, fatigue, difficulty sleeping, anxiety, and depression.

Being male, single, and a history of smoking cigarettes were also associated with urine THC.5 The same research group examined characteristics of young adults with cancer, and found that 30% of persons age 18–39 tested positive for THC.8 Urine THC was again associated with being male, history of cigarette smoking, more recent diagnosis, and moderate-to-severe symptoms. The symptoms associ- ated with THC included pain, nausea, reduced appetite, constipation, trouble sleeping, and worse overall well- being. These studies improve understanding of what types of people with cancer may be more likely to use MMJ. However, they do not incorporate patient-reported informa- tion about how and why they engage in MMJ use.

Researchers at our institution examined the early pat- terns of MMJ in Florida following passage of the state’s first MMJ law.9 A cross-sectional survey of 58 patients receiv- ing palliative care demonstrated that 24% (n = 14) of partic- ipants used THC-containing products, often in conjunction with opioids. Only 50% of THC users had a state-issued card. Further, 21% of THC users believed that it would help cure their underlying illness. All users of THC-containing prod- ucts reported improvements in symptoms, including pain, nausea, and reduced appetite.9

These data suggested that misinformation about MMJ is prevalent; however, the small sample of MMJ users in this study prompted us to further explore the use patterns and perceptions of MMJ among Florida residents with cancer. Therefore, the purpose of this study was to identify patterns of use, perceived benefits, and side effects of MMJ among cancer patients in Florida.

Methods

For this descriptive, cross-sectional study, individuals residing within the state of Florida who had been diagnosed or treated for a malignancy within the last five years and had used medical cannabis for cancer-related symptoms were eligible. Patients were excluded if their only cancer diagno- sis was nonmelanoma skin cancer. The study was approved by the Internal Review Board (IRB). An online survey was developed, and pilot tested among research staff and MMJ users before distribution. The research team shared the sur- vey link with oncology clinicians through e-mail, and with potential participants through social media and flyers dis- tributed within the community and around the health care facility.

No personal identifiers were collected. The survey began by asking, ‘‘Have you been diagnosed with or treated for cancer within the last five years (excluding squamous or basal cell skin cancers)?’’ If the response was yes, participants answered questions about type and stage of cancer, race and ethnicity, age, gender, and current cancer treatment. The sur- vey contained questions about dosing, side effects, perceived benefits, and barriers to use. Descriptive statistics including frequencies, percentages, means, and standard deviations were used to analyze quantitative data. Additional narrative comments were analyzed for common themes by two mem- bers of the study team (C.T., K.S.).

Results

Two hundred one people agreed to participate in the study. Five were excluded because they were not Florida residents. Nine were excluded because they had not received a cancer diagnosis or undergone cancer treatment within the past five years. Twenty-six were excluded because they denied using MMJ for cancer symptoms. A total of 162 individuals were eligible and completed the survey. Participants could leave responses blank or skip over them if they chose. Participants were predominantly White (89.7%), non-Hispanic (89.3%), with a state-issued card (77.2%), and a mean age of just >57 years (Table 1). Approximately 1/3 of participants (36.9%) had stage IV disease, and over half (51.6%) had received chemotherapy.

Most participants (73.9%) felt that they could easily discuss MMJ with their oncologist. The majority either smoked (n = 55; 34.2%) or vaped (n = 61; 37.9%) MMJ, and multiple routes of administration (i.e., edibles, pills) were common. Over 60% used MMJ at least once a day. The majority (55.3%) had used MMJ for recreational use at least once over the course of their lives. About 92.8% reported using THC-containing products; however, the majority did not know the dose of THC (59.7%) or cannabidiol (CBD; 61.7%) they were getting. Sleep (n = 112), pain (n = 96), and anxiety (n = 82) were the most common symptoms partici- pants used MMJ to relieve.

Overall, participants reported that MMJ was highly effective in relieving their symptoms. A minority reported using it as a perceived adjunct to treat their cancer or to control symptoms from other health conditions (Table 2). Participants reported that MMJ was most effective when used for nausea/vomiting, anxiety, or sleep (Table 3). MMJ was well tolerated with a minority (10.3%) reporting any adverse effects at all. Impaired mental functioning (feeling fuzzy

1564 TOFTHAGEN ET AL.

D ow

nl oa

de d

by 7

4. 68

.1 30

.1 95

f ro

m w

w w

.li eb

er tp

ub .c

om a

t 1 0/

12 /2

2. F

or p

er so

na l u

se o

nl y.

or foggy; n = 9), dry mouth (n = 6), and paranoid/thinking or anxiety (n = 5) were the most common adverse effects (Table 4).

The most bothersome adverse effects were tachycardia, dizziness, and paranoid thinking/anxiety. Cost was the most frequent barrier reported by participants (42.8%), and soci- etal stigma was reported as a barrier by 17.8% of partici- pants. Content analysis of free-text comments demonstrated themes related to barriers of obtaining and using medical cannabis, including uncertain dosing/strains, don’t ask/don’t tell, product availability, side effects, bureaucracy, legal/ work repercussions, finances, potential interactions, and endorsements (Table 5).

Participants were also asked if there was anything else they would like to share about their experience using mari- juana for medical purposes. Content analysis revealed 8 additional themes including use in various forms, feelings of nonsupport from their medical team, differences between strains, alternative to opioids, use for concurrent medical conditions, importance of proper use, need for education/ research, and misconceptions (Table 6).

Discussion

Participants in the study used MMJ to alleviate numerous symptoms, most commonly sleep, pain, and anxiety. Overall participants reported that MMJ was highly effective in relieving all the symptoms considered in the survey. MMJ was reported to be well tolerated overall. These findings are consistent with previous studies, demonstrating that patient- perceived efficacy10 is incongruent with clinical trials that have shown limited improvements in cancer symptoms.11–13

For example, a 2020 study examining MMJ for sleep found that despite an increased expectation that MMJ improved sleep, the more frequently a participant used MMJ the more likely they were to report worse subjective sleep quality. Those who used edible MMJ also reported worse sleep effi- ciency and duration.14

Similarly, clinical trials of MMJ for cancer pain15,16 and appetite stimulation13 have failed to demonstrate efficacy. As with many medications, MMJ dose may need to be titrated up or down depending on response and side effects, and may

Table 1. Frequencies and Percentages

of Demographic Variables (n = 162)

Descriptive statistics Range Mean SD

Age 19–82 57.33 13.127 Gender Frequency Percentage

Female 82 50.6 Male 79 48.8 Transgender 1 0.5

Race (could select multiple options) American Indian

or Alaska Native 3 1.8

Asian 3 1.8 Black or African American 7 4.2 Native Hawaiian or Other

Pacific Islander 0 0.0

White 148 89.7 Other, please specify

(Mixed, Hispano, Hispanic)

3 1.8

Prefer not to answer 1 0.6

Ethnicity Hispanic or Latino 13 8.7 Not Hispanic or Latino 133 89.3 Prefer not to answer 3 2.0

Primary cancer Brain 1 0.6 Breast 26 16.0 Colon 9 5.6 Esophageal 2 1.2 Gallbladder 1 0.6 Head and Neck 5 3.1 Kidney 4 2.5 Leukemia 5 3.1 Liver (hepatocellular,

bile duct) 5 3.1

Lung 8 4.9 Lymphoma 9 5.6 Multiple myeloma 11 6.8 Multiple primary cancers 4 2.5 Myelodysplastic syndrome 5 3.1 Neuroendocrine 2 1.2 Ovarian 12 7.4 Pancreatic 16 9.9 Prostate 11 6.8 Rectal 2 1.2 Stomach 1 0.6 Uterine (endometrial) 1 0.6 Other, please specify 22 13.6

Cancer stage Stage 1 17 10.6 Stage 2 18 11.3 Stage 3 20 12.5 Stage 4 59 36.9 Don’t know 33 20.6

Other 13 8.1 Cancer treatment

Chemotherapy 83 51.6 Radiation therapy 15 9.3 Immunotherapy 36 23.1 Hormonal therapy 26 16.3

(continued)

Table 1. (Continued)

Descriptive statistics Range Mean SD

History of marijuana for recreational (nonmedical) purposes Used it at least once

in the past 89 55.3

Have never used marijuana recreationally

43 26.7

Current using recreationally 29 18.0

State-issued card Yes 125 77.2 No 29 17.9 Don’t know 1 0.6 Choose not to answer 7 4.3

SD, standard deviation.

MARIJUANA USE IN CANCER 1565

D ow

nl oa

de d

by 7

4. 68

.1 30

.1 95

f ro

m w

w w

.li eb

er tp

ub .c

om a

t 1 0/

12 /2

2. F

or p

er so

na l u

se o

nl y.

or may not provide the relief from symptom that patients expect. Federal restrictions have limited access to MMJ for research purposes; however, plans to reform these restric- tions may facilitate additional research evaluating different strains, routes, and doses.17

The majority of participants had tried marijuana for rec- reational purposes at least once, which may have resulted in them being open to medical use. Further, 18% were using marijuana concurrently for recreational and medical pur- poses. Use for dual purposes potentially affects ability to determine adequate dosing or efficacy.

Table 2. Overall Survey Results

Frequency (percentage)

Have you used medical marijuana to help relieve any symptoms you had from cancer or cancer treatment? (n = 161) Yes 144 (89.4) No 17 (10.6)

What problems/barriers have you encountered in obtaining/using marijuana for medical purposes (could select multiple responses)? Problem/barrier

Cost 77 (47.8) Stigma 32 (19.8) My doctor doesn’t want me to use it 8 (5.0) Other (see Table 5) 63 (39.1)

Do you feel that you can easily discuss medical marijuana with your oncologist? Yes 119 (73.9) No 21 (13.0) Don’t know 20 (12.4) Not applicable 1 (0.6)

How do you use medical marijuana (could select multiple responses)? Smoke 55 (34.2) Vape 61 (37.9) Edibles 60 (37.3) Pills/capsules 30 (18.6) Liquid 57 (35.4) Topical 24 (14.9) Oil 45 (28.0) Other: patch, spray, sublingual 20 (12.4)

How often do you use medical marijuana? (n = 153) Less than weekly 16 (10.3) Weekly 7 (4.6) 2 - 3 Times a week 16 (10.3) 4 - 6 Times a week 12 (7.8) Daily 52 (34.0) 2 - 3 Times a day 35 (22.9) 4 - 6 Times a day 10 (6.5) >6 times a day 5 (3.3)

Does the type of marijuana product you use have THC? (n = 153) Yes 138 (90.2) No 7 (4.6) Don’t know 8 (5.2)

Do you know the dose of the THC that you take each day? (n = 134) No 80 (59.7) Yes 53 (39.6) Doesn’t have THC 1 (0.7)

Do you know the dose of the CBD that you take each day? (n = 149) No 92 (61.7) Yes 42 (28.8) Doesn’t have CBD 15 (10.1)

Are you using medical marijuana for symptoms related to cancer? (n = 159) Yes 137 (86.2) No 13 (8.2) I am using medical marijuana

for other health problems not related to cancer

9 (5.7)

(continued)

Table 2. (Continued)

Frequency (percentage)

Which cancer symptoms do you use medical marijuana for? (Could select multiple answers) Pain 96 (59.3) Anxiety 82 (50.6) Sleep 112 (69.1) Depression 45 (27.8) Appetite 72 (44.4) Numbness/tingling 40 (24.7) Nausea/vomiting 73 (45.1) Diarrhea 13 (8.0) Other: general well-being, GERD,

chemo brain, slowing cancer growth, dizziness, neuropathy, restless legs, hot flashes

13 (8.0)

Where do you purchase medical marijuana? (Could select multiple answers) Medical marijuana dispensary 126 (77.8) Smoke shop 2 (1.2) A friend or neighbor 17 (10.5) By mail 1 (0.6) Other 9 (5.6)

How would you describe your history with marijuana for recreational (nonmedical) purposes? Used it at least once in the past 89 (55.3) Have never used marijuana

recreationally 43 (26.7)

Currently using recreationally 29 (18.0)

CBD, cannabidiol; GERD, gastroesophageol reflux disease; THC, tetrahydrocannabinol.

Table 3. Perceived Effectiveness of Medical

Marijuana for Specific Symptoms

Symptom N Range Mean SD

On a scale of 0 (not effective) to 10 (extremely effective), how effective is medical marijuana for relief of the following cancer symptoms? Pain 95 0–10 7.6 2.2 Anxiety 81 0–10 8.3 2.1 Sleep 110 0–10 8.3 2.2 Depression 44 3–10 7.7 2.0 Appetite 72 0–10 7.9 2.3 Numbness/tingling 39 0–10 7.0 2.5 Nausea/vomiting 72 3–10 8.5 1.8 Diarrhea 12 4–10 6.8 2.3 Other 13 6–10 9.3 1.3

1566 TOFTHAGEN ET AL.

D ow

nl oa

de d

by 7

4. 68

.1 30

.1 95

f ro

m w

w w

.li eb

er tp

ub .c

om a

t 1 0/

12 /2

2. F

or p

er so

na l u

se o

nl y.

Previous studies have also demonstrated that some indi- viduals use MMJ thinking that it will have effects on the cancer, rather than strictly using it to alleviate symptoms.9,18

Most participants lacked specific dosing information, potentially because of the high majority who vaped or smoked it. However, this likely leads to the oncology team having inaccurate information, underscoring the need for improved communication between the MMJ certifier, medi- cal oncologist, and the patient.

Future descriptive and qualitative research might explore MMJ patient decision making and communication patterns between patients, MMJ certifying physicians, and oncolo- gists. The existing process in Florida for obtaining MMJ could be improved for people with cancer by implementing policies and procedures to enhance communication between MMJ certifying physicians and oncologists. This would help ensure that oncology patients receive accurate and reliable information with which to decide how and if to use MMJ to help manage their cancer-related symptoms, and that any potential drug interactions or side effects are managed in the context of their cancer diagnosis, stage, and treatment.

In addition, participants in the study noted cost, social stigma, legal and bureaucratic barriers. Cost- and system- related barriers negatively impact access to MMJ, while social stigma likely influences patient willingness to openly discuss MMJ use with their oncology team. Lack of disclosure is problematic for patients as MMJ interacts with multiple pre- scription medications commonly used in cancer settings, such as warfarin, pain medications, and benzodiazepines.19

The free-text comments provide important insight into MMJ from a cancer patient’s perspective (Tables 5 and 6).

Several participants described stigma and feeling inade- quately supported in their choice to use MMJ. MMJ seemed to be preferred over opioid use. Some participants had per- ceptions that MMJ was more effective than prescribed opi- oids at managing their cancer pain. In addition to managing cancer symptoms, participants used MMJ to manage con- current medical conditions such as irritable bowel syndrome, muscle spasms, and surgical pain. Participants reported hav- ing misconceptions about MMJ before use.

There is a need for trusted, accurate, evidence-based infor- mation to inform patient decision making. Additional research is needed to help pave the way for further scientific advances, including randomized control trials, testing commercially available products and doses, as well as development and testing of interventions to improve patient knowledge and communication between patients and providers.

Physicians and other health care professionals may wish to seek additional information on the various forms (oils, tinctures, etc.), routes (smoking ‘‘flower,’’ vaping, or topi- cally), and strains. Patients should receive education on the potential risks and benefits, as well as potential drug inter- actions. Providing patients with information about limita- tions of the evidence for MMJ, potential quality control, and risks of obtaining MMJ from nonauthorized distributors or individuals is also important. These discussions would facil- itate a more open dialog and reduce patient misconceptions.

Limitations

The nature of self-reported data allowed for insight into patient perceptions and use patterns but did not allow for

Table 4. Perceived Side Effects Experienced with Use of Medical Marijuana

Frequency (percentage)

Have you experienced any side effects or adverse reactions from the use of medical marijuana? (n = 155) Yes 16 (10.3) No 139 (89.7)

Side effect N Range Mean SD

On a scale of 0 (minimally bothersome) to 10 (extremely bothersome), how bothersome were the side effects experienced in the use of medical marijuana for relief of cancer symptoms? (Could select multiple answers) Headache(s) 1 3–3 3.00 — Dizziness 4 4–6 5.00 0.8 Drowsiness 4 3–8 4.75 2.4 Dry mouth 6 2–8 4.17 2.6 Paranoid thinking/anxiety 5 3–7 5.60 1.7 Unwanted weight gain 1 4–4 4.00 — Cough 2 1–5 3.00 2.8 Increased heart rate 1 10–10 10.00 — Impaired mental functioning 9 2–7 4.56 1.7 Other: hunger, forgetfulness, flushing, rash 5 3–10 7.00 3.2

Frequency (percentage)

Which of the following, if any, have you experienced with your use of medical marijuana? (Could select multiple answers) Medical marijuana makes me feel more relaxed 127 (78.4) Medical marijuana makes me feel ‘‘fuzzy’’ 34 (21.1) Medical marijuana makes me feel ‘‘stoned/high’’ 23 (14.3) Medical marijuana doesn’t change my mood at all 15 (9.3)

MARIJUANA USE IN CANCER 1567

D ow

nl oa

de d

by 7

4. 68

.1 30

.1 95

f ro

m w

w w

.li eb

er tp

ub .c

om a

t 1 0/

12 /2

2. F

or p

er so

na l u

se o

nl y.

Table 5. Themes from Free-Text Comments Related to Barriers to Obtaining and Using Medical Cannabis

What problems/barriers have you encountered in obtaining/using marijuana for medical purposes (themes from write-in responses) Uncertain Dosing/Strains.

Don’t know how to get it. A lot of trial and error. Unsure what to try dosage how often. Finding the specific strain needed to treat pancreatic cancer. It’s hard to know what form to take it in what strain what dose etc. Finding the right strain so many caused me to break out. It’s very hard to know what to try. It would be best if medical professionals would prescribe the best dosage.

Don’t Ask/Don’t tell. Not all doctors are on board, it is like a taboo topic. My medical team just pretends it does not exist. Pain doctor not on board. Some doctors are against using med marijuana which makes things difficult as a patient.

Product Availability. Florida doesn’t have the items available that they had in Maryland. Availability of preferred strains. State of Florida’s unwillingness to enact the medical marijuana wishes of the electorate.

Side Effects. I don’t like the taste. I gave up my card I did not like the symptoms it nauseated me. It has not worked as well as I would have liked for appetite. I have lost the taste for food and am losing weight.

Bureaucracy. Waiting for card to be approved. Wait time to obtain card from State. Length of processing time to obtain the marijuana card. The bureaucratic money mining that adds months to the process for no good reason. Inconvenience. Had to go to another doctor because the cancer center I go to does not prescribe.

Legal/work repercussions. Risk of being arrested. Hospital I work for will dismiss me. I do not want to have THC in urine for a drug test. Residence in Alaska I cannot legally get my card in Florida therefore I must obtain it from a person. Physicians and institutions (like the VA) have started reducing prescribed opioids for pain, without prescribing

effective substitutes. Where medical marijuana might be effective for these patients, the VA will strip veteran benefits if marijuana is discovered in their system. This must be remedied!

If someone has the ability to get the medical marijuana card, they should not be penalized at work for using it. Meaning if they test positive, they should not be dismissed. This is one of the big reasons why I use it without the THC.

Finances. Not being able to purchase what I need to accommodate my levels of pain because of the cost and insurance

doesn’t help pay. Sometimes I just can’t afford it. Having to pay a fee to the State every 12 months. Insurance does not cover. Marijuana doctors charge about $275 to get approved. This approval is good for 7 months at which time you have

to get approved again for an additional $275. Then add the cost of the state license at $75 good for a year. Then add the high cost of the marijuana, it becomes too expensive!

We shouldn’t have to keep paying a fee to the state just to be allowed to buy our medication. If your condition is permanent, you shouldn’t have to keep renewing your prescription.

I hope I live long enough to see that we get support to help with the cost of it one day. It’s my only hope right now. I pray that more research is provided and that this is no longer illegal in any state. It would help lower the cost and

increase access to the many who have no ability to legally obtain this medication. Potential Interactions.

Fear that it will affect my immunotherapy treatment. Possible interactions with chemo.

Endorsement. When I lived in Virginia during my initial diagnosis, I wasn’t legally able to obtain medical marijuana. I couldn’t eat

after my surgery to remove all of the cancer and was down to 94 lbs. from 115 lbs. I was nauseous during chemo when I finally received medical marijuana everything changed for me. I was able to eat, the nausea was controllable without heavy pharma drugs. I was able to sleep and able to be distracted from the pain. I had my own personal resistance at first based on everything I’d been taught about marijuana. I don’t feel that way after almost five years of being blessed by this medication.

1568

D ow

nl oa

de d

by 7

4. 68

.1 30

.1 95

f ro

m w

w w

.li eb

er tp

ub .c

om a

t 1 0/

12 /2

2. F

or p

er so

na l u

se o

nl y.

Table 6. Themes from Free-Text Comments

Is there anything else you would like to share with the researchers about your experiences using any form of marijuana for medical purposes? (Themes from write-in responses) Use in various forms.

Began using oil orally—did not like psychotropic effects, researched and made suppositories. After biopsy then surgery continued to use suppository for pain and topical ‘‘budder’’ for incision and bruising.

I prefer homemade gummy edibles or vape using a volcano that heats the medicine and creates minimal smoke. It does very well in topical form for muscle and joint pain and does well in oil form for nausea and sleep.

Feelings of nonsupport from their medical team. Stigma regarding medical marijuana needs to stop. Until you have gone through chemo with doctors’ reluctance to

prescribe pain meds, you have no idea. I have never abused medication—I resent being treated like an addict. Almost impossible to get medication from the doctors while I was going through chemo and after my surgery. I needed

relief. I did my research, and I went with medical marijuana. Shame on my doctors not trying to find me some relief. I thought it was ‘‘first do no harm.’’

It is a shame that all cancer patients in the US cannot obtain legally. The fact that marijuana is not approved by FDA and not offered by traditional medicine—and (my healthcare

facility)—a big disadvantage and disappointment. My oncologist was only pushing chemo (sure getting perks from big pharma!)

Differences between strains. I prefer the Endica strains as they help better with pain and anxiety. The Sativa strains add to my anxiety and makes it hard to sleep.

Alternative to opioids. Provides superior pain relief to Gabapentin and Tramadol. It is not addicting. If I have to go out of state or something, it doesn’t bother me not to have it. It was extremely helpful in reducing the amount of prescription pain medicine needed. I absolutely hate pain narcotics;

medical marijuana was a very nice alternative. I went through one week post ops breast cancer surgery, taking the prescribed Oxycodone, which is an awful

personality changer for me, although a good pain reliever. I am now no longer taking it, and when needed, am using either a MMJ tincture or hydrocodone 5/325. They are comparable pain relievers. The MMJ has additional benefits of anti-nausea and anti-anxiety, and that is why it is my preferred choice at the current time.

It doesn’t clog my bowels like opioids and is at least as effective for pain. I’m not as worried about overdose. I was moved to try medical marijuana THC and CBD as a mean to avoid prescribed opioid drugs for muscle spasm

from surgery scarring and bone pain. I’m anaphylactic to majority of narcotics that has stopped by breathing and barely survived it in 2017. If I didn’t have

medical marijuana, I would not have survived my pain levels. Marijuana was a gateway drug for me, but for the opposite reason. It got me off the opioids I was taking for pain. Using medical marijuana has helped me sleep through the pain at night and helps reduce my symptoms and daily pain.

This is a much better way to treat my symptoms and pain without having the side effects of taking prescription pain medications.

Use for concurrent medical conditions. I need a hip replacement and it gives me the ability to get some sleep. I also have irritable bowel syndrome. It has reduced my symptoms (severe diarrhea, abdominal spasms and abdominal

pain) from daily to maybe once a month. I have taken every medication available for irritable bowel syndrome and they would work for less than a year and then have no effects after that. I have been using medical marijuana for nearly 2 years now and it has been great.

I have another problem with my left rib that causes a lot of nerve pain. I can’t get surgery on my rib while I am getting cancer treatment. I think if it were just cancer, I wouldn’t need medical marijuana.

It seems to be effective with neuropathy, I am cutting back on Lyrica. Importance of proper use.

If used properly marijuana can be extremely useful and beneficial. Used properly is the key! MMJ use requires maturity, no using and driving, for example.

Need for education/research. Patient education is key to success. Physicians need to understand that there are multiple routes of administration

besides smoking flower or vaping—like transdermal and sublingual products. Doctors need more education on the benefits of cannabis. My oncologist has no clue and has a very closed mind, only

because he is not educated. Much more research needs to be done. We need lots of help and the fact that (healthcare facility) is participating

in research has given me great hope. (Healthcare facility) could pioneer in marijuana treatments but is very conservative about it—disappointing! (Healthcare facility) needs to do more research on it. There needs to be more collaboration between departments.

Misconceptions. I was totally against trying this form of medicine—I was wrong. MMJ has helped control the side effects of dealing

with stage IV cancer. I was the mom that constantly told my kids that marijuana was a gateway drug. That’s all nonsense. I use it in a

controlled environment.

MMJ, medical marijuana.

1569

D ow

nl oa

de d

by 7

4. 68

.1 30

.1 95

f ro

m w

w w

.li eb

er tp

ub .c

om a

t 1 0/

12 /2

2. F

or p

er so

na l u

se o

nl y.

evaluation of changes in dosing or frequency over time. Because participants were self-reported MMJ users, they likely held positive views of MMJ that could have influenced our results. The relatively small sample size (response rate of *0.2% of patients with cancer and a MMJ authoriza- tion in Florida) and lack of racial and ethnic diversity may limit generalizability of our findings. Due to the low response rate, our sample may not be representative of the entire population.

Conclusions

Oncology patients who use MMJ perceived that it served an important role in symptom management. They held neg- ative perceptions of the way MMJ is implemented and inte- grated into their oncology treatment plan. Clinical, research, and policy changes are needed to ensure that all patients have accurate, evidence-based information, from reliable and knowledgeable sources, and that health care providers are comfortable discussing MMJ as a potential option for patients.

Funding Information

No funding was received.

Author Disclosure Statement

C.T. owns stock in Trulieve. All other authors have no competing financial interests.

References

1. Perlman AI, McLeod HM, Ventresca EC, et al.: Medical cannabis state and federal regulations: Implications for United States health care entities. Mayo Clin Proc 2021;96: 2671–2681.

2. Florida Department of Health: Office of Medical Marijuana Update. 2022. https://docs.google.com/viewer?url=https% 3A%2F%2Fknowthefactsmmj.com%2Fwp-content%2Fup loads%2Fommu_updates%2F2022%2F032522-OMMU- Update.pdf (Last accessed March 30, 2022).

3. Rosenthal MS and Pipitone RN: Demographics, percep- tions, and use of medical marijuana among patients in Florida. Med Cannabis Cannabinoids 2021;4:13–20.

4. Florida Department of Health: Office of Medical Marijuana Use. 2019. www.floridahealth.gov/programs-and-services/ office-of-medical-marijuana-use/index.html (Last accessed February 4, 2019).

5. Donovan KA, Chang YD, Oberoi-Jassal R, et al.: Rela- tionship of cannabis use to patient-reported symptoms in cancer patients seeking supportive/palliative care. J Palliat Med 2019;22:1191–1195.

6. Satterlund TD, Lee JP, and Moore RS: Stigma among California’s medical marijuana patients. J Psychoact Drugs 2015;47:10–17.

7. Glode AE, Wright GC, and Leong S: Evaluation of Col- orado oncology providers on the use of medical marijuana. J Clin Oncol 2019;37(15 Suppl):10511.

8. Donovan KA, Oberoi-Jassal R, Chang YD, et al.: Cannabis use in young adult cancer patients. J Adolesc Young Adult Oncol 2020;9:30–35.

9. Highet BH, Lesser ER, Johnson PW, and Kaur JS: Tetra- hydrocannabinol and cannabidiol use in an outpatient pal- liative medicine population. Am J Hosp Palliat Care 2020; 37:589–593.

10. Levin M, Zhang H, and Gupta MK: Attitudes toward and acceptability of medical marijuana use among head and neck cancer patients. Ann Otol Rhinol Laryngol 2022. Online ahead of print.

11. Blake A, Wan BA, Malek L, et al.: A selective review of medical cannabis in cancer pain management. Ann Palliat Med 2017;6(Suppl 2):S215–S222.

12. Bar-Lev Schleider L, Mechoulam R, Lederman V, et al.: Prospective analysis of safety and efficacy of medical cannabis in large unselected population of patients with cancer. Eur J Intern Med 2018;49:37–43.

13. Razmovski-Naumovski V, Luckett T, Amgarth-Duff I, and Agar MR: Efficacy of medicinal cannabis for appetite- related symptoms in people with cancer: A systematic review. Palliat Med 2022;36:912–927.

14. Winiger EA, Hitchcock LN, Bryan AD, and Cinnamon Bidwell L: Cannabis use and sleep: Expectations, outcomes, and the role of age. Addict Behav 2021;112:106642.

15. Chapman EJ, Edwards Z, Boland JW, et al.: Practice review: Evidence-based and effective management of pain in patients with advanced cancer. Palliat Med 2020;34:444–453.

16. Shin S, Mitchell C, Mannion K, et al.: An integrated review of cannabis and cannabinoids in adult oncologic pain management. Pain Manag Nurs 2019;20:185–191.

17. National Academies of Sciences Engineering, and Medi- cine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda: Challenges and barriers in conducting cannabis research. In: The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recom- mendations for Research. Washington, DC: National Aca- demies Press, 2017.

18. Buchwald D, Brønnum D, Melgaard D, and Leutscher PDC: Living with a hope of survival is challenged by a lack of clinical evidence: An interview study among cancer patients using cannabis-based medicine. J Palliat Med 2020;23:1090–1093.

19. Antoniou T, Bodkin J, and Ho JMW: Drug interactions with cannabinoids. CMAJ 2020;192:E206.

Address correspondence to: Cindy Tofthagen, PhD

Division of Nursing Research Mayo Clinic

4500 San Pablo Road Jacksonville, FL 32224

USA

E-mail: [email protected]

1570 TOFTHAGEN ET AL.

D ow

nl oa

de d

by 7

4. 68

.1 30

.1 95

f ro

m w

w w

.li eb

er tp

ub .c

om a

t 1 0/

12 /2

2. F

or p

er so

na l u

se o

nl y.