Differences in cannabis use characteristics, routines, and reasons for use among individuals with and without a medical cannabis card.

We report how we determined our sample size, all data exclusions, all manipulations (not applicable), and all measures in the study. Individuals were recruited from Rhode Island (RI) and Massachusetts (MA) in 2015–2016. Individuals with an MCC ( n = 25, M age = 46.96 year, 60% female, 68% Caucasian) and without ( n = 31, M age = 26.10 year, 29% female, 54.8% Caucasian) participated in semistructured individual interviews and focus groups, respectively. Throughout data collection, medical cannabis use was legal with an MCC and recreational use was illegal but decriminalized in RI and MA. In RI, specific conditions qualified for an MCC (e.g., cancer, epilepsy; see Mercurio et al., 2019 ) per the patient’s certifying healthcare provider (i.e., Doctor of Medicine, Doctor of Osteopathic Medicine, Physician Assistant, Advanced Practice Registered Nurse). In MA, those same conditions plus any debilitating condition qualified for an MCC per the patient’s certifying healthcare provider (i.e., Doctor of Medicine, Doctor of Osteopathic Medicine). Non-MCC participants met the following inclusion criteria for focus groups, which were matched to the associated laboratory cannabis administration study: ages 18–50, English speaking, past-month cannabis use ≥ four times, past 6-month use ≥ monthly, not currently seeking treatment for, or attempting to quit, cannabis, and past 6-month cannabis purchase ≥ twice. MCC participants met identical inclusion criteria as listed above except that the age range was expanded to 70 given that MCC participants did not complete the laboratory cannabis administration study and the prevalence of medical cannabis use among older adults has increased. The present study’s sample size included all available data from participants who met inclusion/exclusion criteria. This study was not preregistered and no manipulations were implemented. All study procedures were approved by the University’s Institutional Review Board (Protocol #: 1502001185; Behavioral Economic Analysis of Demand for Marijuana ). After consenting, participants provided information on sociodemographic characteristics and completed the Marijuana History and Smoking Questionnaire ( Metrik et al., 2009 ) to assess average use days per week, duration of regular use (in years), frequency of use for medical purposes, and typical administration mode (for full review of procedures, see Aston, Scott, & Farris, 2019 ). Interviews and focus groups were moderated by the principal investigator (E.R. Aston); a trained research assistant attended sessions for purposes of note-taking. Participants were asked: “Tell me about your cannabis use routine,” “What do you know about the cannabis you are buying?,” “What are the reasons for using different strains of cannabis?,” and “Are certain strains marketed for certain effects?.” Interviews and focus groups were audio recorded and captured via observational notes. Interviews and focus groups lasted approximately 60 and 75 min, respectively, and proceeded until achieving data saturation (i.e., new or relevant data ceases to arise). Participants were compensated $40. For additional data and study materials, please contact the second author. Independent samples t -tests and chi-square tests were used to determine whether sociodemographic or cannabis use variables differed between groups ( Table 1 ). Interviews and focus groups were transcribed verbatim and identifiers were removed. A qualitative coding structure was developed from the semistructured agenda and refined throughout coding to include emergent topics. Transcripts were coded separately by two research assistants using an open-coding process ( Glaser & Strauss, 1967 ). Codes were subsequently entered into NVivo qualitative data analysis software for thematic analysis. After the initial open-coding review of transcripts was complete, relevant content then underwent secondary coding and analysis. Final codes were reviewed and summarized to identify key themes reported herein. Themes are described but data are not quantified as this would not accurately reflect the prevalence of a given behavior or belief ( Hannah & Lautsch, 2011 ). Each quote includes the assigned participant study number and group (i.e., MCC status) in parentheses. Illustrative quotes were selected to reflect the most accurate representation of each theme, and are presented across groups to compare themes for each topic ( Table 2 ).

MCC participants typically endorsed a preferred administration mode, but most used several modes. Combustible methods and edibles were most common. Many MCC participants also reported vaporization, and fewer reported using tinctures administered sublingually, cannabis-infused topicals, and concentrates. Conversely, most non-MCC participants preferred combustible modes. Further, while non-MCC participants were familiar with vaporization (see Aston, Farris, et al., 2019 ), few endorsed this as a primary or adjunct mode. Most MCC participants reported using cannabis consistently throughout the day and had routine medication schedules (#41, MCC). Participants with an MCC reported cannabis use was intertwined with other regular activities and helped them transition from one task to another. Further, almost all MCC participants reported using cannabis as part of evening or nightly routines, and that using cannabis helped them to relax or unwind (#55, #57, MCC). Conversely, most non-MCC participants reported use routines that were less strict and influenced by day of week or other contextual factors, for example, workload (#3, #21, Non-MCC). Further, non-MCC participants infrequently reported using cannabis prior to completing daytime responsibilities (#18, Non-MCC). Yet, the majority reported using cannabis during the afternoon and/or evenings. Similar to MCC participants, non-MCC participants also discussed using cannabis at night to relax (#11, #29, Non-MCC). MCC participants generally believed that cannabis could effectively manage numerous symptoms and conditions (#42, MCC) ranging from bipolar disorder (#36, #53, MCC) to endometriosis (#57, MCC). Several MCC participants indicated that edibles optimally managed inflammatory diseases, for example, Crohn’s disease (#42, MCC), provided longer effects, and more pain relief than other formulations/modes (#37, #42, #51, #58, MCC). Many participants noted cannabis effectively treated pain from various sources (#42, #43, #45, #46, #54, #57, #58), but some believed certain strains were better for pain (#51, MCC). Others perceived that combustible forms effectively treated nausea due to rapid antiemetic effects (#56, MCC). Perhaps unsurprisingly, few non-MCC participants used cannabis to manage psychiatric and/or physical symptoms; those that did described how cannabis helped with managing pain and/or mitigating anxiety (#11, #19, #29, Non-MCC). Further, some participants believed individuals who use cannabis for medical purposes would prefer certain strains based on medical conditions (#2, Non-MCC). Participants with and without an MCC agreed cannabis was an effective sleep aid, noting it helped them to relax so they could fall and stay asleep (#24, Non-MCC). Moreover, participants agreed that Indica strains were better able to engender sleep than were Sativa strains (#9, Non-MCC; #43, MCC). Many MCC participants described receiving recommendations for cannabis products at dispensaries, but experiences varied. In some cases, participants described a personalized experience (#50, #55, MCC). Others described how staff recommendations were based on patient-reported symptoms, such as anxiety and/or pain (#41, #46, #50, #55, MCC). In other instances, participants indicated dispensary staff would make broader recommendations based on strain (#36, #46, MCC) or cannabinoid composition (#35, #55, MCC). Notably, a few participants expressed skepticism about the accuracy of dispensary staff recommendations and perceived the information to be subjective (#35, MCC). As expected, most non-MCC participants described a dissimilar experience when purchasing cannabis from illegal suppliers (i.e., dealer). They described receiving minimal information about available products prior to purchasing and some expressed skepticism about the details of certain cannabis characteristics (e.g., strain name; #7, #28, Non-MCC). However, some explained that they had considerable knowledge regarding their cannabis because their dealers grew their own products (#1, #27, Non-MCC) or purchased diverted cannabis from retail dispensaries (#16, Non-MCC). Several MCC participants used cannabis to prevent certain symptoms, such as pain (#43, MCC) or nausea (#41, MCC), and described how using cannabis before physical activity helped mitigate experiences of pain (e.g., intensity) later. Conversely, non-MCC participants did not discuss using cannabis prophylactically. Participants perceived Indica strains most often produced pleasurable, relaxing, and sedating effects (#21, Non-MCC; #43, MCC). Many also discussed perceived analgesic effects of Indica strains (#29, Non-MCC; #40, #43, #44, #45, MCC). However, beliefs about sedating effects of Indica strains were not universal. Some participants noted using Indica strains for energy (#29, Non-MCC) or while engaging in daytime tasks (e.g., work; #37, MCC). Participants agreed Sativa strains produced stimulating subjective effects such as enhanced mood (#40, #45, MCC) and increased focus (#46, #48, MCC). Accordingly, participants primarily used Sativa strains during the day (#36, #46, #48, MCC) and perceived them to be less impairing than Indica strains (#9, Non-MCC). Multiple participants conveyed feeling more creative after using Sativa strains (#1, #2, Non-MCC). Others noted Sativa strains permit altered mindset to help tolerate pain (#44, MCC). Many, but not all, MCC participants indicated it was important to know characteristics about their cannabis, such as strain or cannabinoid composition (e.g., THC:CBD ratio), because it denoted expected subjective effects for a given product and informed purchasing decisions (#36, #41, MCC). However, some MCC participants noted strain was less relevant due to individual differences and that symptom reduction should be the driving factor rather than strain (#40, #45, MCC). Alternatively, non-MCC participants evaluated cannabis quality based more on physical sensory aspects (e.g., taste, smell, visual; #4, Non-MCC) and rarely noted strain or cannabinoid composition as important factors influencing purchase or use. Indifference toward strain may be attributed to general apathy toward strains or cannabinoid compositions (#18, #19, Non-MCC) or access constraints, as most were using cannabis obtained illegally (#9, Non-MCC).

In the present study, MCC participants reported frequent use of multiple cannabis products, whereas non-MCC participants reported less frequent, more opportunistic use. No consensus emerged among participants regarding specific cannabis characteristics that were preferred for certain conditions. Rather, a general belief persisted that cannabis effectively treated many physical and psychiatric symptoms, including conditions with moderate to limited evidence of efficacy ( Abrams, 2018 ). Accordingly, consistent informational campaigns are needed to accurately educate all consumers about cannabis’ ability to treat medical conditions and to counteract widespread misperceptions about cannabis’ therapeutic and subjective effects. Individuals who use cannabis must rely on subjective input from dealers, dispensary staff, or “trial and error” approaches to determine if product information is accurate or certain dosing regimens are effective ( Mercurio et al., 2019 ). Oftentimes, non-MCC participants had minimal information on products they used. While dispensary staff helped inform product selection for many MCC participants, they are allowed to make recommendations without medical education ( Haug et al., 2016 ), including unsubstantiated claims that directly contradict established medical consensus ( Dickson et al., 2018 ). Thus, more precise guidelines are needed so individuals can make informed decisions about the products they purchase. While participants generally agreed that Sativa and Indica strains engendered distinct subjective effects, it is unclear to what extent differences were due to expectancies. Indeed, misconceptions surrounding cannabis’ therapeutic benefit are pervasive among individuals regardless of MCC status (e.g., that Indica strains reliably produce sedative effects). Identifying misconceptions about cannabis’ medical benefits may inform future prevention/intervention efforts. This study was not without limitations. Participants were classified based on MCC status, however, non-MCC participants also endorsed infrequent cannabis use for medical purposes, on average. Further, some participants may have obtained an MCC to facilitate nonmedical use, but this theme did not emerge during individual interviews. Regardless, a meaningful and parsimonious way to distinguish between people who use cannabis only recreationally versus only medically remains elusive ( Budney, 2021 ). Second, participants were required to have their MCC card registered in RI/MA. Recreational cannabis use was illegal during data collection but is currently legal in MA. Thus, generalizability may be limited due to potential differences in legal status or accessibility. However, all participants reported near-daily cannabis use, and while MCC participants preferred more administration modes than non-MCC participants, participants across groups indicated usual use of many different administration modes. Further, use and/or access to various cannabis products is not required for individuals to hold specific beliefs about their subjective effects or medical benefit. Additionally, there were some notable differences between the groups; those in the MCC group were older with more years of regular use, and it is possible that these differences or other underlying factors (e.g., tolerance) influenced thematic group differences. However, study themes remained consistent when comparing the top versus bottom three quartiles of participants based on age/duration of regular use (i.e., oldest participants and participants with the longest duration of use versus younger participants and participants with a shorter duration of regular use). Finally, data collection methods differed between groups that may have elicited different responses. The interactive component of focus groups can elicit a broader range of beliefs and ideas ( Agar & MacDonald, 1995 ; Powell & Single, 1996 ), whereas interviews can provide more nuanced information about one’s personal beliefs and feelings ( Knodel, 1993 ; Morgan et al., 1998 ). Altogether, it is critical to understand differences in cannabis use patterns, perceptions about different products, and purchasing behaviors among individuals with and without an MCC. Given misperceptions of cannabis’ ability to treat medical conditions among individuals regardless of MCC status, these beliefs may be beneficial intervention targets. Additional research is also needed to establish evidence-based guidelines for medical cannabis dosing regimens.