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Despite limited scientific evidence for the medicinal benefits of cannabis (ie, double blind placebo-controlled trials1,2), a growing number of countries have facilitated greater legal access to cannabis and/or cannabis-based preparations for medicinal use, including Australia, UK, Canada, Germany, Israel, Netherlands and over half of US states.3–6 Australia has recently made cannabis-based products legally available for medical patients, but only limited numbers of people have utilised the scheme to date, prompting a Senate inquiry into barriers to patient access.7

In December 2019, the New Zealand Ministry of Health (MOH) released regulations for the new Medicinal Cannabis Scheme (MSC), which will establish a domestic medical cannabis industry with cannabidiol (CBD) and tetrahydrocannabinol (THC) products available on prescription from general practitioners.8 The new MCS regime became operational on 1 April 2020, with opening of the product applications assessment process by MOH.9 Products brought within the regime must meet minimum quality standards as specified by MOH10 (efficacy data does not need to be provided) and they must not be in a form intended for smoking (although dried cannabis flower intended for vaping is allowed). Therefore, products under the new MCS scheme can include tablets, capsules, oral liquids, lozenges, but not herbal cannabis for smoking.10

Since September 2017, medical practitioners have been allowed to prescribe products containing CBD without sign-off from the MOH. CBD products must contain no more than 2% of tetrahydrocannabinol and other psychoactive-related substances. In the first half of 2019, there were 2,504 prescriptions for CBD products (up from 2,130 for the entire year in 2018),11 but the cost of imported products remains prohibitive. At the time of publication, prescriptions for products that contain more than 2% THC still require a sign-off from the MOH (with the exception of Sativex which is a consented "approved" medicine, including for off-label use from 1 April 2020).9 This is likely to change soon as new cannabis-based products will be brought within the scheme (following their assessment against new MCS quality standards). Since December 2018, patients in palliative care have been permitted to possess and use illicit cannabis for their own medical needs without the risk of being prosecuted.12

Largely due to the illegality of cannabis, understanding of how New Zealanders use and access cannabis for medicinal reasons remains highly fragmented. A recent survey of medicinal cannabis users in Australia found that patients self-medicate with illegal cannabis to treat a wide range of conditions, including anxiety (51%), back pain (50%), depression (49%) and sleep problems (44%).13 In New Zealand, an estimated 5% of the population (aged 15 years+) used cannabis medicinally at the time of the New Zealand Health Survey 2013 (NZHS).14 Medicinal cannabis users were more likely to be male, younger, Māori, less well-educated and poor. However, the NZHS only included a handful questions on medicinal cannabis use and consequently many aspects of medicinal cannabis use in New Zealand remain unexplored, including reasons for use, modes of administration, means of procurement, interaction with legal medicines, and experience of side-effects. In addition, it is important to explore the extent to which users are aware of recent policy changes and their intention to engage with the new regime.

The aim of this study was therefore to provide exploratory research on patterns of medicinal cannabis use in New Zealand during a period of changing policy.

Methods

An online convenience survey was undertaken of adults (16 years+) who self-report using cannabis or cannabis-based products for medicinal purpose in the last 12 months in New Zealand. The survey was conducted using QualtricsTM software and could be completed on either a desktop computer or mobile device. The survey was promoted on FacebookTM from May to August 2019 via a paid promotional campaign targeting medicinal cannabis users in New Zealand aged 16 years and older. The URL link to the survey was also shared on Facebook forums dedicated to medicinal cannabis use. The survey preamble included a phone contact for the primary researcher providing an option to complete the survey over the phone (four participants chose to do so). The survey preamble defined “medicinal cannabis” as the “use of cannabis or cannabis-based products to treat a medical condition or alleviate a symptom”. The questionnaire was developed building on a number of other overseas surveys, including a recent Australian study.13,15,16 Ethical approval for the study was obtained from the Massey University Human Ethics Committee (SOA 19/19).

A total of 3,847 respondents commenced the survey. Completed surveys were audited for consistency and extent of completion. Surveys where respondents did not progress beyond demographic questions (ie, a total of 185 surveys) were removed. Respondents who reported they had suffered from more than 15 health conditions (n=28) or were suffering from cancer but did not have a medical diagnosis for cancer (n=42) were reviewed in detail. Six surveys were subsequently removed during this process due to lack of consistency. A custom survey software solution was developed to convert computer IP addresses into a unique number that facilitated the identification of instances where multiple surveys were completed from the same device, or from outside the country, while ensuring respondent anonymity and avoiding storage of IP addresses. Twenty-two duplicate responses were identified and removed through this process. The final sample consisted of 3,634 respondents.

Measures and analysis

The survey consisted of nine modules: (1) demographics; (2) patterns of use (types of cannabis products, main and preferred route of administration; frequency and history of use); (3) medical conditions and symptoms for which cannabis is used (including conditions diagnosed by a health professional); (4) perceived effectiveness (rated on a seven-point Patient Global Impression of Change scale) and side effects; (6) sources of cannabis supply; (7) discussions with health providers; (8) use of other pharmaceuticals; and (9) knowledge and engagement with the MCS.

Results

Demographics

Fifty percent of the sample were female, 48.4% male and 1.6% gender diverse (Table 1). The median age of respondents was 38 years. Seventy-six percent identified as New Zealanders of European descent and 17.8% as Māori. The majority were in full-time (41.4%) or part-time employment (14.8%), and a further 17.3% reported they were on a sickness benefit. Overall, 27.6% were receiving some financial benefit related to their medical condition. Over half the sample (52.2%) reported a combined annual household gross income of $50,000 NZD or less (Table 1).

Table 1: Sample characteristics.

Patterns of cannabis use for medicinal reasons

Participants had used cannabis for medicinal reasons for a median of five years (mean 10 years, s.d. 11 years, n=3,128). Approximately two-thirds of respondents (68.5%) reported daily or near daily use of cannabis for medicinal purposes, a further 17.5% used it “once or twice per week”, and 9.6% “once or twice a month” (n=3,240). A median twice-daily frequency of administration was reported.

Medical conditions and symptoms

Participants were asked to select all the medical conditions and symptoms for which they had used cannabis from structured lists. The condition groups for which cannabis was used most often were: pain (80.9% of respondents used cannabis for at least one pain condition), sleep (65.9%) and mental health conditions (64.0%), followed by gastrointestinal (17.1%) and neurological (12.2%) conditions and cancers (6.7%) (Table 2).

Table 2: Conditions treated with medicinal cannabis in the past 12 months and medical diagnoses.

Participants reported the highest rates of medical diagnoses for gastrointestinal conditions (85.4%) and neurological conditions (82.4%), and the lowest for sleep disorders (49.3%).

History of medicinal cannabis use

Nearly half the participants (47.2%) were using cannabis recreationally at the time they started using it for medicinal reasons. A further 38.4% had tried cannabis before using it medically but never used it regularly, and 14.5% had never used cannabis recreationally (n=3,228). Nearly 60% (58.5%) reported that, in addition to their medicinal use, they had also used cannabis for recreational reasons in the past year.

Reasons for changing levels of medicinal cannabis use

Most respondents (54.5%) reported their use of cannabis for medicinal reasons had not changed in the last year. One in four (25.6%) reported a decrease in medicinal use of cannabis, including 5.7% who completely stopped (n=3,224). The main reasons for stopping or reducing cannabis use for medicinal reasons were participants’ concerns over related “legal risks”, “improvement of the health complaint”, financial cost or inability to find a supplier (Table 3). The leading reasons for using more medicinal cannabis were: “like effect on my wellbeing”, “in order to reduce use of other medicines” and “need more to get relief from symptoms” (Table 3).

Table 3: Reasons for stopping, reducing or using more cannabis for medicinal reasons during past 12 months (multiple responses permitted).

Modes of administration

Smoking was the most common way of administering cannabis for medicinal reasons: in the last year 66.3% of participants smoked cannabis in a joint; 53.2% smoked cannabis through a water pipe or bong; 48.4% smoked cannabis through a dry pipe. This was followed by eating cannabis in baked edibles (48.4%), taking cannabis by mouth as a tincture or oil (32.9%), vaping (31.5%) and topical application (29.5%) (n=3,588). Respondents were asked to identify the main way they used cannabis in the past 12 months and the most preferred way they would like to use it (if they could access any form). Both response categories were topped by smoking cannabis through a water pipe (Figure 1).

Figure 1: Main route of cannabis administration during the past 12 months and preferred way.

Perceived effectiveness of medicinal cannabis

Participants overwhelmingly believed their symptoms had improved since starting to use cannabis for medicinal reasons. Seizures received the highest scores for perceived improvement (ie, 97.2% who suffered from seizures reported their symptoms had improved) (Figure 2).

Figure 2: Perceived impact of medicinal cannabis use on the severity of symptoms assessed using Patient Global Impression of Change scale.

Interaction with legal medicines

Eighty-nine percent of participants reported using pharmaceutical medications to treat their health condition(s) in addition to using cannabis. The pharmaceutical drugs used most often included: NSAIDs (eg, ibuprofen) and paracetamol (70.5%); opioids (55.5%), antidepressants (46.5%) and benzodiazepines (34.6%) (n=2,841). High rates of substituting pharmaceutical medicines with cannabis were reported, particularly for opioids: 95% of those who used opioid medications reported reducing their opioid dose since using medicinal cannabis, including 53% who stopped opioid treatment completely (Figure 3).

Figure 3: Self-reported change in use of non-cannabinoid pharmaceutical medicines due to use of cannabis for medicinal reasons.

Side effects

Approximately half the respondents (51.8%) experienced side effects from their use of cannabis in the past 12 months. The most common side effects were increased appetite (29.2%), drowsiness (11.6%), eye irritation (11.1%), craving for cannabis (dependency) (10.4%) and memory impairment (10.3%). A minority reported psychological problems including anxiety (6.4%), paranoia (4.1%), confusion (3.8%) and “depressed mood” (3.1%) (Table 4). Those who experienced side effects reported a median of two side effects in the past year.

Table 4: Side effects from use of medicinal cannabis experienced in the past 12 months (n=2,639, multiple responses were allowed unless the “no side effects” response was chosen).

Access and the cost of cannabis therapy

The majority of respondents (51.4%) reported accessing medicinal cannabis from multiple sources. The main method of access was by purchase from a drug dealer (27.7%), followed by home-growing (12.6%), buying from friends and family (12.2%,) and gifts from friends or family (10.0%). Only 4.7% of respondents reported accessing cannabis via prescription (Figure 4).

Figure 4: Ways of accessing medicinal cannabis in the past 12 months.

Participants spent an average $305NZD (median $217) on medicinal cannabis supply per month. Over a quarter (27.7%) received all their medicinal cannabis supply for free (ie, by growing their own or as gifts from friends or family) (n=3,074). Those who accessed legal cannabis via prescription reported an average monthly spend on prescribed products of $656 NZD (median $350).

Discussions with health providers

Nearly two-thirds of respondents (63.5%) had discussed their use of cannabis for medicinal reasons with a health provider, and nearly half of the sample (46.6%) had done so in the past year (n=2,810). GPs were most commonly consulted (89.8%), followed by specialist doctors (45.5%), counsellors or psychologists (39.2%), nurses (21.8%), alternative health providers (21%) and pharmacists (11.1%) (n=1,770).

Fourteen percent (14.1%) of participants requested a prescription for a medical cannabis product in the past year and 4.9% had been prescribed a medical cannabis product. The top three prescribed cannabis products were: Tilray CBD100TM (43%), Tilray CBD25TM (31%) and Sativex (18%). Participants who did not ask for a prescription (85.9%) were asked about reasons for not doing so. The main reasons given were lack of faith that the health provider would prescribe a cannabis product (40.8%), the bureaucracy involved in access (39.8%) and unaffordable prices (36.2%) (Table 5).

Table 5: Reasons for not asking for a prescription and intention not to engage in the Medicinal Cannabis Scheme (multiple responses permitted).

Anticipated engagement with future regime and preferred legal access

Participants were asked if they were aware of the new Medicinal Cannabis Scheme being developed at the time of data collection. Three quarters (78.2%) were aware of the regime and around two-thirds of those (66%) said they were “likely” or “very likely” to use it. Those who did not intend to engage with the new scheme most often explained their position in terms of the anticipated high financial cost of accessing products (Table 5).

Asked to choose their preferred way of accessing medicinal cannabis in a legal regime, most participants indicated home-growing (77.7%) and purchase from a licensed dispensary (73.9%) (n=2,573, multiple responses permitted). Less popular were social supply arrangements (ie, “buying from a green fairy or a friend”, 40.9%) and access from a pharmacy on prescription (as proposed under the Medicinal Cannabis Scheme) (39.1%).

Discussion

Consistent with similar research overseas13,15,17 we found that cannabis is used to treat a wide range of health complaints, with most users taking it to manage pain, anxiety, depression and sleeping problems. Cannabis use has been associated with mental health problems, including depression,18 and consequently the level of using cannabis to medicate these disorders reported in our survey indicates the need for further research to determine efficacy and best practice.

Smoking was the most common way of administering cannabis in our sample, reflecting the fact that cannabis flower is currently the most common form available on the black market. Smoking cannabis exposes users to respiratory health risks, which could be addressed if the new MCS succeeds in encouraging users' transition to other forms, including oral administration. Cannabis users in our survey were cognisant of alternative delivery methods that minimise respiratory damage, including oral administration and vaping cannabis. Vaping can potentially reduce respiratory harms from smoking,19,20 but safety may vary depending on the vaping method21 and the long-term effects of cannabis vaping have not been studied.

Despite some relaxation in access to cannabis-based products in New Zealand in the last two years, only 14% of this survey sample had asked their health professional for a prescription for a cannabis-based product, and only 5% received a prescription. Medicinal cannabis users noted the barriers of price and the limited range of cannabis-based products available on prescription, something the new MCS aims to address. However, many respondents also explained they were reluctant to ask for a prescription due to the fear of being judged. As reported by our respondents, only one in three patient requests for a cannabis prescription were successful. This is in line with other recent New Zealand research where approximately two out of three surveyed GPs did not prescribe a cannabis-based product at the time of patient request.22 Under the planned reforms there is currently no list of eligible conditions and the decision about prescribing is left to treating clinicians.

The MCS will not require efficacy data (unlike for standard medicines). The scarcity of high-quality evidence for cannabis therapy in specific conditions has been a major challenge in implementing medical cannabis schemes overseas.23 Our survey shows a clear discord between user-reported experiences with a range of conditions and symptoms and the existing medical evidence. Based on the currently available studies, there is a reasonable level of evidence that medical-quality cannabis preparations and cannabinoids help reduce symptoms of epilepsy, nausea and vomiting.24,25 Cannabinoids are superior to placebo for chronic pain, but only marginally so, and the recent systematic review of controlled trials and observational studies concluded that the evidence for effectiveness of cannabinoids in chronic non-cancer pain remains “limited”.26 The evidence for effectiveness of cannabinoids for the treatment of mental disorders also remains scarce.27,28 CBD has been found to reduce anxiety symptoms at the time of a stressful events29 but larger studies are needed to verify its usefulness in the treatment of social anxiety disorder. Overall, medical research on cannabis is in its early stages and more evidence will be available in the coming years.

The high efficacy scores reported in our survey may reflect sampling bias (those having positive experiences being more likely to participate in the survey) and a placebo effect. Many participants also reported reducing or stopping their use of other pharmaceutical drugs, and the improvement in symptoms may be due to the reduction of side effects from pharmaceutical drugs or negative interactions between different pharmaceuticals. On the other hand, the positive therapeutic benefits of the pharmaceutical medicines would also be lost, complicating this explanation. The interaction of medicinal cannabis with traditional pharmaceutical medicines deserves further study. Some American studies have found reduced opioid overdose deaths in US states with medical cannabis programmes.30

Despite the limited engagement of medicinal cannabis users with the current legal access route, most respondents indicated their willingness to engage with the new MSC. The legality and consistency of legal products may encourage the transition from unofficial sources of supply to legal supply, but the availability of potentially cheaper cannabis from the black market will also provide an alternative if administrative barriers are high.31 Finally, the legalisation of cannabis for recreational use, pending results of the September 2020 referendum, may also provide an alternative way of supply, with the convenience of price and access but at the expense of medical oversight.

A challenge in studying medicinal cannabis use lies in the blurred boundary between medical, therapeutic and recreational uses of cannabis. Like other studies,32,33 including previous analysis of New Zealand Health Survey data,14 we found a significant proportion of medicinal cannabis users also use cannabis recreationally.

Limitations

The study has a number of important limitations. As outlined, the survey was a convenience sample, and consequently is not representative of the medicinal cannabis user population in New Zealand. At the very least, our recruitment strategy is likely to be biased towards Facebook™ users. New Zealand has a high level of digital engagement by international standards.34 For example, 2.3 million New Zealanders log on to Facebook™ every day (from a total population of 4.8 million).35 Further, the challenges and costs of recruiting a representative sample of a small hidden population of medicinal cannabis users are likely to be high.36 Representative household surveys also have their own issues, including low response rates, particularly with regard to hard-to-reach, stigmatised populations.

Our online sample broadly resembles the demographic profile of the New Zealand population. For example, 50% of our online sample were female, 18% Māori and 76% European (as compared to the wider New Zealand population at the 2018 Census, of whom 17% were Māori and 70% European37). Our online sample included lower proportions of Asian people (<2%) compared to the Census (where 15% identify with at least one Asian ethnicity).37,38 The online survey sample were more likely to have university qualifications compared to the national 2018 Census (28% had a university degree compared to 23% in the Census38). Furthermore, employment was lower in the online survey than in the general population (ie, 56% of the online sample was in full-time or part-time employment vs 65% employment according to the 2018 Census data). Support from a government benefit was also more common in our online sample, eg, 17% of the sample were receiving Supported Living Payments (compared to 2–3% estimates for the New Zealand population38,39). It is unclear the extent to which these differences represent specific characteristics of medicinal cannabis users or the consequences of the online convenience sample recruitment.

Summary

Abstract

Aim

To explore patterns of medicinal cannabis use prior to implementation of the new Medicinal Cannabis Scheme (MCS) in New Zealand.

Method

An anonymous online convenience survey of 3,634 last-year medicinal users of cannabis promoted via Facebook™ from May to August 2019.

Results

Fifty percent of the sample were female, 18% were Māori and the median age was 38 years. The medical conditions for which cannabis was most often used were pain (81%), sleep (66%) and mental health conditions (64%). Respondents perceived cannabis to be an effective therapy and reported reducing use of other pharmaceutical medicines. Fifty-two percent reported side effects from cannabis use, including increased appetite (29%), drowsiness (12%), eye irritation (11%), dependency (10%), memory impairment (10%) and lack of energy (9%). Smoking was the dominant route of administration. Nearly half (47%) had discussed their use of cannabis with a medical professional in the previous year, while 14% had requested a prescription and 5% accessed a prescribed cannabis-based product (mostly oral CBD).

Conclusion

Respondents self-medicated with cannabis to treat a wide range of health complaints. Only half discussed medicinal cannabis use with their medical professional, and a minority requested a prescription and used a prescribed cannabis-based product.

Author Information

Marta Rychert, Senior Research Officer, Shore & Whāriki Research Centre, College of Health, Massey University; Chris Wilkins, Associate Professor, Shore & Whāriki Research Centre, College of Health, Massey University; Karl Parker, Statistician, Shore & Whāriki Research Centre, College of Health, Massey University; Thomas Graydon-Guy, Technical Officer, Shore & Whāriki Research Centre, College of Health, Massey University.

Acknowledgements

The research was supported by a New Zealand Health Research Council Grant (19/647) and the Massey University Research Fund. We would like to thank the Ministry of Health medical cannabis regulatory group and the Auckland Patients Group for help with promoting the survey.

Correspondence

Dr Marta Rychert, Senior Research Officer, Shore & Whāriki Research Centre, College of Health, Massey University.

Correspondence Email

m.rychert@massey.ac.nz

Competing Interests

All authors report a grant from the Health Research Council during the conduct of the study.

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Despite limited scientific evidence for the medicinal benefits of cannabis (ie, double blind placebo-controlled trials1,2), a growing number of countries have facilitated greater legal access to cannabis and/or cannabis-based preparations for medicinal use, including Australia, UK, Canada, Germany, Israel, Netherlands and over half of US states.3–6 Australia has recently made cannabis-based products legally available for medical patients, but only limited numbers of people have utilised the scheme to date, prompting a Senate inquiry into barriers to patient access.7

In December 2019, the New Zealand Ministry of Health (MOH) released regulations for the new Medicinal Cannabis Scheme (MSC), which will establish a domestic medical cannabis industry with cannabidiol (CBD) and tetrahydrocannabinol (THC) products available on prescription from general practitioners.8 The new MCS regime became operational on 1 April 2020, with opening of the product applications assessment process by MOH.9 Products brought within the regime must meet minimum quality standards as specified by MOH10 (efficacy data does not need to be provided) and they must not be in a form intended for smoking (although dried cannabis flower intended for vaping is allowed). Therefore, products under the new MCS scheme can include tablets, capsules, oral liquids, lozenges, but not herbal cannabis for smoking.10

Since September 2017, medical practitioners have been allowed to prescribe products containing CBD without sign-off from the MOH. CBD products must contain no more than 2% of tetrahydrocannabinol and other psychoactive-related substances. In the first half of 2019, there were 2,504 prescriptions for CBD products (up from 2,130 for the entire year in 2018),11 but the cost of imported products remains prohibitive. At the time of publication, prescriptions for products that contain more than 2% THC still require a sign-off from the MOH (with the exception of Sativex which is a consented "approved" medicine, including for off-label use from 1 April 2020).9 This is likely to change soon as new cannabis-based products will be brought within the scheme (following their assessment against new MCS quality standards). Since December 2018, patients in palliative care have been permitted to possess and use illicit cannabis for their own medical needs without the risk of being prosecuted.12

Largely due to the illegality of cannabis, understanding of how New Zealanders use and access cannabis for medicinal reasons remains highly fragmented. A recent survey of medicinal cannabis users in Australia found that patients self-medicate with illegal cannabis to treat a wide range of conditions, including anxiety (51%), back pain (50%), depression (49%) and sleep problems (44%).13 In New Zealand, an estimated 5% of the population (aged 15 years+) used cannabis medicinally at the time of the New Zealand Health Survey 2013 (NZHS).14 Medicinal cannabis users were more likely to be male, younger, Māori, less well-educated and poor. However, the NZHS only included a handful questions on medicinal cannabis use and consequently many aspects of medicinal cannabis use in New Zealand remain unexplored, including reasons for use, modes of administration, means of procurement, interaction with legal medicines, and experience of side-effects. In addition, it is important to explore the extent to which users are aware of recent policy changes and their intention to engage with the new regime.

The aim of this study was therefore to provide exploratory research on patterns of medicinal cannabis use in New Zealand during a period of changing policy.

Methods

An online convenience survey was undertaken of adults (16 years+) who self-report using cannabis or cannabis-based products for medicinal purpose in the last 12 months in New Zealand. The survey was conducted using QualtricsTM software and could be completed on either a desktop computer or mobile device. The survey was promoted on FacebookTM from May to August 2019 via a paid promotional campaign targeting medicinal cannabis users in New Zealand aged 16 years and older. The URL link to the survey was also shared on Facebook forums dedicated to medicinal cannabis use. The survey preamble included a phone contact for the primary researcher providing an option to complete the survey over the phone (four participants chose to do so). The survey preamble defined “medicinal cannabis” as the “use of cannabis or cannabis-based products to treat a medical condition or alleviate a symptom”. The questionnaire was developed building on a number of other overseas surveys, including a recent Australian study.13,15,16 Ethical approval for the study was obtained from the Massey University Human Ethics Committee (SOA 19/19).

A total of 3,847 respondents commenced the survey. Completed surveys were audited for consistency and extent of completion. Surveys where respondents did not progress beyond demographic questions (ie, a total of 185 surveys) were removed. Respondents who reported they had suffered from more than 15 health conditions (n=28) or were suffering from cancer but did not have a medical diagnosis for cancer (n=42) were reviewed in detail. Six surveys were subsequently removed during this process due to lack of consistency. A custom survey software solution was developed to convert computer IP addresses into a unique number that facilitated the identification of instances where multiple surveys were completed from the same device, or from outside the country, while ensuring respondent anonymity and avoiding storage of IP addresses. Twenty-two duplicate responses were identified and removed through this process. The final sample consisted of 3,634 respondents.

Measures and analysis

The survey consisted of nine modules: (1) demographics; (2) patterns of use (types of cannabis products, main and preferred route of administration; frequency and history of use); (3) medical conditions and symptoms for which cannabis is used (including conditions diagnosed by a health professional); (4) perceived effectiveness (rated on a seven-point Patient Global Impression of Change scale) and side effects; (6) sources of cannabis supply; (7) discussions with health providers; (8) use of other pharmaceuticals; and (9) knowledge and engagement with the MCS.

Results

Demographics

Fifty percent of the sample were female, 48.4% male and 1.6% gender diverse (Table 1). The median age of respondents was 38 years. Seventy-six percent identified as New Zealanders of European descent and 17.8% as Māori. The majority were in full-time (41.4%) or part-time employment (14.8%), and a further 17.3% reported they were on a sickness benefit. Overall, 27.6% were receiving some financial benefit related to their medical condition. Over half the sample (52.2%) reported a combined annual household gross income of $50,000 NZD or less (Table 1).

Table 1: Sample characteristics.

Patterns of cannabis use for medicinal reasons

Participants had used cannabis for medicinal reasons for a median of five years (mean 10 years, s.d. 11 years, n=3,128). Approximately two-thirds of respondents (68.5%) reported daily or near daily use of cannabis for medicinal purposes, a further 17.5% used it “once or twice per week”, and 9.6% “once or twice a month” (n=3,240). A median twice-daily frequency of administration was reported.

Medical conditions and symptoms

Participants were asked to select all the medical conditions and symptoms for which they had used cannabis from structured lists. The condition groups for which cannabis was used most often were: pain (80.9% of respondents used cannabis for at least one pain condition), sleep (65.9%) and mental health conditions (64.0%), followed by gastrointestinal (17.1%) and neurological (12.2%) conditions and cancers (6.7%) (Table 2).

Table 2: Conditions treated with medicinal cannabis in the past 12 months and medical diagnoses.

Participants reported the highest rates of medical diagnoses for gastrointestinal conditions (85.4%) and neurological conditions (82.4%), and the lowest for sleep disorders (49.3%).

History of medicinal cannabis use

Nearly half the participants (47.2%) were using cannabis recreationally at the time they started using it for medicinal reasons. A further 38.4% had tried cannabis before using it medically but never used it regularly, and 14.5% had never used cannabis recreationally (n=3,228). Nearly 60% (58.5%) reported that, in addition to their medicinal use, they had also used cannabis for recreational reasons in the past year.

Reasons for changing levels of medicinal cannabis use

Most respondents (54.5%) reported their use of cannabis for medicinal reasons had not changed in the last year. One in four (25.6%) reported a decrease in medicinal use of cannabis, including 5.7% who completely stopped (n=3,224). The main reasons for stopping or reducing cannabis use for medicinal reasons were participants’ concerns over related “legal risks”, “improvement of the health complaint”, financial cost or inability to find a supplier (Table 3). The leading reasons for using more medicinal cannabis were: “like effect on my wellbeing”, “in order to reduce use of other medicines” and “need more to get relief from symptoms” (Table 3).

Table 3: Reasons for stopping, reducing or using more cannabis for medicinal reasons during past 12 months (multiple responses permitted).

Modes of administration

Smoking was the most common way of administering cannabis for medicinal reasons: in the last year 66.3% of participants smoked cannabis in a joint; 53.2% smoked cannabis through a water pipe or bong; 48.4% smoked cannabis through a dry pipe. This was followed by eating cannabis in baked edibles (48.4%), taking cannabis by mouth as a tincture or oil (32.9%), vaping (31.5%) and topical application (29.5%) (n=3,588). Respondents were asked to identify the main way they used cannabis in the past 12 months and the most preferred way they would like to use it (if they could access any form). Both response categories were topped by smoking cannabis through a water pipe (Figure 1).

Figure 1: Main route of cannabis administration during the past 12 months and preferred way.

Perceived effectiveness of medicinal cannabis

Participants overwhelmingly believed their symptoms had improved since starting to use cannabis for medicinal reasons. Seizures received the highest scores for perceived improvement (ie, 97.2% who suffered from seizures reported their symptoms had improved) (Figure 2).

Figure 2: Perceived impact of medicinal cannabis use on the severity of symptoms assessed using Patient Global Impression of Change scale.

Interaction with legal medicines

Eighty-nine percent of participants reported using pharmaceutical medications to treat their health condition(s) in addition to using cannabis. The pharmaceutical drugs used most often included: NSAIDs (eg, ibuprofen) and paracetamol (70.5%); opioids (55.5%), antidepressants (46.5%) and benzodiazepines (34.6%) (n=2,841). High rates of substituting pharmaceutical medicines with cannabis were reported, particularly for opioids: 95% of those who used opioid medications reported reducing their opioid dose since using medicinal cannabis, including 53% who stopped opioid treatment completely (Figure 3).

Figure 3: Self-reported change in use of non-cannabinoid pharmaceutical medicines due to use of cannabis for medicinal reasons.

Side effects

Approximately half the respondents (51.8%) experienced side effects from their use of cannabis in the past 12 months. The most common side effects were increased appetite (29.2%), drowsiness (11.6%), eye irritation (11.1%), craving for cannabis (dependency) (10.4%) and memory impairment (10.3%). A minority reported psychological problems including anxiety (6.4%), paranoia (4.1%), confusion (3.8%) and “depressed mood” (3.1%) (Table 4). Those who experienced side effects reported a median of two side effects in the past year.

Table 4: Side effects from use of medicinal cannabis experienced in the past 12 months (n=2,639, multiple responses were allowed unless the “no side effects” response was chosen).

Access and the cost of cannabis therapy

The majority of respondents (51.4%) reported accessing medicinal cannabis from multiple sources. The main method of access was by purchase from a drug dealer (27.7%), followed by home-growing (12.6%), buying from friends and family (12.2%,) and gifts from friends or family (10.0%). Only 4.7% of respondents reported accessing cannabis via prescription (Figure 4).

Figure 4: Ways of accessing medicinal cannabis in the past 12 months.

Participants spent an average $305NZD (median $217) on medicinal cannabis supply per month. Over a quarter (27.7%) received all their medicinal cannabis supply for free (ie, by growing their own or as gifts from friends or family) (n=3,074). Those who accessed legal cannabis via prescription reported an average monthly spend on prescribed products of $656 NZD (median $350).

Discussions with health providers

Nearly two-thirds of respondents (63.5%) had discussed their use of cannabis for medicinal reasons with a health provider, and nearly half of the sample (46.6%) had done so in the past year (n=2,810). GPs were most commonly consulted (89.8%), followed by specialist doctors (45.5%), counsellors or psychologists (39.2%), nurses (21.8%), alternative health providers (21%) and pharmacists (11.1%) (n=1,770).

Fourteen percent (14.1%) of participants requested a prescription for a medical cannabis product in the past year and 4.9% had been prescribed a medical cannabis product. The top three prescribed cannabis products were: Tilray CBD100TM (43%), Tilray CBD25TM (31%) and Sativex (18%). Participants who did not ask for a prescription (85.9%) were asked about reasons for not doing so. The main reasons given were lack of faith that the health provider would prescribe a cannabis product (40.8%), the bureaucracy involved in access (39.8%) and unaffordable prices (36.2%) (Table 5).

Table 5: Reasons for not asking for a prescription and intention not to engage in the Medicinal Cannabis Scheme (multiple responses permitted).

Anticipated engagement with future regime and preferred legal access

Participants were asked if they were aware of the new Medicinal Cannabis Scheme being developed at the time of data collection. Three quarters (78.2%) were aware of the regime and around two-thirds of those (66%) said they were “likely” or “very likely” to use it. Those who did not intend to engage with the new scheme most often explained their position in terms of the anticipated high financial cost of accessing products (Table 5).

Asked to choose their preferred way of accessing medicinal cannabis in a legal regime, most participants indicated home-growing (77.7%) and purchase from a licensed dispensary (73.9%) (n=2,573, multiple responses permitted). Less popular were social supply arrangements (ie, “buying from a green fairy or a friend”, 40.9%) and access from a pharmacy on prescription (as proposed under the Medicinal Cannabis Scheme) (39.1%).

Discussion

Consistent with similar research overseas13,15,17 we found that cannabis is used to treat a wide range of health complaints, with most users taking it to manage pain, anxiety, depression and sleeping problems. Cannabis use has been associated with mental health problems, including depression,18 and consequently the level of using cannabis to medicate these disorders reported in our survey indicates the need for further research to determine efficacy and best practice.

Smoking was the most common way of administering cannabis in our sample, reflecting the fact that cannabis flower is currently the most common form available on the black market. Smoking cannabis exposes users to respiratory health risks, which could be addressed if the new MCS succeeds in encouraging users' transition to other forms, including oral administration. Cannabis users in our survey were cognisant of alternative delivery methods that minimise respiratory damage, including oral administration and vaping cannabis. Vaping can potentially reduce respiratory harms from smoking,19,20 but safety may vary depending on the vaping method21 and the long-term effects of cannabis vaping have not been studied.

Despite some relaxation in access to cannabis-based products in New Zealand in the last two years, only 14% of this survey sample had asked their health professional for a prescription for a cannabis-based product, and only 5% received a prescription. Medicinal cannabis users noted the barriers of price and the limited range of cannabis-based products available on prescription, something the new MCS aims to address. However, many respondents also explained they were reluctant to ask for a prescription due to the fear of being judged. As reported by our respondents, only one in three patient requests for a cannabis prescription were successful. This is in line with other recent New Zealand research where approximately two out of three surveyed GPs did not prescribe a cannabis-based product at the time of patient request.22 Under the planned reforms there is currently no list of eligible conditions and the decision about prescribing is left to treating clinicians.

The MCS will not require efficacy data (unlike for standard medicines). The scarcity of high-quality evidence for cannabis therapy in specific conditions has been a major challenge in implementing medical cannabis schemes overseas.23 Our survey shows a clear discord between user-reported experiences with a range of conditions and symptoms and the existing medical evidence. Based on the currently available studies, there is a reasonable level of evidence that medical-quality cannabis preparations and cannabinoids help reduce symptoms of epilepsy, nausea and vomiting.24,25 Cannabinoids are superior to placebo for chronic pain, but only marginally so, and the recent systematic review of controlled trials and observational studies concluded that the evidence for effectiveness of cannabinoids in chronic non-cancer pain remains “limited”.26 The evidence for effectiveness of cannabinoids for the treatment of mental disorders also remains scarce.27,28 CBD has been found to reduce anxiety symptoms at the time of a stressful events29 but larger studies are needed to verify its usefulness in the treatment of social anxiety disorder. Overall, medical research on cannabis is in its early stages and more evidence will be available in the coming years.

The high efficacy scores reported in our survey may reflect sampling bias (those having positive experiences being more likely to participate in the survey) and a placebo effect. Many participants also reported reducing or stopping their use of other pharmaceutical drugs, and the improvement in symptoms may be due to the reduction of side effects from pharmaceutical drugs or negative interactions between different pharmaceuticals. On the other hand, the positive therapeutic benefits of the pharmaceutical medicines would also be lost, complicating this explanation. The interaction of medicinal cannabis with traditional pharmaceutical medicines deserves further study. Some American studies have found reduced opioid overdose deaths in US states with medical cannabis programmes.30

Despite the limited engagement of medicinal cannabis users with the current legal access route, most respondents indicated their willingness to engage with the new MSC. The legality and consistency of legal products may encourage the transition from unofficial sources of supply to legal supply, but the availability of potentially cheaper cannabis from the black market will also provide an alternative if administrative barriers are high.31 Finally, the legalisation of cannabis for recreational use, pending results of the September 2020 referendum, may also provide an alternative way of supply, with the convenience of price and access but at the expense of medical oversight.

A challenge in studying medicinal cannabis use lies in the blurred boundary between medical, therapeutic and recreational uses of cannabis. Like other studies,32,33 including previous analysis of New Zealand Health Survey data,14 we found a significant proportion of medicinal cannabis users also use cannabis recreationally.

Limitations

The study has a number of important limitations. As outlined, the survey was a convenience sample, and consequently is not representative of the medicinal cannabis user population in New Zealand. At the very least, our recruitment strategy is likely to be biased towards Facebook™ users. New Zealand has a high level of digital engagement by international standards.34 For example, 2.3 million New Zealanders log on to Facebook™ every day (from a total population of 4.8 million).35 Further, the challenges and costs of recruiting a representative sample of a small hidden population of medicinal cannabis users are likely to be high.36 Representative household surveys also have their own issues, including low response rates, particularly with regard to hard-to-reach, stigmatised populations.

Our online sample broadly resembles the demographic profile of the New Zealand population. For example, 50% of our online sample were female, 18% Māori and 76% European (as compared to the wider New Zealand population at the 2018 Census, of whom 17% were Māori and 70% European37). Our online sample included lower proportions of Asian people (<2%) compared to the Census (where 15% identify with at least one Asian ethnicity).37,38 The online survey sample were more likely to have university qualifications compared to the national 2018 Census (28% had a university degree compared to 23% in the Census38). Furthermore, employment was lower in the online survey than in the general population (ie, 56% of the online sample was in full-time or part-time employment vs 65% employment according to the 2018 Census data). Support from a government benefit was also more common in our online sample, eg, 17% of the sample were receiving Supported Living Payments (compared to 2–3% estimates for the New Zealand population38,39). It is unclear the extent to which these differences represent specific characteristics of medicinal cannabis users or the consequences of the online convenience sample recruitment.

Summary

Abstract

Aim

To explore patterns of medicinal cannabis use prior to implementation of the new Medicinal Cannabis Scheme (MCS) in New Zealand.

Method

An anonymous online convenience survey of 3,634 last-year medicinal users of cannabis promoted via Facebook™ from May to August 2019.

Results

Fifty percent of the sample were female, 18% were Māori and the median age was 38 years. The medical conditions for which cannabis was most often used were pain (81%), sleep (66%) and mental health conditions (64%). Respondents perceived cannabis to be an effective therapy and reported reducing use of other pharmaceutical medicines. Fifty-two percent reported side effects from cannabis use, including increased appetite (29%), drowsiness (12%), eye irritation (11%), dependency (10%), memory impairment (10%) and lack of energy (9%). Smoking was the dominant route of administration. Nearly half (47%) had discussed their use of cannabis with a medical professional in the previous year, while 14% had requested a prescription and 5% accessed a prescribed cannabis-based product (mostly oral CBD).

Conclusion

Respondents self-medicated with cannabis to treat a wide range of health complaints. Only half discussed medicinal cannabis use with their medical professional, and a minority requested a prescription and used a prescribed cannabis-based product.

Author Information

Marta Rychert, Senior Research Officer, Shore & Whāriki Research Centre, College of Health, Massey University; Chris Wilkins, Associate Professor, Shore & Whāriki Research Centre, College of Health, Massey University; Karl Parker, Statistician, Shore & Whāriki Research Centre, College of Health, Massey University; Thomas Graydon-Guy, Technical Officer, Shore & Whāriki Research Centre, College of Health, Massey University.

Acknowledgements

The research was supported by a New Zealand Health Research Council Grant (19/647) and the Massey University Research Fund. We would like to thank the Ministry of Health medical cannabis regulatory group and the Auckland Patients Group for help with promoting the survey.

Correspondence

Dr Marta Rychert, Senior Research Officer, Shore & Whāriki Research Centre, College of Health, Massey University.

Correspondence Email

m.rychert@massey.ac.nz

Competing Interests

All authors report a grant from the Health Research Council during the conduct of the study.

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Despite limited scientific evidence for the medicinal benefits of cannabis (ie, double blind placebo-controlled trials1,2), a growing number of countries have facilitated greater legal access to cannabis and/or cannabis-based preparations for medicinal use, including Australia, UK, Canada, Germany, Israel, Netherlands and over half of US states.3–6 Australia has recently made cannabis-based products legally available for medical patients, but only limited numbers of people have utilised the scheme to date, prompting a Senate inquiry into barriers to patient access.7

In December 2019, the New Zealand Ministry of Health (MOH) released regulations for the new Medicinal Cannabis Scheme (MSC), which will establish a domestic medical cannabis industry with cannabidiol (CBD) and tetrahydrocannabinol (THC) products available on prescription from general practitioners.8 The new MCS regime became operational on 1 April 2020, with opening of the product applications assessment process by MOH.9 Products brought within the regime must meet minimum quality standards as specified by MOH10 (efficacy data does not need to be provided) and they must not be in a form intended for smoking (although dried cannabis flower intended for vaping is allowed). Therefore, products under the new MCS scheme can include tablets, capsules, oral liquids, lozenges, but not herbal cannabis for smoking.10

Since September 2017, medical practitioners have been allowed to prescribe products containing CBD without sign-off from the MOH. CBD products must contain no more than 2% of tetrahydrocannabinol and other psychoactive-related substances. In the first half of 2019, there were 2,504 prescriptions for CBD products (up from 2,130 for the entire year in 2018),11 but the cost of imported products remains prohibitive. At the time of publication, prescriptions for products that contain more than 2% THC still require a sign-off from the MOH (with the exception of Sativex which is a consented "approved" medicine, including for off-label use from 1 April 2020).9 This is likely to change soon as new cannabis-based products will be brought within the scheme (following their assessment against new MCS quality standards). Since December 2018, patients in palliative care have been permitted to possess and use illicit cannabis for their own medical needs without the risk of being prosecuted.12

Largely due to the illegality of cannabis, understanding of how New Zealanders use and access cannabis for medicinal reasons remains highly fragmented. A recent survey of medicinal cannabis users in Australia found that patients self-medicate with illegal cannabis to treat a wide range of conditions, including anxiety (51%), back pain (50%), depression (49%) and sleep problems (44%).13 In New Zealand, an estimated 5% of the population (aged 15 years+) used cannabis medicinally at the time of the New Zealand Health Survey 2013 (NZHS).14 Medicinal cannabis users were more likely to be male, younger, Māori, less well-educated and poor. However, the NZHS only included a handful questions on medicinal cannabis use and consequently many aspects of medicinal cannabis use in New Zealand remain unexplored, including reasons for use, modes of administration, means of procurement, interaction with legal medicines, and experience of side-effects. In addition, it is important to explore the extent to which users are aware of recent policy changes and their intention to engage with the new regime.

The aim of this study was therefore to provide exploratory research on patterns of medicinal cannabis use in New Zealand during a period of changing policy.

Methods

An online convenience survey was undertaken of adults (16 years+) who self-report using cannabis or cannabis-based products for medicinal purpose in the last 12 months in New Zealand. The survey was conducted using QualtricsTM software and could be completed on either a desktop computer or mobile device. The survey was promoted on FacebookTM from May to August 2019 via a paid promotional campaign targeting medicinal cannabis users in New Zealand aged 16 years and older. The URL link to the survey was also shared on Facebook forums dedicated to medicinal cannabis use. The survey preamble included a phone contact for the primary researcher providing an option to complete the survey over the phone (four participants chose to do so). The survey preamble defined “medicinal cannabis” as the “use of cannabis or cannabis-based products to treat a medical condition or alleviate a symptom”. The questionnaire was developed building on a number of other overseas surveys, including a recent Australian study.13,15,16 Ethical approval for the study was obtained from the Massey University Human Ethics Committee (SOA 19/19).

A total of 3,847 respondents commenced the survey. Completed surveys were audited for consistency and extent of completion. Surveys where respondents did not progress beyond demographic questions (ie, a total of 185 surveys) were removed. Respondents who reported they had suffered from more than 15 health conditions (n=28) or were suffering from cancer but did not have a medical diagnosis for cancer (n=42) were reviewed in detail. Six surveys were subsequently removed during this process due to lack of consistency. A custom survey software solution was developed to convert computer IP addresses into a unique number that facilitated the identification of instances where multiple surveys were completed from the same device, or from outside the country, while ensuring respondent anonymity and avoiding storage of IP addresses. Twenty-two duplicate responses were identified and removed through this process. The final sample consisted of 3,634 respondents.

Measures and analysis

The survey consisted of nine modules: (1) demographics; (2) patterns of use (types of cannabis products, main and preferred route of administration; frequency and history of use); (3) medical conditions and symptoms for which cannabis is used (including conditions diagnosed by a health professional); (4) perceived effectiveness (rated on a seven-point Patient Global Impression of Change scale) and side effects; (6) sources of cannabis supply; (7) discussions with health providers; (8) use of other pharmaceuticals; and (9) knowledge and engagement with the MCS.

Results

Demographics

Fifty percent of the sample were female, 48.4% male and 1.6% gender diverse (Table 1). The median age of respondents was 38 years. Seventy-six percent identified as New Zealanders of European descent and 17.8% as Māori. The majority were in full-time (41.4%) or part-time employment (14.8%), and a further 17.3% reported they were on a sickness benefit. Overall, 27.6% were receiving some financial benefit related to their medical condition. Over half the sample (52.2%) reported a combined annual household gross income of $50,000 NZD or less (Table 1).

Table 1: Sample characteristics.

Patterns of cannabis use for medicinal reasons

Participants had used cannabis for medicinal reasons for a median of five years (mean 10 years, s.d. 11 years, n=3,128). Approximately two-thirds of respondents (68.5%) reported daily or near daily use of cannabis for medicinal purposes, a further 17.5% used it “once or twice per week”, and 9.6% “once or twice a month” (n=3,240). A median twice-daily frequency of administration was reported.

Medical conditions and symptoms

Participants were asked to select all the medical conditions and symptoms for which they had used cannabis from structured lists. The condition groups for which cannabis was used most often were: pain (80.9% of respondents used cannabis for at least one pain condition), sleep (65.9%) and mental health conditions (64.0%), followed by gastrointestinal (17.1%) and neurological (12.2%) conditions and cancers (6.7%) (Table 2).

Table 2: Conditions treated with medicinal cannabis in the past 12 months and medical diagnoses.

Participants reported the highest rates of medical diagnoses for gastrointestinal conditions (85.4%) and neurological conditions (82.4%), and the lowest for sleep disorders (49.3%).

History of medicinal cannabis use

Nearly half the participants (47.2%) were using cannabis recreationally at the time they started using it for medicinal reasons. A further 38.4% had tried cannabis before using it medically but never used it regularly, and 14.5% had never used cannabis recreationally (n=3,228). Nearly 60% (58.5%) reported that, in addition to their medicinal use, they had also used cannabis for recreational reasons in the past year.

Reasons for changing levels of medicinal cannabis use

Most respondents (54.5%) reported their use of cannabis for medicinal reasons had not changed in the last year. One in four (25.6%) reported a decrease in medicinal use of cannabis, including 5.7% who completely stopped (n=3,224). The main reasons for stopping or reducing cannabis use for medicinal reasons were participants’ concerns over related “legal risks”, “improvement of the health complaint”, financial cost or inability to find a supplier (Table 3). The leading reasons for using more medicinal cannabis were: “like effect on my wellbeing”, “in order to reduce use of other medicines” and “need more to get relief from symptoms” (Table 3).

Table 3: Reasons for stopping, reducing or using more cannabis for medicinal reasons during past 12 months (multiple responses permitted).

Modes of administration

Smoking was the most common way of administering cannabis for medicinal reasons: in the last year 66.3% of participants smoked cannabis in a joint; 53.2% smoked cannabis through a water pipe or bong; 48.4% smoked cannabis through a dry pipe. This was followed by eating cannabis in baked edibles (48.4%), taking cannabis by mouth as a tincture or oil (32.9%), vaping (31.5%) and topical application (29.5%) (n=3,588). Respondents were asked to identify the main way they used cannabis in the past 12 months and the most preferred way they would like to use it (if they could access any form). Both response categories were topped by smoking cannabis through a water pipe (Figure 1).

Figure 1: Main route of cannabis administration during the past 12 months and preferred way.

Perceived effectiveness of medicinal cannabis

Participants overwhelmingly believed their symptoms had improved since starting to use cannabis for medicinal reasons. Seizures received the highest scores for perceived improvement (ie, 97.2% who suffered from seizures reported their symptoms had improved) (Figure 2).

Figure 2: Perceived impact of medicinal cannabis use on the severity of symptoms assessed using Patient Global Impression of Change scale.

Interaction with legal medicines

Eighty-nine percent of participants reported using pharmaceutical medications to treat their health condition(s) in addition to using cannabis. The pharmaceutical drugs used most often included: NSAIDs (eg, ibuprofen) and paracetamol (70.5%); opioids (55.5%), antidepressants (46.5%) and benzodiazepines (34.6%) (n=2,841). High rates of substituting pharmaceutical medicines with cannabis were reported, particularly for opioids: 95% of those who used opioid medications reported reducing their opioid dose since using medicinal cannabis, including 53% who stopped opioid treatment completely (Figure 3).

Figure 3: Self-reported change in use of non-cannabinoid pharmaceutical medicines due to use of cannabis for medicinal reasons.

Side effects

Approximately half the respondents (51.8%) experienced side effects from their use of cannabis in the past 12 months. The most common side effects were increased appetite (29.2%), drowsiness (11.6%), eye irritation (11.1%), craving for cannabis (dependency) (10.4%) and memory impairment (10.3%). A minority reported psychological problems including anxiety (6.4%), paranoia (4.1%), confusion (3.8%) and “depressed mood” (3.1%) (Table 4). Those who experienced side effects reported a median of two side effects in the past year.

Table 4: Side effects from use of medicinal cannabis experienced in the past 12 months (n=2,639, multiple responses were allowed unless the “no side effects” response was chosen).

Access and the cost of cannabis therapy

The majority of respondents (51.4%) reported accessing medicinal cannabis from multiple sources. The main method of access was by purchase from a drug dealer (27.7%), followed by home-growing (12.6%), buying from friends and family (12.2%,) and gifts from friends or family (10.0%). Only 4.7% of respondents reported accessing cannabis via prescription (Figure 4).

Figure 4: Ways of accessing medicinal cannabis in the past 12 months.

Participants spent an average $305NZD (median $217) on medicinal cannabis supply per month. Over a quarter (27.7%) received all their medicinal cannabis supply for free (ie, by growing their own or as gifts from friends or family) (n=3,074). Those who accessed legal cannabis via prescription reported an average monthly spend on prescribed products of $656 NZD (median $350).

Discussions with health providers

Nearly two-thirds of respondents (63.5%) had discussed their use of cannabis for medicinal reasons with a health provider, and nearly half of the sample (46.6%) had done so in the past year (n=2,810). GPs were most commonly consulted (89.8%), followed by specialist doctors (45.5%), counsellors or psychologists (39.2%), nurses (21.8%), alternative health providers (21%) and pharmacists (11.1%) (n=1,770).

Fourteen percent (14.1%) of participants requested a prescription for a medical cannabis product in the past year and 4.9% had been prescribed a medical cannabis product. The top three prescribed cannabis products were: Tilray CBD100TM (43%), Tilray CBD25TM (31%) and Sativex (18%). Participants who did not ask for a prescription (85.9%) were asked about reasons for not doing so. The main reasons given were lack of faith that the health provider would prescribe a cannabis product (40.8%), the bureaucracy involved in access (39.8%) and unaffordable prices (36.2%) (Table 5).

Table 5: Reasons for not asking for a prescription and intention not to engage in the Medicinal Cannabis Scheme (multiple responses permitted).

Anticipated engagement with future regime and preferred legal access

Participants were asked if they were aware of the new Medicinal Cannabis Scheme being developed at the time of data collection. Three quarters (78.2%) were aware of the regime and around two-thirds of those (66%) said they were “likely” or “very likely” to use it. Those who did not intend to engage with the new scheme most often explained their position in terms of the anticipated high financial cost of accessing products (Table 5).

Asked to choose their preferred way of accessing medicinal cannabis in a legal regime, most participants indicated home-growing (77.7%) and purchase from a licensed dispensary (73.9%) (n=2,573, multiple responses permitted). Less popular were social supply arrangements (ie, “buying from a green fairy or a friend”, 40.9%) and access from a pharmacy on prescription (as proposed under the Medicinal Cannabis Scheme) (39.1%).

Discussion

Consistent with similar research overseas13,15,17 we found that cannabis is used to treat a wide range of health complaints, with most users taking it to manage pain, anxiety, depression and sleeping problems. Cannabis use has been associated with mental health problems, including depression,18 and consequently the level of using cannabis to medicate these disorders reported in our survey indicates the need for further research to determine efficacy and best practice.

Smoking was the most common way of administering cannabis in our sample, reflecting the fact that cannabis flower is currently the most common form available on the black market. Smoking cannabis exposes users to respiratory health risks, which could be addressed if the new MCS succeeds in encouraging users' transition to other forms, including oral administration. Cannabis users in our survey were cognisant of alternative delivery methods that minimise respiratory damage, including oral administration and vaping cannabis. Vaping can potentially reduce respiratory harms from smoking,19,20 but safety may vary depending on the vaping method21 and the long-term effects of cannabis vaping have not been studied.

Despite some relaxation in access to cannabis-based products in New Zealand in the last two years, only 14% of this survey sample had asked their health professional for a prescription for a cannabis-based product, and only 5% received a prescription. Medicinal cannabis users noted the barriers of price and the limited range of cannabis-based products available on prescription, something the new MCS aims to address. However, many respondents also explained they were reluctant to ask for a prescription due to the fear of being judged. As reported by our respondents, only one in three patient requests for a cannabis prescription were successful. This is in line with other recent New Zealand research where approximately two out of three surveyed GPs did not prescribe a cannabis-based product at the time of patient request.22 Under the planned reforms there is currently no list of eligible conditions and the decision about prescribing is left to treating clinicians.

The MCS will not require efficacy data (unlike for standard medicines). The scarcity of high-quality evidence for cannabis therapy in specific conditions has been a major challenge in implementing medical cannabis schemes overseas.23 Our survey shows a clear discord between user-reported experiences with a range of conditions and symptoms and the existing medical evidence. Based on the currently available studies, there is a reasonable level of evidence that medical-quality cannabis preparations and cannabinoids help reduce symptoms of epilepsy, nausea and vomiting.24,25 Cannabinoids are superior to placebo for chronic pain, but only marginally so, and the recent systematic review of controlled trials and observational studies concluded that the evidence for effectiveness of cannabinoids in chronic non-cancer pain remains “limited”.26 The evidence for effectiveness of cannabinoids for the treatment of mental disorders also remains scarce.27,28 CBD has been found to reduce anxiety symptoms at the time of a stressful events29 but larger studies are needed to verify its usefulness in the treatment of social anxiety disorder. Overall, medical research on cannabis is in its early stages and more evidence will be available in the coming years.

The high efficacy scores reported in our survey may reflect sampling bias (those having positive experiences being more likely to participate in the survey) and a placebo effect. Many participants also reported reducing or stopping their use of other pharmaceutical drugs, and the improvement in symptoms may be due to the reduction of side effects from pharmaceutical drugs or negative interactions between different pharmaceuticals. On the other hand, the positive therapeutic benefits of the pharmaceutical medicines would also be lost, complicating this explanation. The interaction of medicinal cannabis with traditional pharmaceutical medicines deserves further study. Some American studies have found reduced opioid overdose deaths in US states with medical cannabis programmes.30

Despite the limited engagement of medicinal cannabis users with the current legal access route, most respondents indicated their willingness to engage with the new MSC. The legality and consistency of legal products may encourage the transition from unofficial sources of supply to legal supply, but the availability of potentially cheaper cannabis from the black market will also provide an alternative if administrative barriers are high.31 Finally, the legalisation of cannabis for recreational use, pending results of the September 2020 referendum, may also provide an alternative way of supply, with the convenience of price and access but at the expense of medical oversight.

A challenge in studying medicinal cannabis use lies in the blurred boundary between medical, therapeutic and recreational uses of cannabis. Like other studies,32,33 including previous analysis of New Zealand Health Survey data,14 we found a significant proportion of medicinal cannabis users also use cannabis recreationally.

Limitations

The study has a number of important limitations. As outlined, the survey was a convenience sample, and consequently is not representative of the medicinal cannabis user population in New Zealand. At the very least, our recruitment strategy is likely to be biased towards Facebook™ users. New Zealand has a high level of digital engagement by international standards.34 For example, 2.3 million New Zealanders log on to Facebook™ every day (from a total population of 4.8 million).35 Further, the challenges and costs of recruiting a representative sample of a small hidden population of medicinal cannabis users are likely to be high.36 Representative household surveys also have their own issues, including low response rates, particularly with regard to hard-to-reach, stigmatised populations.

Our online sample broadly resembles the demographic profile of the New Zealand population. For example, 50% of our online sample were female, 18% Māori and 76% European (as compared to the wider New Zealand population at the 2018 Census, of whom 17% were Māori and 70% European37). Our online sample included lower proportions of Asian people (<2%) compared to the Census (where 15% identify with at least one Asian ethnicity).37,38 The online survey sample were more likely to have university qualifications compared to the national 2018 Census (28% had a university degree compared to 23% in the Census38). Furthermore, employment was lower in the online survey than in the general population (ie, 56% of the online sample was in full-time or part-time employment vs 65% employment according to the 2018 Census data). Support from a government benefit was also more common in our online sample, eg, 17% of the sample were receiving Supported Living Payments (compared to 2–3% estimates for the New Zealand population38,39). It is unclear the extent to which these differences represent specific characteristics of medicinal cannabis users or the consequences of the online convenience sample recruitment.

Summary

Abstract

Aim

To explore patterns of medicinal cannabis use prior to implementation of the new Medicinal Cannabis Scheme (MCS) in New Zealand.

Method

An anonymous online convenience survey of 3,634 last-year medicinal users of cannabis promoted via Facebook™ from May to August 2019.

Results

Fifty percent of the sample were female, 18% were Māori and the median age was 38 years. The medical conditions for which cannabis was most often used were pain (81%), sleep (66%) and mental health conditions (64%). Respondents perceived cannabis to be an effective therapy and reported reducing use of other pharmaceutical medicines. Fifty-two percent reported side effects from cannabis use, including increased appetite (29%), drowsiness (12%), eye irritation (11%), dependency (10%), memory impairment (10%) and lack of energy (9%). Smoking was the dominant route of administration. Nearly half (47%) had discussed their use of cannabis with a medical professional in the previous year, while 14% had requested a prescription and 5% accessed a prescribed cannabis-based product (mostly oral CBD).

Conclusion

Respondents self-medicated with cannabis to treat a wide range of health complaints. Only half discussed medicinal cannabis use with their medical professional, and a minority requested a prescription and used a prescribed cannabis-based product.

Author Information

Marta Rychert, Senior Research Officer, Shore & Whāriki Research Centre, College of Health, Massey University; Chris Wilkins, Associate Professor, Shore & Whāriki Research Centre, College of Health, Massey University; Karl Parker, Statistician, Shore & Whāriki Research Centre, College of Health, Massey University; Thomas Graydon-Guy, Technical Officer, Shore & Whāriki Research Centre, College of Health, Massey University.

Acknowledgements

The research was supported by a New Zealand Health Research Council Grant (19/647) and the Massey University Research Fund. We would like to thank the Ministry of Health medical cannabis regulatory group and the Auckland Patients Group for help with promoting the survey.

Correspondence

Dr Marta Rychert, Senior Research Officer, Shore & Whāriki Research Centre, College of Health, Massey University.

Correspondence Email

m.rychert@massey.ac.nz

Competing Interests

All authors report a grant from the Health Research Council during the conduct of the study.

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