Reasons for Use and Perceived Effects of Medical Cannabis: A Cross-Sectional Statewide Survey
Self-Reported Reasons for Medical Cannabis Use
Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, FL, USA
Center for Drug Evaluation and Safety (CoDES), Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
Correspondence to: Ruba Sajdeya, rubasajdeya@ufl.eduAbstract
Introduction
Medical cannabis (MC) is available upon certification for one of several qualifying conditions in Florida, USA. Previous studies suggested that some people seek cannabis for medical conditions/symptoms beyond those legally permitted. However, data remain limited on patient motives for seeking MC and their experiences around its impact on their health. We aimed to compare reported qualifying conditions for MC certification with the most frequently self-reported reasons for using MC while assessing the alignment between the two and understanding the perceived impacts of MC on self-reported conditions and symptoms.
Methods
We conducted a cross-sectional study using survey data from the Medical Marijuana and Me (M3) Data Bank of individuals receiving MC in Florida, USA, in 2022. Participants were recruited via convenience sampling from nine MC clinics/clinic networks across Florida and were asked to fill out an online survey. The study measures included sociodemographic variables, self-reported health conditions, self-reported main reasons for using MC, self-reported qualifying conditions for MC certification, and self-reported perceived impact of MC on health conditions. We cross-tabulated reported qualifying conditions and reasons for MC use and reported the perceived impact per condition.
Results
A total of 632 participants completed the survey, of whom 396 (62.66%) were female and 471 (74.53%) were non-Hispanic white. The median (IQR) age was 45 (35, 58). The most frequently reported qualifying conditions were post-traumatic stress disorder (PTSD) (n = 187, 29.59%), a condition not on the qualifying conditions list (n = 175, 27.69%), medical conditions of the same kind/comparable to those listed (n = 140, 22.15%), and chronic nonmalignant pain (n = 62, 25.63%). The top ten most frequently reported reasons for using MC were anxiety (n = 383, 60.60%), chronic pain (n = 278, 43.99%), depression (n = 252, 39.87%), PTSD (n = 220, 34.81%), headaches/migraine (n = 134, 21.20%), fibromyalgia (n = 67, 10.60%), attention-deficit hyperactivity disorder (ADHD) (n = 59, 9.34%), bipolar disorder (n = 53, 8.39%), high blood pressure (n = 41, 6.49%), and cancer (n = 18,2.85%). Of respondents, 70–90% with each qualifying condition reported it as one of the main reasons for using MC. Most respondents reported improvement of anxiety (n = 430/451, 95.34%), depression (n = 381/392, 97.20%), chronic pain (n = 305/310, 98.39%), insomnia/sleeping problems (n = 225/295, 86.44%), PTSD (n = 247/270, 91.48%), headaches/migraine (n = 172/218, 78.90%), ADHD (n = 82/123, 66.67%), bipolar disorder (n = 79/89, 88.76%), and fibromyalgia (n = 77/82, 93.90%). Most respondents were unsure/reported no change in blood pressure (n = 93/162, 57.41%). A small percentage reported perceived worsening impacts on their conditions.
Conclusion
Qualifying conditions and self-reported reasons for using MC aligned for most respondents. Yet, a notable proportion of respondents sought MC for broader treatment effects beyond those delineated by the officially recognized qualifying conditions in Florida, USA. Most patients perceived positive effects, including those with limited available evidence on efficacy.
Plain Language Summary
In Florida, USA, medical cannabis (MC) is accessible for certified individuals with specific health conditions. Previous research found that many people seek MC for conditions beyond the officially approved ones. We aimed to understand the alignment between qualifying conditions per statute, the reasons patients reported for using MC, and the perceived impacts on health conditions and symptoms. In a 2022 survey of 632 MC users, the top reported qualifying conditions were post-traumatic stress disorder (PTSD), medical condition comparable to listed conditions, and chronic nonmalignant pain. The top ten self-reported reasons for using MC were anxiety, chronic pain, depression, PTSD, headaches/migraine, fibromyalgia, attention-deficit hyperactivity disorder (ADHD), bipolar disorder, high blood pressure, and cancer. Many patients reported multiple reasons for MC use, including typically one reason that matched their reported qualifying condition. Most respondents noted improvements in anxiety, depression, chronic pain, insomnia, PTSD, headaches/migraine, ADHD, bipolar disorder, and fibromyalgia. These findings suggest that in addition to the officially recognized qualifying conditions, people often use MC for a broader range of conditions and symptoms, some of which are not included in the current statute and/or without evidence of efficacy.
Introduction
Although cannabis remains a Schedule I substance on the federal level [1], the landscape of medical cannabis (MC) use continues to rapidly evolve, driven by changes in state-level legislation that have made MC accessible to individuals with qualifying medical conditions in many states, including Florida [2, 3]. Florida’s qualifying medical conditions are cancer, epilepsy, glaucoma, human immunodeficiency virus/acquired immunodeficiency syndrome, post-traumatic stress disorder (PTSD), amyotrophic lateral sclerosis, Crohn’s disease, Parkinson’s disease, multiple sclerosis, chronic nonmalignant pain, other debilitating medical conditions of the same kind or class as or comparable to those listed, and terminal conditions diagnosed by a physician other than the qualified physician issuing the physician certification [4].
However, the alignment between the officially sanctioned qualifying conditions and self-reported motives for MC use remains a focal point of exploration. Patients certified to use MC for specific conditions might opt for this therapeutic avenue for reasons beyond the confines of the legally predefined list. For instance, many individuals turn to MC for conditions and symptoms not traditionally recognized as qualifying medical conditions, such as anxiety, depression, and sleep disturbances [5]. For qualifying conditions such as cancer, patients may articulate varied motivations for seeking cannabis as a remedy, including symptom relief of chemotherapy-associated nausea and vomiting, improving appetite, pain management, and others [6–9]. Gaining insights into the specific conditions and symptoms MC is employed to address informs the potential therapeutic scope of MC, can inform decisions on expanding qualifying conditions for MC, and define the research agenda to evaluate MC efficacy and safety. This study aimed to (1) assess the alignment of the reported qualifying conditions for MC certification and the self-reported reasons for using MC and (2) describe the perceived impacts of MC on self-reported symptoms and medical conditions.
Methods
Study Design and Population
We conducted a cross-sectional study of individuals receiving MC in Florida, USA, in 2022 using survey data from the Medical Marijuana and Me (M3) study [10]. The detailed methods involved in the M3 study design, survey development, data collection, and study measures have been previously published [11]. Here, we provide a brief description of the study methods.
Survey participants represented a convenience sample recruited from nine major MC clinics across Florida between May 1 and December 31, 2022, who were using MC at the time of enrollment. The study utilized a comprehensive set of self-reported surveys covering sociodemographic information, history of cannabis use, health history, reasons for using MC, perceived impacts of MC on health conditions, changes in substance use and concurrent medications, changes in general health status, MC products and use patterns, side effects, and expectations and beliefs about MC. Data were collected via an online survey directly filled out by the participants. This study was approved by the University of Florida Institutional Review Board (IRB202002925). The survey respondents provided consent before completing the survey and received a USD 20 gift card compensation after completion. We followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cross-sectional studies (online suppl. 1; for all online suppl. material, see https://doi.org/10.1159/000540593).
Respondent Characteristics
Demographic variables included age, sex at birth, race/ethnicity, the highest level of education, employment status, veteran status, type of health insurance coverage, and combined annual family income. Age was further categorized into age groups (18–24 years old, 25–34 years old, 35–44 years old, 45–54 years old, 55–64 years old, and 65 years or older) to compare reasons for using MC across different age groups. We assessed the frequency of using cannabis, including that from outside dispensaries, in the past 6 months, in addition to the lifetime daily cannabis use history.
Descriptive Outcome Measures
Self-Reported Health Conditions and Reasons for MC Use
Initially, the survey provided a list of 27 medical conditions, including qualifying conditions in Florida and those reported as frequent reasons for MC use in previous studies, and an option to specify other health conditions [5, 12–14]. The participants were asked to indicate all conditions they had been diagnosed with via a healthcare professional [11]. From the list of medical conditions, we then asked the participants to identify which health conditions they considered to be among their main reasons for using MC. We compared the top five main reasons for using MC by sex and age groups and cross-tabulated the main reasons against the reported qualifying conditions.
Perceived Health Impacts
We asked all survey participants, for each health condition, to indicate their perceived impact of MC on this health condition as worse, no change, better, or unsure.
Statistical Analysis
We conducted a descriptive statistical analysis to describe categorical and continuous measures using SAS version 9.4 (Cary, NC, USA). For items with missing data, the valid percentage is reported (excluding missing cases), and missing data are reported accordingly. For health conditions, including qualifying conditions, with cell sizes of less than ten respondents, the results were not displayed in the tables or figures for data privacy considerations. We assessed the alignment between self-reported qualifying conditions and self-reported main reasons for using MC by calculating agreement percentages of reporting a qualifying condition as a main reason for using MC. Finally, we assessed the frequencies of self-reported perceived impact of MC on the top ten most frequently self-reported medical conditions in our sample. Given that reported health conditions and reasons for using MC were not mutually exclusive, we analyzed each condition and reason separately and reported percentages relative to the appropriate denominator for each descriptive outcome.
Results
A total of 632 participants completed the survey. The median (IQR) age was 45 (35, 58) years. In the total sample, 396 (62.7%) were female, and 471 (74.5%) were non-Hispanic white (Table 1). Most respondents had higher education; specifically, 408 (64.6%) respondents had some college or were college graduates, and 116 (18.4%) had a graduate degree (e.g., MS, PhD). Most participants were employed (293 [46.4%] worked full-time and 76 [12.0%] worked part-time), and 330 (52.2%) had private health insurance. In the past 6 months, 548 (86.7%) participants used cannabis (including that obtained outside dispensaries) four or more times a week. Most survey respondents (>90%) reported daily cannabis use for at least 1 year (1–2 years: 118 [18.67%]; 3–4 years: 105 [16.61%]; 5–10 years: 103 [16.30%]; 11–20 years: 84 [13.29%]; >20 years: 102 [16.13]), as shown in Table 1.
| Variable | Results |
|---|---|
| Age in years, median (IQR) (missing = 4) | 45 (35, 58) |
| Sex at birth, N (%) | |
| Female | 396 (62.66) |
| Male | 236 (37.34) |
| Race/ethnicity, N (%) | |
| Non-Hispanic white | 471 (74.53) |
| Non-Hispanic black | 35 (5.54) |
| Hispanic | 93 (14.72) |
| Other (American Indian or Alaska Native, Native Hawaiian or Pacific Islander, Asian, other) | 33 (5.22) |
| Education level, N (%) | |
| Graduate degree (e.g., MS, PhD) or professional degree after graduating college | 116 (18.35) |
| Some college or college graduate | 408 (64.56) |
| High school or GED | 103 (16.3) |
| Middle school | 5 (0.79) |
| Elementary school or below | 0 (0) |
| Employment status, N (%) | |
| Currently working full-time (including self-employment) | 293 (46.36) |
| Currently working part-time (including self-employment) | 76 (12.03) |
| Unemployed – looking for work | 20 (3.16) |
| Unemployed – disabled/unable to work | 101 (15.98) |
| Student | 15 (2.37) |
| Retired | 102 (16.14) |
| Other | 20 (3.16) |
| Missing | 5 (0.79) |
| Veteran status (yes), N (%) | 61 (9.56) |
| Health insurance, N (%) | |
| Private health insurance | 330 (52.22) |
| Medicaid | 88 (13.92) |
| Medicare | 160 (25.32) |
| VA coverage | 32 (5.06) |
| No health insurance | 70 (11.08) |
| Other | 47 (7.44) |
| Annual household income in USD, N (%) | |
| <USD 20,000 | 84 (13.29) |
| USD 20,000–USD 39,999 | 130 (20.57) |
| USD 40,000–USD 59,999 | 108 (17.09) |
| USD 60,000–USD 79,999 | 98 (15.51) |
| USD 80,000–USD 99,999 | 51 (8.07) |
| ≥USD 100,000 | 130 (20.57) |
| Do not know/do not want to answer | 25 (3.96) |
| Missing | 6 (0.95) |
| Cannabis use frequency in past 6 months, N (%) | |
| 4 or more times a week | 548 (86.71) |
| 2–3 times a week | 51 (8.07) |
| 2–4 times a month | 21 (3.32) |
| Monthly or less | 9 (1.42) |
| Never | 3 (0.47) |
| Years of daily cannabis use, N (%) | |
| No history of daily cannabis use | 57 (9.02) |
| <1 year | 63 (9.97) |
| 1–2 years | 118 (18.67) |
| 3–4 years | 105 (16.61) |
| 5–10 years | 103 (16.30) |
| 11–20 years | 84 (13.29) |
| >20 years | 102 (16.13) |
The top ten most frequently self-reported medical conditions among the survey respondents were anxiety (n = 451, 71.4%), depression (n = 392, 62.0%), chronic pain (n = 310, 49.1%), insomnia/sleeping problems (n = 295, 46.7%), PTSD (n = 270, 42.7%), headaches/migraines (n = 218, 34.5%), high blood pressure (n = 162, 25.6%), attention-deficit hyperactivity disorder (ADHD; n = 123, 19.5%), bipolar disorder (n = 89, 14.1%), and fibromyalgia (n = 82, 13.0%), respectively. Of all reported health conditions, the top ten most frequently reported as main reasons for using MC in the total sample were anxiety (n = 383, 60.6%), chronic pain (n = 278, 44.0%), depression (n = 252, 39.9%), PTSD (n = 220, 34.8%), headaches/migraine (n = 134, 21.2%), fibromyalgia (n = 67, 10.6%), ADHD (n = 59, 9.3%), bipolar disorder (n = 53, 8.4%), high blood pressure (n = 41, 6.5%), and cancer (n = 18, 2.9%), respectively (Fig. 1).
The top five most prevalent reasons for using MC were consistent between females and males with anxiety being the most frequently reported main reason for MC use among both (67.7% and 48.7%, respectively), as shown in Figure 2. Anxiety was the most frequently reported main reason for using MC (70.0%, 78.3%, 64.4%, and 64.4%) among younger age groups (18–24, 25–34, 35–44, and 45–54 years old, respectively), while chronic pain was the most frequently reported main reason (62.1% and 47.5%) among older age groups (55–64 years old and 65 years or older, respectively) as shown in Figure 3. Still, anxiety was the second most frequently reported main reason (50.8% and 35.0%) among those in the 55–64 years old and 65 years or older age groups, respectively. Depression was the second most frequently reported main reason (46.7%, 54.2%, and 44.97%) among 18–24, 25–34, and 35–44 year olds, respectively. Furthermore, insomnia/sleeping problems were a top reason for using MC, with more than 30% using MC for insomnia across all age groups as shown in Figure 3.
Among those certified for PTSD, the most frequently reported main reasons for using MC was PTSD (n = 155/187, 82.9%), followed by anxiety (n = 134/187, 71.7%), depression (n = 96/187, 51.3%), insomnia/sleeping problems (n = 83/187, 44.4%), and chronic pain (n = 75/187, 40.1%), respectively. Among those who reported being certified for a condition other than those listed, the most frequently reported main reasons for using MC was anxiety (n = 107/175, 61.1%), followed by depression (n = 71/175, 40.6%), insomnia/sleeping problems (n = 59/175, 32.7%), and chronic pain (n = 52/175, 29.7%), respectively. Among those certified for medical conditions of the same kind or class as or comparable to the others listed, the most frequently reported main reason for using MC was anxiety (n = 100/140, 71.4%), followed by insomnia/sleeping problems (n = 67/140, 47.9%), depression (n = 66/140, 47.1%), and chronic pain (n = 61/140, 43.6%), respectively. Finally, among those certified for chronic nonmalignant pain, the most frequently reported main reason for using MC was chronic pain (n = 138/162, 85.2%), followed by anxiety (n = 82/162, 50.6%), insomnia/sleeping problems (n = 66/162, 40.7%), and depression and PTSD (for both, n = 46/162, 28.4%).
The most frequently reported qualifying conditions for MC certification in the total sample were PTSD (n = 187, 29.6%), a condition not listed on the qualifying conditions list (n = 175, 27.7%), a medical condition of the same kind or class as or comparable to the others listed (n = 140, 22.2%), and chronic nonmalignant pain (n = 62, 25.6%), respectively. No individuals reported being certified for amyotrophic lateral sclerosis in our sample.
Figure 4 depicts the alignment between the self-reported qualifying conditions for MC certification and self-reported main reasons for using MC and illustrates the full ranking of the main reasons for using MC within each qualifying condition category expressed in percentages. Figure 5 illustrates the perceived impacts of MC on self-reported health conditions. Among those who had the top ten most frequently reported medical conditions, most respondents reported improvement in chronic pain (n = 305/310, 98.4%), depression (n = 381/392, 97.2%), anxiety (n = 430/451, 95.3%), fibromyalgia (n = 77/82, 93.9%), PTSD (n = 247/270, 91.5%), bipolar disorder (n = 79/89, 88.8%), insomnia/sleeping problems (n = 225/295, 86.4%), headaches/migraine (n = 172/218, 78.9%), and ADHD (n = 82/123, 66.7%). For high blood pressure, our respondents most frequently reported improvement (n = 69/162, 42.6%); however, a high percentage of the respondents also reported experiencing no change (n = 57/162, 35.2%) or being unsure (n = 36/162, 22.2%) about MC’s impact on their blood pressure. A small percentage reported a perceived worsening impact of MC on ADHD (n = 2/123, 1.6%), fibromyalgia (n = 1/28, 1.2%), anxiety (n = 4/451, 0.9%), depression (n = 3/392, 0.8%), insomnia/sleeping problems (n = 2/295, 0.7%), headaches/migraine (n = 3/218, 1.4%), bipolar disorder (n = 1/89, 1.1%), PTSD (n = 1/270, 0.4%), and chronic pain (n = 1/310, 0.3%).
Discussion
In this cross-sectional survey of MC patients in Florida, USA, the most frequently reported qualifying conditions were PTSD, a condition not on the qualifying conditions list, medical conditions of the same kind/comparable to those listed, and chronic nonmalignant pain. The top ten most frequently self-reported reasons for using MC were anxiety, chronic pain, depression, PTSD, headaches/migraine, fibromyalgia, ADHD, bipolar disorder, high blood pressure, and cancer. Of overall survey respondents, 70–90% with each qualifying condition reported it as one of the main reasons for using MC. Most respondents reported improvement in chronic pain, depression, anxiety, fibromyalgia, PTSD, bipolar, insomnia/sleeping problems, headaches/migraine, and ADHD. Most respondents were unsure/reported no change in blood pressure. A small percentage reported perceived worsening impacts on their conditions.
Consistent with data from the Physician Certification Pattern Review 2023 Annual Report [15], PTSD was the most frequently reported qualifying condition. Consistent with previous reports, anxiety, depression, chronic pain, and insomnia/sleeping problems emerged as the most prevalent self-reported reasons for using MC [14, 16, 17]. It is noteworthy that anxiety was the most frequently reported reason among younger groups, while chronic pain was the most frequent among older groups. Anxiety was most frequently reported as a main reason for using MC among females. These observations can be explained by the higher prevalence of anxiety among females and younger populations [18] and the higher prevalence of chronic pain in older populations [19].
Reported qualifying conditions and self-reported reasons for using MC aligned for most survey respondents, suggesting that certification data accurately reflect the spectrum of conditions that are treated with MC in Florida. However, more than a quarter of the survey respondents reported being certified for a condition they do not recognize from the list of qualifying conditions in the Florida MC program. Among those respondents, the most frequently self-reported reasons for using MC were anxiety, depression, and sleeping disturbances. While this finding deviates from the formally recognized list of qualifying conditions, these self-reported reasons are comparable to those attributed to the “other” condition category that may be used for conditions with comparable symptoms. Moreover, the main reasons for use were multifaceted among most survey respondents, suggesting expectations for broader treatment effects than usually described for allopathic medications. For example, among those who reported being certified for chronic nonmalignant pain, a considerable proportion reported using MC for other conditions or symptoms, mainly anxiety (51%), sleeping disturbances (41%), and depression (28%). These findings support the notion that individuals often seek MC for broader symptom management rather than adhering strictly to state-authorized conditions [6], while simultaneously suggesting that MC appears to have more dimensions of treatment effects, an observation rarely seen with allopathic pharmacotherapy (e.g., opioid use for pain). The participants overwhelmingly reported positive impacts of MC on various health conditions, including anxiety, depression, chronic pain, insomnia, PTSD, and headaches, consistent with previous studies and surveys [5, 12–14, 20, 21]. However, it is crucial to acknowledge that our study lacked a control group to allow MC effectiveness assessment and its cross-sectional nature focusing on current users prevented from examining MC discontinuation (i.e., prevalent user bias) [22, 23]. Finally, a small percentage reported perceived worsening of their health conditions, emphasizing the need for individualized approaches and ongoing monitoring of potential MC adverse effects.
Our study population lacked representation of minority population groups, which is a shortcoming of the M3 study and likely of Florida’s MC program itself. Unfortunately, no data describing the demographic characteristics of Florida’s MC population are available yet, but a previous survey with findings aligning with ours underscored an over-representativeness of non-Hispanic white populations compared to Florida’s census data [14].
Limitations
Our study had limitations. First, our study employed a cross-sectional design, capturing a snapshot of participants at a specific point in time. This design restricts our ability to establish causal relationships or track changes over time, particularly in assessing the long-term impacts of MC use on specific health conditions. Second, assessing perceived MC impacts on health conditions relied on self-reporting. Objective measures or additional clinical data would strengthen the robustness of our findings regarding the effectiveness of MC for specific health conditions. Specifically, given that our study used a convenience sample of individuals using MC, it is expected that these patients are more likely to have positive views on MC and, therefore, more likely to report positive impacts. In a study conducted in the state of Minnesota, USA, it was estimated that only half of individuals initially enrolled in the state’s MC program renewed their enrollment [24]. As reasons for MC discontinuation are not yet fully characterized, such findings support the suggestion that people who persist in MC programs, akin to those included in our study, are more likely to experience and report positive impacts. To retain representativeness in our sample, we did not restrict the analysis to those who identified a health condition as a main reason for using MC. This approach may have increased the frequency of responses corresponding to uncertainty about MC impact. However, this approach also allowed us to capture a small percentage of participants who reported negative impacts of MC on their other health conditions. Finally, the quantitative nature of our study restricts our ability to explore nuanced aspects of participants’ experiences with MC. Qualitative data could provide a richer understanding of motivations, challenges, and perceptions related to MC use.
Conclusion
Reported qualifying conditions and self-reported reasons for using MC aligned for most patients, suggesting that certification data accurately reflect the spectrum of conditions that are treated with MC in Florida. However, about one-quarter of patients reported being certified for a condition that is currently not available in the Florida MC program. Main reasons for use were commonly multifaceted, suggesting expectations for broader treatment effects than usually described for allopathic medications. Most patients perceived positive effects, including those with limited available evidence on efficacy. Yet, a small percentage reported negative effects of MC on their health conditions. Controlled studies targeting specific, well-defined outcomes remain needed to evaluate MC’s effectiveness and safety.
Statement of Ethics
This study was approved by the University of Florida Institutional Review Board (IRB202002925). All study participants provided written informed consent. Survey responses are saved as deidentified data on ResVault, a highly secure computing environment at the University of Florida for protecting restricted and confidential data.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
This study was funded by the Consortium for Medical Marijuana Clinical Outcomes Research, a state-funded research consortium of nine universities in the state of Florida.
Data Availability Statement
Study surveys are available upon request from the authors. Data collected in the M3 study are available for researchers interested in using it to answer MC-related specific research questions upon application and approval by the M3 Data Bank. Further inquiries can be directed to the corresponding author.