It has been estimated that chronic pain (CP) is one of the leading reasons for patients to seek medical care with 20% of Americans suffering from this group of conditions. Risk factors include female gender, low socioeconomic status, living in a rural area, and disability (Interagency Pain Research Coordinating Committee, 2016). Unfortunately, at least one-fifth of these patients continue to rely on opioid analgesics despite resulting complications and evidence against their use for most CP conditions (Yasaei et al., 2021). Pain specialists following guidelines for minimizing opioid use incorporate multimodal treatment models which include procedures, behavioral approaches, and coordinated care with psychologists, physical therapists, chiropractors, and occupational therapists (Chou et al., 2016). Even with these extensive approaches, however, the refractory nature of both opioid dependence and chronic pain is leading many to consider less conventional approaches such as medical marijuana (MMJ).

As of 2021, MMJ is legal in two-thirds of the USA and there is widespread interest in its potential to decrease the opioid burden of CP patients (Boehnke et al., 2019). However, a critical disparity has arisen between greater availability of MMJ and the lack of clear evidence for its effectiveness and safety (Bigand et al., 2019; Nugent et al., 2017). As a result, pain specialists and other medical providers are often faced with the dilemma of responding to patients’ questions without the high level of confidence they have with conventional medications. In addition to educating themselves, they can partially address this knowledge gap by gathering information from patients in order to determine the best candidates for MMJ therapy, select educational materials, and prepare institutional protocols. Though there have been some surveys seeking to characterize other populations of MMJ and recreational marijuana users, little data have been collected to date specifically on the attitudes of CP patients (Takakuwa & Sulak, 2020).

We surveyed patients with CP at the Western Reserve Hospital Center for Pain Medicine (CPM) who had not yet tried MMJ regarding their interest in it. Though some of our patients had already begun using MMJ and a study of this population could yield useful data, we chose to study MMJ-naïve patients for several reasons. First, they represented a sufficiently large sample from which to draw statistically significant conclusions, whereas only several dozen patients had experience with it. We decided that this much smaller group would be better studied retrospectively and presented with descriptive rather than statistical methods. Another factor that led to this decision was the implausibility of formulating the same questions for both MMJ-naïve and MMJ-experienced patients. Therefore, we decided to research both groups separately but to study the larger group first, as the need to address their educational and clinical needs was more relevant to our daily practice.

The survey concerned three main lines of inquiry. The first was patients’ interest in MMJ for the purpose of reducing opioids, a class of drugs with significant adverse events, addiction potential, and long-term health risks (Abdel Shaheed et al., 2016). Though patients are often reluctant to accept alternatives to opioid therapy, our anecdotal experience was that patients were very curious about MMJ as a replacement and often brought up this topic in office visits. Our second goal was to assess compliance with recommendations of dosing and routes of administration. This was of particular interest to us because current MMJ laws in Ohio do not allow MMJ-certified providers to specify doses, cannabinoid ratios, or routes of administration as with other prescribed drugs (The Ohio Legislature, 2018). Instead, these factors are determined by the dispensary staff while providers can only see what products were actually bought weeks later in the prescription drug monitoring report (PDMP). This policy may contribute to the view of many Ohio physicians that MMJ laws are too lenient and limit their willingness to become certified providers of MMJ cards (Lombardi et al., 2020). The third area of inquiry regarded patients’ concerns about using MMJ, as knowing about them could inform risk-benefit discussions involving safety and affordability.

In addition to gathering information to further our clinicians’ goals of opioid reduction, safety, and education, we wanted to contribute to the growing literature on attitudes toward MMJ in various geographic locations (Rochford et al., 2019; Lintzeris et al., 2020; Azcarate et al., 2020). Indeed, the population discussed here was particularly relevant for two reasons. First, MMJ is relatively new in the state of Ohio, having been legalized in 2018 for approved conditions (see Appendix 1). Since then, patients were exposed to frequent media coverage of MMJ developments from initial legislation to dispensary openings. Secondly, the reduction of opioids is of particular interest to them as residents of Summit County, an epicenter of the opioid crisis and litigation with prescription opioid manufacturers covered in the national media (Cooper et al., 2019).