Our study explored the prevalence and sociodemographic determinants of cannabis use for chronic pain management during the COVID-19 pandemic. Our results showed that 50.1% of participants reported using cannabis for chronic pain management. While bivariate analyses (Table 1) indicated significant associations between sociodemographic factors: age, race/ethnicity, income, and education level with cannabis use to manage chronic pain, the multivariable regression analysis (Table 3), adjusted for confounders/covariates, including the phases of the COVID-19 pandemic, offered a more nuanced understanding. Although the bivariate analysis suggested higher cannabis use among older age groups and non-Hispanic White participants, multivariable logistic regression results revealed that younger individuals and those of Hispanic/Latino ethnicity had higher odds of using cannabis for chronic pain. Furthermore, while bivariate results indicated a higher prevalence of cannabis use among lower-income groups, the multivariable analysis showed that higher-income individuals had higher odds of consuming cannabis for chronic pain, probably attributed to better access to legal medical cannabis products because of greater financial resources [35, 36]. Age-related trends in cannabis use for pain management vary across studies. Some studies reported that younger adults are more likely to use cannabis for pain, while others documented increasing use among older adults [37–39]. Higher-income individuals are more likely to access medical cannabis programs, which require physician certification and often involve additional costs [40, 41]. However, some studies found a higher concentration of cannabis stores in lower-income neighborhoods [41, 42]. Additionally, neighborhoods with higher racial and ethnic minority populations typically have fewer medical cannabis-certifying providers [43]. This disparity indicates that while physical access to cannabis may be greater in certain areas, financial barriers and limited access to medical authorization remain significant in lower-income and minority groups.

Participants with chronic pain in our study were more likely to use cannabis for medical reasons or both medical and recreational purposes, often choosing CBD and THC-dominant products. Research indicates that individuals with chronic pain are increasingly turning to cannabis as an alternative or adjunct to conventional pain medications [44]. They also reported daily or almost daily use and were more likely to receive recommendations from healthcare providers. In contrast, those not using cannabis for chronic pain were more likely to use it recreationally and preferred THC-dominant products. The study found significant changes in cannabis consumption methods before and after the COVID-19 pandemic. Smoking, which was the predominant method before the pandemic, decreased notably, while the use of edibles increased significantly. Among those using cannabis for chronic pain, there was a notable rise in the use of edibles and tinctures, with a decrease in vaping. Conversely, vaping increased among nonchronic pain users, and the use of cannabis pills rose slightly in both groups after the pandemic began.

Cannabis use patterns and motivations differ among various populations. Research indicates that lower-income individuals and those with chronic pain are more likely to use cannabis for medical purposes, including pain management. This preference may be attributed to the high cost of prescription medications and limited insurance coverage, which make traditional pain treatments less accessible [45–47]. However, in our study, individuals with higher income were more likely to use cannabis for chronic pain management. Additionally, medical cannabis users frequently report preferring cannabis over pharmaceutical drugs, citing better effectiveness, fewer side effects, and lower costs [48]. Although 85.7% of participants using cannabis for pain management in our study were non-Hispanic White, the odds of using cannabis for chronic pain were higher among Hispanic/Latino individuals compared to non-Hispanic White participants. This contrasts with other studies in the United States that often report higher medical cannabis use rates among non-Hispanic White individuals [49]. This discrepancy may stem from differences in study populations, access to medical cannabis, socioeconomic factors, or variations in cultural attitudes toward cannabis.

Our data indicate a significant rise in the use of edibles among those managing chronic pain, suggesting a preference for methods that offer sustained relief without the adverse effects associated with inhalation [44, 50, 51]. This shift toward edibles and tinctures reflects an adaptation to health concerns and a desire for more prolonged pain management [44, 51]. However, it is important to note that edibles come with their challenges, such as delayed onset and unpredictable effects [51]. These findings highlight the need to consider individual preferences and values when discussing medical cannabis options for chronic pain management.

Biologically, the efficacy of cannabis in managing chronic pain is supported by its interaction with the endocannabinoid system (ECS) [12]. THC, the primary psychoactive cannabinoid, binds to CB1 receptors in the central nervous system, potentially altering pain perception and providing analgesic effects [52, 53]. CBD, another key cannabinoid, modulates the ECS and interacts with serotonin and TRPV1 receptors, contributing to its therapeutic effects without THC's psychoactive effects [54, 55]. The observed preference for cannabis products with a balanced THC/CBD ratio and nonsmoking methods may aim to maximize therapeutic benefits while minimizing adverse effects. These findings highlight the need for further research to clarify how different cannabinoids and consumption methods affect pain management and health outcomes.

Our study has several strengths. It addresses a gap in the literature by examining how the COVID-19 pandemic has affected cannabis consumption patterns for chronic pain management. Key strengths include the use of a large, diverse sample from the CCHS, and the complete anonymity provided by the survey, which safeguards participants and ensures genuine responses. The use of REDCap for data collection further ensured data integrity and participant confidentiality. However, the study also has limitations. The cross-sectional design limits causal inferences, and self-reported data may be prone to recall or social desirability bias. The survey's availability only in English may restrict generalizability to non-English–speaking populations. Additionally, while the online format was suitable during the pandemic, it could have led to duplicate responses, although REDCap helped manage this risk. The predominance of non-Hispanic White participants and potential internet access disparities may affect the generalizability of the findings to other racial and ethnic groups. Moreover, the comparison group (non–chronic pain users) includes individuals using cannabis for other medical or recreational reasons, which may mask important differences in use patterns and motivations across these subgroups. Future studies should consider disaggregating these groups to better understand nuances in cannabis use behaviors and clinical relevance. This study used a convenience sample of cannabis users, providing timely insights into use patterns during the pandemic, though generalizability to the broader population is limited. Despite these limitations, the study's methodological rigor, including pilot testing, helps mitigate some potential biases. Additionally, covariates potentially associated with access to cannabis and its use for pain or other reasons, such as US state or country of residence, were not controlled for in our regression analysis.

Our findings have significant implications for public health, clinical practice, and policy. The shift to nonsmoking cannabis methods indicates a growing awareness of the health risks associated with smoking, which should be reflected in public health campaigns and educational efforts. Clinically, the high prevalence of cannabis use for chronic pain underscores the need for healthcare providers to discuss cannabis use with patients, addressing its benefits, risks, and safe consumption practices. Policy-wise, the observed disparities in cannabis use among different racial and ethnic groups highlight the need for equitable access and accurate information regarding risks and benefits. Future research should focus on the long-term effects of the pandemic on cannabis use and the biological mechanisms of cannabis for pain management to guide clinical practices and policy decisions, ultimately improving health outcomes. Furthermore, future studies should include specific information about the type of chronic pain (e.g., time with pain and type of pain) as this may influence the effectiveness of cannabis and, thus, the decision to use it for managing pain.