In this survey of people in the United States and Canada with a rheumatic condition who use MC, nearly two‐thirds reported substituting MC for medications associated with rheumatic disease symptom control, including NSAIDs, opioids, antidepressants, gabapentinoids, and benzodiazepines. Reasons for substitution were better symptom management and harm reduction, such as fewer adverse effects. Those who substituted reported a longer duration of use, had a higher frequency of use (both daily and weekly), were more likely to inhale MC, and used THC‐dominant products. Those who substituted used MC to treat more symptoms, reported a higher use of smoking and vaporizing compared with nonsubstitutors, and reported a higher number of administration routes used. Compared with those who did not substitute MC for medications, those who substituted used MC for more symptoms and reported larger improvements in pain, sleep, joint stiffness, muscle spasm, inflammation, and global health.

Consistent with previous studies, experience with recreational cannabis use was prevalent and reported by three‐quarters of all study participants. In addition, there were several MC use characteristics that were worth noting. First, inhalation was the most common method of administration, with all the attendant risks of respiratory disease and aggravation of an inflammatory condition. However, given the immediate pharmacokinetic effect of inhaled MC, this administration method may be most satisfactory for people seeking rapid symptom relief, especially for pain. Second, MC products containing THC were most used, especially for those reporting daily use (although dosing was not specified). This raises concerns for cognitive impairments related to THC as well as the potential for tolerance and physiologic dependence caused by prolonged use. ²⁵ It is also plausible that some individuals may require cannabis products containing at least some THC for effective pain management, a point that should be explored in future studies. Third, it is noteworthy that more than half of participants in this survey were using MC at least daily, with those substituting more likely to be using regularly. This pattern of use supports the notion of daily continuous symptoms that need continuous management. Finally, this survey reports persistence in the use of MC, with 520 (68%) of the whole cohort reporting use for at least 1 year, a finding that suggests satisfaction with use and can be seen as a surrogate for efficacy.

Two‐thirds of MC users in this survey reported a diagnosis of an inflammatory rheumatic disease, and a similar number reported concomitant conditions, such as fibromyalgia, osteoarthritis, and mechanical spinal pain. Therefore, overlapping rheumatic complaints may represent an increased burden of disease, increased number of prescription medications, and increased risks of medication‐associated side effects. Furthermore, more than half of those substituting reported substituting MC for more than one medication. With polypharmacy an increasing problem, especially in the older adult population, the substitution of numerous medications with MC as a single product may be seen as advantageous. Poor adherence to prescribed pharmacotherapies for chronic pain has been associated with the complexity of a treatment regimen, multiple medications, and medication‐associated side effects. ²⁶ , ²⁷ , ²⁸ , ²⁹ A small number of individuals (n = 37) reported substituting MC for DMARDs, a potential cause for concern given that discontinuation of these medications without careful consultation with and oversight from one's clinician may result in symptom flares.

When considering our results as part of the broader literature, the evidence consistently demonstrates a correlation between MC use and reducing the use of prescription/over‐the‐counter medication, especially opioids. ¹⁰ , ¹¹ , ¹⁴ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ For example, almost half of 2,697 Canadian participants in an online survey receiving legal MC reported that cannabis had enabled substitution for other substances (alcohol 18%, tobacco 8%, opioids 18%, and other prescription medications 18%). ³⁶ Similarly, an observational study of 757 patients observed at community‐based cannabis clinics in Ontario, Canada, reported that the proportion of those using opioids decreased by half from 41% to 24% at 12 months. ¹⁴ In an online survey of more than 800 people with fibromyalgia, 53% reported that CBD products allowed them to reduce or even discontinue opioid use. ³⁷ , ⁴⁰ These findings are mirrored in prospective studies as well. In a prospective open‐label study of patients with chronic pain observed at a pain clinic in Israel, 32 of 73 participants receiving opioid therapy at baseline had discontinued treatment at 6‐month follow up. ⁴¹ When MC was added to standard treatments for 102 patients with fibromyalgia with a 64% retention rate, almost half reduced or discontinued analgesic treatment and reported improved sleep parameters and quality of life. ³¹ , ⁴⁰ , ⁴² Additional research is needed to investigate the temporal and causal nature of this relationship.

However, these findings have not been replicated in clinical trials. Recent systematic reviews and meta‐analyses, including clinical trials of patients with cancer‐related pain, show little evidence of opioid reduction following cannabinoid use. ⁴³ As noted by the authors, one key challenge of these clinical trials is the frequent requirement to maintain a stable opioid dose, thus confounding any possible substitution effects in these trials. ³³ , ⁴⁴ With the lack of clinical trial data and expanding legality of and access to MC, there have been modified Delphi panel studies as well as proposed clinical practice guidelines for the use of cannabis and cannabinoids for chronic pain, ⁴⁵ , ⁴⁶ , ⁴⁷ including potential methodologies for the safe introduction and titration of cannabinoids in concert with opioid tapering. ⁴⁷ These proposed approaches cite more evidence for the analgesic effect of THC compared with CBD but also more safety issues with THC, highlighting the importance of graduated dose progression according to symptom response, a recommendation for vaporizing over smoking, and consideration of attenuation of THC‐related side effects by the coadministration of CBD.

The limitations of this study included a lack of determination of causality because of its cross‐sectional design. Further, the nature of survey collection at a single timepoint allowed for potential recall bias in answering survey questions. These results are not generalizable to all demographic groups because of the sample makeup of mostly older, White females, with 40% reporting a university degree. Recruiting for this study occurred during the COVID‐19 pandemic, which may have affected our recruitment pool and potentially how participants were using MC because of changes in daily habits or routines. Additionally, many participants in this study had used cannabis for >6 months, thus our results may be biased toward those who found it more effective for symptom management. Our results may also be limited because we did not account for multiple comparisons in our statistical analyses. Finally, policy efforts to decrease opioid prescribing may have contributed to the discontinuation of opioids or increased attempts to substitute MC for opioids.

The acceptance of MC as a treatment strategy for rheumatic conditions is evolving. The changing legal status of cannabis has allowed a greater openness with more people willing to try cannabis for symptom relief. These encouraging results of medication reduction and favorable effect of MC require confirmation with more rigorous methods. At this time, survey information may be seen as a signal for effect, rather than sound evidence that could be applicable to those with musculoskeletal complaints in general. Comparative effective clinical trials of MC versus other pain treatments are needed, as are more prospective studies investigating the effects of MC on the use of medications and other substances in rheumatic populations.