Medical cannabis-related stigma: cancer survivors’ perspectives
grid.65499.370000 0001 2106 9910Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA USA
grid.65499.370000 0001 2106 9910Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA LW-51902215 USA
grid.65499.370000 0001 2106 9910Survey and Qualitative Methods Core, Department of Population Sciences, Dana-Farber Cancer Institute, Boston, MA USA
grid.62560.370000 0004 0378 8294Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA USA
grid.516087.dThe Koch Institute for Integrated Cancer Research, Massachusetts Institute of Technology, Cambridge, MA USA
grid.245849.60000 0004 0457 1396The Fenway Institute, Boston, MA USA
grid.19006.3e0000 0000 9632 6718School of Nursing, University of California Los Angeles, Los Angeles, CA USA
grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
Abstract
Background
Although the vast majority of medical cannabis laws in the USA includes cancer as a qualifying condition and medical cannabis-related stigma influences decision-making regarding the botanical, few studies have explored the phenomenon in oncology. Early findings indicated oncologic cannabis-related stigma to be quite widespread.
Methods
Semi-structured interviews with 24 adults with cancer histories using medical cannabis were analyzed using the Health Stigma and Discrimination Framework.
Results
Sixteen out of 24 participants discussed medical cannabis-related stigma in some depth. The phenomena emerged as more pervasive in medical than personal/professional domains and was internalized as well as experienced directly. It led some participants, but not others, to practice partial or complete secrecy.
Discussion
Taken together, our findings suggest that, while medical cannabis-related stigma remains widespread and led some study participants to alter behavior, an early shift in ethos towards greater medical cannabis acceptance could be underway. If so, this transition may be occurring more rapidly in non-medical than in clinical settings.
Conclusion
Cancer survivors may experience heightened medical cannabis-related stigma in the clinic as compared to their personal/professional lives. Healthcare providers who depend on patient transparency when gathering medical histories and devising care plans may wish to neutralize perceptions of medical cannabis-related stigma.
Introduction
Medical cannabis is nonpharmaceutical, herbal cannabinoid products that individuals use for medical purposes, sometimes authorized by clinical professionals in compliance with state laws. Thirty-seven states in the United States (U.S.) permit medical cannabis use and a cancer diagnosis qualifies for medical cannabis in nearly every such state law. For this reason, understanding the role medical cannabis plays in oncology should be of import to all clinicians. Defined as a social process of stereotyping, labeling and grouping, stigma triggers loss of social status and discrimination, which in turn influences health and other outcomes [1, 2]. Although stigma associated with medical cannabis may influence decision-making regarding the botanical, only one stigma-related study (to our knowledge) has focused on an oncologic population. In it, stigma emerged as a significant barrier to medical cannabis use by cancer survivors [3].
Outside of oncology, the limited number of studies examining medical cannabis-related stigma have suggested that the phenomenon is pervasive, if gradually shifting [3–9]. Testimony from individuals using or considering use of medical cannabis indicated a perception that their communities view the practice as deviant and that stigma exists in an internalized form (e.g., assumed) in addition to an externalized (e.g., directly experienced) one [2]. Both forms seem to impact patient transparency about use with healthcare teams, as well as with social networks [1, 3, 4].Of note, a recent study (out of Canada) identified less stigma than earlier investigations. The paper’s authors attributed the finding to liberalization of Canadian medical cannabis laws, allowing medical cannabis use greater social acceptance and legitimacy [5, 10].
The studies above were conducted regionally (e.g., Canada/Israel/California) and differing cultural norms across geographies may have limited generalizability. Our study aimed for broader applicability by including a geographically diverse U.S. sample as well as individuals across the disease trajectory and aimed to understand the drivers and facilitators of oncologic cannabis stigma, guided by the Health Stigma and Discrimination Framework [11]. This multidimensional, theory- and evidence-based framework was selected to allow exploration of medical cannabis-related stigma at an individual as well as macro levels.
Materials and methods
Complete methodology is described in the initial paper [12]. In brief, researchers selected eight geographically/culturally diverse states/districts with legal medical cannabis: Arizona, California, Florida, Illinois, Massachusetts, Oregon, New York, and the District of Columbia. Through state-sanctioned medical cannabis dispensaries, researchers recruited 24 individuals 21-years or older, certified to use medical cannabis and with physician-verified cancer histories. Participants received $75 honoraria for approximately 45-min interviews. Written informed consent enabled confidential, audio-recorded phone interviews which adhered to a semi-structured interview guide that included prespecified inquiries pertaining to stigma: Have you experienced stigma around [medical cannabis]? If yes, from where/whom? How, if at all, has stigma affected your decisions around using [medical cannabis]? Between April 2017 and March 2019, recruitment occurred in phases to ensure adequate capture of emergent themes. A qualitative research expert (AR) coded and analyzed transcripts using a multi-stage thematic analysis that combined prefigured and emergent codes and incorporated aspects of grounded theory, more applied framework analysis and a Health Stigma and Discrimination Framework [11, 13–16]. Each stage of coding/analysis was iteratively designed and discussed by an interdisciplinary research team (I. M. B., M. M. N., A. R.) to address trustworthiness in approach/interpretations and resolve conflicts. Recruitment ceased following achievement of thematic saturation. The Dana-Farber Cancer Institute Institutional Review Board approved this study (Protocol 15-449).
Results
Of 24 participants, 16 (67%) were women and the median age was 57 years [range: 30–71 years]. Eleven (46%) resided in the Eastern U.S.; seven (29%) in the Western; and six (25%), in the Midwestern. Twelve (51%) had stage IV or metastatic disease, eight (33%) early-stage diagnoses, and four (17%) were in remission. Participant used medical cannabis for symptom management including for pain (n = 19), nausea/poor appetite (n = 14), anxiety/depression (n = 13), and poor sleep (n = 10), and more than half also used the botanical as treatment for cancer itself. Additional demographics are described elsewhere [12].
Discussion
In exploring whether individuals with cancer histories using medical cannabis experience stigma around this practice, we learned that medical cannabis-related stigma was perceived in medical and personal/professional domains but seemed more prevalent in the former. In fact, a quarter of those interviewed—all from the Eastern U.S.—denied any stigma in their personal lives. A sizeable proportion of the stigma discussed was presumed rather than directly experienced. While many participants responded to stigma with partial or complete secrecy, a few reported being impervious, altering neither transparency nor behavior, in other words, endorsing few health or social impacts. Taken together, these findings suggest that, as articulated by a study participant, the door to medical cannabis acceptance may be creaking open but seems to be doing so more gradually in the medical realm as compared to the personal/professional one.
Clinical implications
Our findings extend those of earlier research investigations that pointed both to widespread medical cannabis-related stigma, as well as to possible early shifts in culture around medical cannabis. The fact that participants in our study frequently reported presumed stigma suggested that historic antecedents served as facilitators. The finding of regional differences in medical cannabis-related stigma is also of interest, particularly since this is, to our knowledge, the first study of medical cannabis-related stigma to capture a geographically diverse U.S. sample. One could hypothesize that local variations in legal/cultural/informational milieus might underlie these differences. Our study should be followed by a quantitative, longitudinal assessment of oncologic medical cannabis-related stigma in the U.S among patients, caregivers, and clinical care teams, in order to quantify regional differences, their etiologies, and trends over time. To fully capture the experiences of affected populations, a more comprehensive study should include individuals with cancer acquiring cannabis from medical cannabis dispensaries, adult use dispensaries as well as informal sources. If quantitative assessments support our findings, greater medical cannabis-related communication in the clinic may be necessary to improve transparency on the part of individuals with cancer histories regarding decisions about whether to use medical cannabis, modes of self-administration, ratios of active ingredients, target indications, potential risks, and adverse events, etc. One could imagine that an important component for improved communication would be strengthened cannabinoid therapeutics education for clinicians [10, 17].
Study limitations
This study has important limitations. It is cross-sectional, a weakness given the rapid pace of change regarding state cannabis legalities. The sample, which consisted of individuals state-sanctioned to use medical cannabis, might differ in viewpoint from those accessing cannabis from adult use dispensaries or sans state approval. Our study specifically evaluated medical cannabis perceptions among individuals with cancer histories. Levels of perceived stigma may differ among individuals with other illnesses turning to medical cannabis.
Conclusions
Our study also has important strengths. We achieved thematic saturation suggesting that our sample size did in fact allow for broader perceptions of medical cannabis-related stigma among cancer patients to be reflected. The study’s wide geographic sampling also strengthened its generalizability as compared to earlier studies on this topic. Finally, its key findings—that medical cannabis-related stigma, while highly prevalent, exists more in medical than in personal/professional domains and often leads to a degree of secrecy—will be of considerable interest to healthcare providers who depend on patient transparency when gathering medical history and in the devising optimal care plans.
Funding
M. M. N., P. R. C., S. T., T. S., and I. M. B. are funded by the Hans and Mavis Lopater Foundation; PC by K23DA044847.
Declarations
Conflict of interest
The authors declare no competing interests.