Following the widespread prohibition of cannabis in the early 1970s, legislation to liberate the medical use of the plant has slowly been adopted in different jurisdictions across the globe. Medical cannabis is subsequently now legal in many Western countries, in addition to many South American and Asian countries. Canada became one of the first countries to create an official medical cannabis programme in 2001, authorising the possession, production, and distribution of cannabis for therapeutic purposes
(CTP). More recently, in the UK in 2018, the government removed cannabis from Schedule 1 of the Misuse of Drugs Act, allowing it to be prescribed for medical conditions that had not responded sufficiently to first-line medications.
Despite these laws – supported by changes in public opinion – research shows that stigmas surrounding medical cannabis persist. Surprisingly, given the ever-growing body of evidence of cannabis-based drugs, medical cannabis patients continue to find themselves stigmatised for their use of such medicines. A 2013 Canadian study aimed to understand, in more detail, medical cannabis users’ perceptions of and responses to the stigma attached to using CTP.
While it is widely recognised that the use of medical cannabis continues to perpetuate a stigma around the user, the authors of this study recognised that little is known about how this stigmatisation may influence the users’ patterns of use and personal lives. ‘Stigma’ is defined by Goffman, who’s 1963 work underpins our understanding of the concept, as “The phenomenon whereby an individual with an attribute which is deeply discredited by his/her society is rejected as a result of the attribute” – in this case, the phenomenon may be related to both the occurrence of serious illness as well as the use of cannabis.
Stigma may be externally applied (by others’ judgements upon the person resulting in discriminatory practices) or internally applied (where individuals’ assumption or fear of discrimination result in self- perceptions of shame and self-induced isolation). Disease-related stigma may be bolstered by the patients’ use of particular medications – in this case, cannabis, which has long been classified as an illicit drug.
Past studies (including one which assessed HIV/AIDS CTP users and another in pregnant women experiencing Hyperemesis Gravidarum) have found that many CTP users are met with “laughter, skepticism, or with negative reactions”, largely related to concerns over the legal implications and the potential of negative health effects and addiction. Therefore, a clearer understanding of the experiences of stigma among CTP users is increasingly important and relevant in relation to the health services
provided to these patients.
Design and Methods of the Study
The specific research questions guiding this study were: 1) “What are CTP users’ experiences of stigma?” And 2) “What strategies do CTP users employ to negotiate their experiences of stigma?”
The aim of the study was that, by understanding how individuals perceive the potential social implications of CTP use, new approaches can be identified to reduce the stigma of medical cannabis use as well as to help patients to deal with this stigma.
The researchers used qualitative methods, inductive analysis, and purposive sampling to develop an in- depth account of the experiences of CTP users. Current CTP users were recruited through four British Columbia community-based cannabis dispensaries as well as through a Canadian online forum of CTP users in 2007-2008. For inclusion, patients must have used medical cannabis in the last 30 days and for over 6 consecutive months and be at least 19 years of age.
Data were collected using either face-to-face or telephone interviews in which participants were invited to discuss their beliefs about and experiences of CTP and any experiences of associated stigma. Interviews were carried out by trained research assistants. Questionnaires were also used to collect demographic data, history of cannabis use, and additional information about health issues related to CTP use.
Information collected through participant interviews revealed a “predominant discourse of stigma associated with CTP use”. Such experiences of stigma were reported to commonly arise in interactions with family members and close friends, as well as from others in society. The evidence collected revealed that, in order to benefit from medical cannabis use, participants had to “negotiate social censorship, disapproval, threats, and isolation.”
The researchers identified three dimensions of stigma through the details provided by participants,
related to negative views of cannabis as a recreational drug, illegal activity surrounding cannabis use, and layered vulnerabilities related to poverty and particular illnesses and disabilities.
Stigma associated with cannabis as a recreational drug
Participants revealed that medical cannabis use is more difficult to conceal, in comparison to other medications – particularly when consumed through smoking, which most participants favoured. This method of consumption was likely to invoke negative images of medical patients, due to its widespread association with recreational use and criminality – such as the popular portrayal of “potheads” or “criminals” which has been reinforced by the media and public opinion.
It must be noted, that in the UK medical cannabis is not prescribed or recommended to be smoked due to the production of cancer-causing agents through igniting cannabis flower. Instead, cannabis flower in the UK is prescribed to be vaporised. At lower temperatures this significantly reduces the exposure to potentially harmful chemicals.
Perceptions of cannabis as an addictive drug were also perceived to contribute to condemnations of its use as a medical product. Participants reported being labelled “drug addicts” and some even described being reminded by others, including physicians, that cannabis was a “bad medicine” that could lead to addiction. This is a significant finding as, even when patients were prescribed other potentially addictive medications (e.g., oxycontin, sleeping pills), it was their use of cannabis that was scrutinised. In some cases, healthcare providers even offered participants counselling to address their assumed cannabis addiction.
Family members and healthcare professionals were also reported to express a lack of trust in the participants because of their use of cannabis. In some cases, participants were not believed by physicians or those close to them when reporting on the benefits they had experienced from cannabis. Some participants reported that they were accused of “making things up”, “faking things”, or “manipulating symptoms” in order to access medical cannabis. Participants also revealed how they were reluctant to tell their employers or coworkers about their medical cannabis use out of fear that they would lose their job or that they and their work performance would be negatively judged.
Stigma associated with legality
In addition to experiences of external stigma, participants also described internal stigma towards cannabis – largely influenced by the legality of the drug. Furthermore, while holding a federal license or community-based dispensary membership card provided recognition of participants’ need for medical cannabis, this did not negate the stigma they experienced.
Some participants described their belief that their use of CTP drew into question and invited judgement on their ability to parent. Several patients feared losing custody of, or access to, their children as a direct result of their medical cannabis use. For some patients, being a parent therefore led to increased steps to conceal their cannabis use from those around them.
Managing stigma associated with the use of CTP
For many participants, the idea that others were able to differentiate them from recreational users was very important. The researchers noted, “as a result of the necessity of their use of CTP, participants were very particular in how they procured cannabis, how much they used, and when so as not to be confused .”
For many, this also meant being open and honest about their use of CTP. Applying for a federally-issued license for use and production, in addition to alerting the authorities of their CTP production were ways some participants attempted to manage their image as a responsible cannabis user.
Following the review of the data collected in this study, the researchers note that this evidence builds upon previous literature on experiences of stigma among those with illness and the role this plays in seeking medical cannabis. However, it is also noted that in the past literature, it is not necessarily the cannabis that is stigmatised, but the illness requiring CTP. This makes medical cannabis one of the few medications where patients are directly stigmatised due to their access.
The findings presented in this study build upon our understanding of how medical cannabis patients continue to experience stigma, and the potential negative effects on their physical and mental wellbeing, as well as the impact on healthcare interventions. The researchers conclude that these findings demonstrate “the urgent need for finding better solutions and strategies to reduce stigmatisation associated with use of CTP.”