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Table 2 Patterns of medical cannabis use and utilization of medical cannabis as a substitute for prescription medications

From: Cannabis against chronic musculoskeletal pain: a scoping review on users and their perceptions

Article Mode of cannabis administration Mode advantages Mode Disadvantages Quantity1/Frequency of cannabis use Cannabis used as a substitute for prescription medications
Aggarwal et al. 2009 When mentioned, mainly smoking. Not reported Not reported From “as needed” to over 10 times daily.
From ½ to 14 g/week.
Not reported
Boehnke et al. 2016 Not reported Not reported Not reported Not reported 45% of respondents reported a 64% reduction in opioid use with medical cannabis use.
Decrease in the number of medications classes used with medical cannabis use (2.38 to 1.81, P < .001).
Bonn-Miller et al. 2014 Not reported Not reported Not reported Participants used 2 to 3 times/day.
They used 6–12 g/week.
Not reported
Bottorff et al. 2011 Primarily smoking. Smoking:
• convenient
• affordable
• more effective regulation of dosing.
Smoking-related concerns:
• coughing
• breathing difficulties
• fear of lung cancer.
Not reported Not reported
Bruce et al. 2018 60% of participants preferred smoking;
20% vaporizing;
17% ingestion;
3% topical use.
Not reported Not reported Not reported medical cannabis use reported as:
• alternative to prescription (opioids, anticonvulsants, anti-inflammatories) or OTC medications;
• complementary, with prescription medications;
• a means for tapering off prescription medications.
Brunt et al. 2014 81% inhalation; 19% tea. Not reported Not reported 90% of participants used daily.
Mean cumulative dose: 0.65 ± 0.63 g/day [4.5 g/week].
Not reported
Coomber et al. 2003 73% smoking. Smoking: less amount required than eating or drinking. Not reported 48% used daily; 24% used 1–3 times/week.
24% used 1–3 joints/day.
Not reported
Corroon et al. 2017 Not reported Not reported Not reported Not reported Odds of reporting substitution 4.59 (95% CI, 3.87–5.43) times greater among self-identified medical cannabis than among non-medical cannabis users.
Most common classes of drugs substituted: narcotics/opioids (36%), anxiolytics/BZD (14%), and antidepressants (13%).
Cranford et al. 2016 91% reported smoking;
44% eating, drinking, or ingesting;
39% vaping;
11% topical use.
> 50% indicated > 1 mode for past month cannabis use.
Not reported Not reported 74% of participants used almost daily.
From none to > 1 ounce (14.5% of participants)/month [0 to 6.5 g/week].
Not reported
Crowell 2017 Most frequent mode: 80% smoking; 7% vaporizing; 12% edibles. Not reported Not reported 3–4 times/day (41.6–37.9%); 1–2 times/day (38.7–27.1%). At first visit: 50% of participants had reduced use of pain medication; at visit 2: 62.4%; at visit 3: 60%.
Erkens et al. 2005 70% as tea; 20% smoked. Not reported Not reported 1 to 4 times/day. Not reported
Fanelli et al. 2017 Primarily cannabis tea (smoking cannabis not permitted in Italy).
92% used 22% THC/< 1% CBD Bedrocan.
Not reported Not reported From 56.7 ± 45.5 mg/day [0.4 g/week] at treatment initiation; to 67.0 ± 58.8 mg/day [0.5 g/week] at follow-up (98 ± 145 days). Not reported
Grella et al. 2014 51% used a pipe/water pipe, 47% smoked joints or blunts; 23% used vaporizers; 16.5% edibles; 3.3% oral tincture. Not reported Not reported 2.5 ± 2.6 dispensary visits/month.
57% of focus group participants used several times daily.
A common theme among participants was the preference for using medical cannabis instead of prescription medications.
In the previous 30 days, 7% had non-medical use of painkillers, 4% of stimulants, and 8% of tranquillizers.
Grotenhermen & Schnelle 2003 56% inhalation; 17% oral use; 23% used both modes. Not reported Not reported Average doses of natural cannabis products (109 participants): 1.3 ± 0.9 (0.02–3.5) g/day [9.1 g/week]. Not reported
Haroutounian et al. 2016 77% received cannabis cigarettes; 5% received a combination of cigarettes and drops; 10% only drops; 5% only cookies; 3% combination of cookies and drops. Not reported Not reported Monthly prescribed cannabis: 43.2 ± 17.9 g/month 44% of participants on opioid therapy at baseline had discontinued (P < 0.001).
Harris et al. 2000 Mainly smoking. Not reported Not reported 65% daily use.
86% used ≥ 2 cigarettes/day.
1 g/day.
Not reported
Hazekamp et al. 2013 63% preferred smoking; 24% vaporizing; 8% food/tincture; 2.4% tea.
Fewer participants had experience with dronabinol 11.3%, nabilone 2.1%, nabiximols 1.1%.
Not reported Not reported On average
Times per day: smoking 6.0, vaporizing 5.2, tea 1.9, food/tincture 1.8.
Grams per day: smoking 3, vaporizing 3, tea 2.4, food/tincture 3.4 g.
Not reported
Hoffman et al. 2017 73% smoking; 32% ingestion; 23% vaporizing; 9% topical use. • Most felt vaporizing healthier than smoking.
• Of those who ingested, most felt it more effective for pain relief than smoking.
Not reported Not reported Not reported
Lavie-Ajayi and Shvartzman 2018 Smoking and others (not reported) Not reported Unpleasant taste or smell of cannabis. 20–60 g/month Reduction in side effects of prescription medication.
Medical cannabis use reported as alternative to other medication used for sleeplessness, irritability, restlessness, inability to focus, and depression.
Lintzeris et al. 2018 Inhalation (83.4%) Not reported Not reported Participants used 3 times/day Not reported
Lucas and Walsh 2017 90% had tried joints, 86% vaporizers, 76% oral/edibles, 16% topical.
Primary methods of use:
38% vaporizing, 25% smoking joints, 14% oral/edibles, 12% waterpipe/bongs, 11% pipes, 1% topicals.
Preferred method:
44% vaporization, 23% edibles.
Not reported Not reported 88% of participants used at least daily.
Modal: 1–2 g/day [7-14 g/week], with 29% (n = 79) using a larger amount.
63% of participants reported substitution for prescription medication.
The most common form of substitution was for opioids (32%), BZD (16%), and antidepressants (12%).
Lynch et al. 2006 All participants reported smoking some of the time.
30% used both the smoking and oral routes;
7% used primarily the oral route.
Not reported Not reported 1 to > 6 times/day.
2.5 g/day [17.5g/week].
70% decreased use of other medications that had been causing side effects (NSAIDs, opioids, and antidepressants).
Nunberg et al. 2011 & Reinarman et al. 2011 Not reported Not reported Not reported Not reported 51% reported using cannabis as a substitute for prescription medications.
Ogborne et al. 2000 Mainly smoking. Smoking:
• enjoyable
• immediate, effective
• less expensive
Eating/drinking:
• “less of a head stone…”
• longer lasting
• no smell
Smoking:
• Respiratory side effects (cough, throat irritation)
Eating/drinking:
• too slow
• less effective
• more difficult to regulate in terms of dose.
70% of participants smoked every day.
They smoked 1 to 10 joints/day.
They used 28 to 56 g/month [6.5-13 g/week].
Not reported
Piper et al. 2017 46% of participants smoked medical cannabis; 23% vaporizing; 14% edibles; 12% tincture. Vaping: medical cannabis administered with joints was significantly more expensive than via vaporizer. Smoking:
• not always convenient
• gross
• bad taste.
Vaporizing:
• cumbersome
• too expensive.
Edibles:
• Lack of availability.
Tincture:
• takes too long
• complex dosing.
Not reported Decrease in prescription medications.
Reiman 2009 Not reported Not reported Not reported Not reported 66% of participants reported having used cannabis as a substitute for prescription drugs.
Reiman et al. 2017 50% smoking; 30% vaporizing; 10% edibles. Not reported Not reported Not reported 97% of participants decreased the amount of opioids they consume when they also use cannabis.
96% do not need to take as much of their nonopioid-based pain medication when they use cannabis.
Reinarman et al. 2011 86% smoking; 24% orally; 22% vaporizing. Not reported Not reported 67% daily use; 53% use 1–2 times per day.
≤3 grams (40%) to ≥7 grams (23%) per week.
50.9% of participants reported use of medical cannabis to substitute prescription medication.
Sagy et al. 2019 Smoking, oil Not reported Not reported From 670 to 1000 mg/day After 6 months of medical cannabis therapy, a substantial proportion of participants stopped or decreased the dosage of other medical therapies.
Schnelle et al. 1999 49% inhalation; 14% eating, drinking; 36% used both the oral and inhalation routes
4% used dronabinol.
Not reported Not reported Not reported Not reported
Sexton et al. 2016 84% inhalation: 32% pipes, 19% bongs, 16.5% joints/blunts, 16% vaporizer; 8% oral (edibles, tinctures, capsules); 6% concentrates (oil, keif, hash); 0.6% topical; 0.5% fresh juice. Not reported Not reported 61% reported using 1–5 hits per smoking session, 21.3% reported 6–10 hits, 18% reported >10 hits/session.
25% reported using less than 1 once/day; 1–4 times/day (47.6%); 5–10 times/day (14.9%), and 12.2% reported using all day, every day.
Reported use (g/week):
< 1 (12.3%); 1–2 (20.3%); 3–5 (31.8%); 7 (26.1%); 28 (6%), > 28 (3.4%).
60% reported substitute medical cannabis for prescription drugs, 25% for pain medications, including opiates.
Shah et al. 2017 54% smoking; 29% tablets; 8% edibles. Not reported Not reported 62.5% of medical cannabis users endorsed daily use, 21% weekly use. Cannabis use was not associated with a significantly lower morphine equivalence level for participants using prescription opioids.
Shiplo et al. 2016 53% of participants preferred vapourizing; 47% smoking a joint.
Among those reporting multiple modes: 25% eating in food, 23% drinking.
• Time to onset of effect.
• Ability to find correct dose.
• Smoking lower cost and more accessible.
• Eating/drinking had more durable effect.
• Harm from smoking.
Eating in foods:
• producing the worst high
• most stigma
• hardest to find a correct dose.
Almost every day: 77%, > once a day: 82%.
1.8 ± 1.6 g/day [12.6 g/week].
Not reported
Ste-Marie et al. 2012 Out of the 59 medical cannabis users: 80% smoked herbal cannabis; 24% used prescription cannabinoids; 3% used both. Not reported Not reported 72% used < 1 g/day [< 7 g/week]. Not reported
Ste-Marie et al. 2016 86% smoking; 21% vaporizing; 18% ingestion; 4% topical. Not reported Not reported For the 22 patients who recorded amounts used, most reported ≤ 1.5 g/day [≤ 10.5g/week]. Not reported
Swift et al. 2005 91% smoked.
74% considered smoking the most helpful route.
Smoking:
• Instant effect.
• Ease of titration.
• Cost-effectiveness.
Edibles:
• Healthier
• Tasty when cooked in a recipe
• Less obvious
• Slow onset and long-lasting effects.
Smoking:
• Detrimental to respiratory function (and health)
Edibles:
• Availability of recipes
• Difficulties with titration
• expensive and ineffective for rapid relief.
75% used at least weekly, 59% used almost daily, 22% used “as required.” 62% of participants claimed they decreased or discontinued their use of other medicines with medical cannabis use.
Troutt & DiDonato 2015 67% inhalation: ~ 42% smoking, ~ 25% vaporizing; ~ 27% edibles; ~ 4% tincture; ~ 2% oils. Not reported Not reported 84% used several times per week or more, 61% used daily.
78% used < 14 g/month [3.2 g/week].
90% of chronic pain, 81% of arthritis, 94% of fibromyalgia, and 84% of osteoarthritis patients report less frequent use of other medications.
Walsh et al. 2013 57% smoking; 43% vaporizing; 28% orally. Not reported Not reported 53% used 2–3 times/day, 42 used ≥ 4 times/day.
45% used >14 g/week.
 
Ware et al. 2003 Among users for pain:
81% joint, 47% joint with tobacco, 34% pipe, 16% water pipe; 9% orally.
Not reported Not reported 53% used ≤ 4 puffs/dosing interval, 25% smoked a whole cannabis cigarette, 12% smoked ≥ 1 joint.
22% of these participants used cannabis > 1 time/day, 16% used daily, 25% used weekly and 28% rarely used medical cannabis.
Not reported
Webb & Webb 2014 Not reported Not reported Not reported Not reported 6% wrote brief notes relating how cannabis helped them to decrease or to discontinue other medications.
Zaller et al. 2015 74% smoking; 16.5% vaporizing; 7% orally. Not reported Not reported 60.5% used ≥ 3 times/day.
48.5% used 3–8 g/day, 34.5% used > 8 g/day [21–56 g/week].
55% indicated they had used cannabis as a substitute for prescription medications.
  1. 1[calculated amount of cannabis use in grams per week]
  2. THC: delta-9-tetrahydrocannabinol