As research continues, it will be important to include underrepresented populations as patterns of use for medical purposes may differ by socioeconomic status, race, and access to medical care. Despite the lack of evidence on the efficacy of marijuana use for health conditions, nearly half of those who disclosed medical marijuana use to their doctors reported they were supportive and only 8% of patients felt their doctors were not supportive. The overall high perception of support in our survey contrasts several prior physician surveys describing low approval rates of medical marijuana. In 2005, a survey of 960 physicians nationwide found that only 36% supported legalization of medical marijuana and 26% were neutral.A 2013 survey of 520 family physicians in Colorado found that, despite medical marijuana being legal, only 19% of physicians believed they should be able to recommend it and most agreed it posed serious mental and physical health risks.We did not query healthcare providers directly but instead asked participants their perception of their healthcare providers’ level of support. As such, participants who reported marijuana use to their doctor may have already known they would be supportive. Our data is also more recent compared to the prior surveys, and physicians’ attitudes may parallel the decreased perception of harm that has been documented in surveys of the general population.Indeed,curing weed a more recent survey of 400 medical oncologists found that 46% would recommend medical marijuana to their patients and 67% viewed it as a helpful adjunct to pain management.We also found that 26% of those who used marijuana for medical purposes did not inform their doctor and that this rate was higher in states where medical marijuana was illegal.
Potential reasons for non-disclosure include mistrust, fear of disapproval or bias, and legal consequences in states where marijuana is illegal. Additionally, it is possible patients did not disclose their use because their doctor did not directly ask them. Given the lack of evidence, training, and guidelines on the use of marijuana for medical purposes, some healthcare providers may feel uncomfortable discussing this with patients. Regardless of the reasons why marijuana use was not disclosed, this demonstrates a concerning lack of communication and missed opportunity for providers to counsel patients about the risks and benefits of marijuana use. Additionally, we found that 21% of participants using medical marijuana did not have a doctor. The majority were between ages 18 and 34 and only 22% had a total household income of more than $75,000. Therefore, while their insurance status is unknown, their young age and lower income may have impacted their decision or ability to see a provider. Despite the limitations of the evidence, several healthcare institutions and societies have created policies and guidelines for their healthcare workers to have these important conversations. For example, while Veterans Health Administration providers are unable to complete forms referring patients to State-approved marijuana programs, 2017 VA guidelines encourage physicians to discuss marijuana use with patients and explore how its use may be affecting their health.Though our study benefits from a nationally representative sample, it has several limitations. First, the ordering of the list was not randomized across participants. Also, our results may be more reflective of individuals who are willing to participate in online surveys. However, demographics of our survey respondents were similar to those from prior national studies and there was no evidence of non-response bias on key demographics.Another limitation is that our survey did not directly address perceived efficacy of marijuana use for medical conditions. It would be helpful to know if patients and their healthcare providers believe marijuana is improving their symptoms. Also, we asked about chronic pain as a general category and not specific sub-types of pain.
Finally, we did not survey providers directly, rather, respondents reported their perception of their doctors’ views on marijuana and we did not ask about disclosure to other types of healthcare providers. Despite these limitations, our results demonstrate that US adults are using marijuana to treat conditions where it has not been convincingly shown to provide benefit and highlight the urgent need for higher quality studies on the effectiveness of medical marijuana. They also underscore the need for clinical guidelines to support more complete and informed discussions between patients and providers about medical marijuana use.Marijuana use is common, particularly in people living with HIV . Prior studies suggest that the prevalence of current marijuana use in PLWH ranges from 20% to 60%. In the general population, this number is 8%8 . Discussions with patients about marijuana have taken on more urgency in HIV primary care over the past several years as over half of states have moved to legalize medical marijuana, which is likely to increase use. Furthermore, at least 27 states have designated HIV seropositivity as a qualifying diagnosis for medical marijuana certification. Although experimental trials that substantiate specific benefits are lacking, commonly reported reasons for marijuana use in PLWH include pain relief, as well as other symptoms such as nausea and anorexia. Additionally, chronic pain is common in PLWH, with prevalence estimates ranging from 25% to 85% depending on the cohort studied, and is the most common reason why people seek treatment with medical marijuana. However, recent systematic reviews have highlighted the limited evidence base for medical marijuana in treating pain and other symptoms in the general population, and specifically in PLWH. Another common perception includes a belief that marijuana may allow patients prescribed long-term opioid therapy for chronic pain to reduce their opioid use. Ecological studies in the general population and one study in PLWH support this possibility. With this background, HIV clinicians need empirically based findings to guide patients regarding marijuana use. Additionally, clinicians are faced with the tension between state laws naming HIV as a qualifying diagnosis for medical marijuana and the limited evidence base.
Recent studies suggest that the lay public has generally positive views of the benefits of medical marijuana and views risks as minimal. Given the limited evidence base, providers may be influenced by the layperson’s view of marijuana. Since clinical trials studying the effects of medical marijuana are hampered by federal classification of marijuana as a schedule I substance,weed curing observational data must be relied on to advance our understanding of the impact of marijuana on health outcomes. We investigated whether recreational marijuana use among PLWH who have chronic pain is associated with two clinically important chronic pain-related outcomes: changes in pain severity and prescribed opioid use . We first asked whether a change in marijuana use over time predicted a change in pain severity, hypothesizing that an increase in marijuana use would be associated with decreased pain and a decrease in marijuana use would be associated with an increase in pain severity. We then asked whether baseline marijuana use would be associated with lower opioid prescribing. We hypothesized that baseline marijuana use would be associated with lower rates of initiation and higher rates of discontinuation of prescribed opioids. This study is an analysis of data from a large, ongoing national prospective cohort study of chronic pain and HIV outcomes embedded within the Centers for AIDS Research Network of Integrated Clinical Systems. CNICS sites are patient-centered medical homes for PLWH, meaning that they provide primary and specialty care for PLWH including mental health treatment and social services. The majority of patients from CNICS sites are enrolled in the cohort. CNICS collects demographic and clinical data at routine clinic visits, including laboratory tests, visit data, and prescribed medications from the electronic medical record. Additionally, as part of routine clinical care appointments, participants complete in-person Patient Reported Outcome measures on a computer or tablet on a variety of social and behavioral domains approximately every 4 to 6 months. The CNICS clinical assessment of PROs includes the Alcohol, Smoking, and Substance Involvement Screening Test , which collects self-report of “non-medical” marijuana use over the past 3 months.
The possible categories are no current use, use 1–2 times in the past 3 months, monthly, weekly, or daily. Pain instruments were added to the CNICS clinical assessment between July 2015 and July 2016, providing 12 months of data from which to study chronic pain in this cohort. The following five CNICS sites included the Pain instruments and contributed data to this analysis: Fenway Health in Boston, the University of Alabama at Birmingham , University of California, San Diego , University of North Carolina , and University of Washington . At the time of this study, marijuana was legal recreationally in Washington , medically in Washington and California , and illegal in all other sites. Pain instruments included the Brief Chronic Pain Questionnaire . The BCPQ asks whether participants have pain that has lasted for more than 3 months, and the severity of their pain. Participants who reported at least “moderate” pain for at least 3 months were classified as “chronic pain” and also received the three-item PEG to assess pain severity. This instrument assesses pain intensity , interference with enjoyment of life , and interference with general activity on a scale of 0–10 for each item. Participants with at least moderate chronic pain were also asked to complete the following question: “Check everywhere you have had pain for at least 3 months: numbness or tingling in hands and/or feet; headache; abdominal pain; low back pain; hip pain; shoulder pain; knee pain; pain everywhere in your body.” This study was approved by the Institutional Review Board of the University of Alabama at Birmingham . The date participants completed their first pain PRO instrument was defined as their “index visit.” The study period was defined as the 1-year period following the index visit. Criteria for inclusion in this analysis were age ≥18 years, participation in CNICS for at least one year prior to the index visit to allow for assessment of prescribed opioids during this period and to prevent inclusion of participants new to HIV care, and chronic pain. We also required participants to have two marijuana and two pain PRO measurements during the study period so that changes in these variables could be assessed. Marijuana use—Marijuana use was assessed at the PRO assessments during the study period. Among participants who reported no current use, use monthly, use 1–2 times per month, or use weekly, we defined an increase in marijuana use as any change to a category of more frequent use during the study period. Participants who reported daily use were not able to increase their use and therefore were not included in this analysis. Among participants who reported use 1–2 times in the past 3 months, monthly, weekly, or daily, we defined a decrease in marijuana use as any change to a category of less frequent use during the study period. Participants who reported no current use were not able to decrease their use and therefore were not included in this analysis. For analysis of marijuana use at the index visit, levels were combined to improve interpretations such that three groups were considered; daily/weekly use, monthly/1–2 times in past 3 months, and no current use.The PEG score was calculated as the mean of the 3 items in the questionnaire. We defined long-term opioid therapy as opioid therapy for 90 consecutive days based on medical record data. Prescribed opioid discontinuation was defined as being prescribed LTOT at any point during the year prior to the index visit, and not being prescribed LTOT during the follow-up period. Prescribed opioid initiation was defined as not being prescribed LTOT for one year prior to the index visit and having LTOT initiated during the study period. While it may be of interest to examine longitudinal relationships using all potential visits, only 12% of patients have more than two visits during the follow-up period and it is not clear how having less than the maximum number of observations would be considered statistically significant as this is a clinical cohort without a formal protocol. Change in pain severity outcome: For the relationship between marijuana use and change in pain severity, we considered whether an individual’s marijuana use increased or decreased during the study period.