Australia’s medical cannabis patients are still turning to the illicit market, despite legal medical cannabis.
The Australian government passed a law in 2016 that allowed patients with qualifying conditions to access medical cannabis products, provided that they received a prescription from their doctor.
Researchers surveyed medical cannabis patients just before the law was passed, and showed that the “vast majority” of respondents were buying cannabis on the illicit market. They were mostly sourcing cannabis flower to smoke, and the conditions they sought to treat were mental health, chronic pain, and sleep issues.
Researchers followed up with a second survey to better understand patient cannabis use patterns two years after the law was passed. They surveyed 1,388 patients who said they used cannabis for therapeutic purposes within the last year.
The results showed that 36.4% of respondents used cannabis to treat pain, which was the most frequently cited condition, followed by 32.8% reporting use for treating mental health issues, and 9.2% for sleep issues.
Most respondents (71.4%) said they inhaled their cannabis, and spent, on average, AUD$82.27 ($101.27) each week.
“There were high levels of self-reported effectiveness, but also high rates of side effects. There was uncertainty regarding the composition of illicit cannabinoid products and concerns regarding their possible contamination,” researchers noted.
Very few respondents (2.7%) had “accessed legally prescribed medical cannabis, with the main perceived barriers being cost, disinterest from the medical profession and stigma regarding cannabis use.”
“Despite 2 years of legal availability, most consumers in Australia reported accessing illicit cannabis products, with uncertainty regarding the quality or composition of cannabis products,” researchers concluded.
In 2016, the Australian federal government passed legislation enabling a range of cannabis-based products to be prescribed to patients by registered healthcare professionals. An online survey conducted immediately prior to these legislative changes found that the vast majority of respondents at the time were illicitly sourcing cannabis plant matter, smoking was the preferred route of administration and mental health, chronic pain, and sleep conditions were the most frequently cited reasons for medical cannabis use. This manuscript reports the results of a follow-up survey conducted in 2018–2019, the Cannabis As Medicine Survey (CAMS-18). The goal of this second questionnaire was to examine patterns of use and consumer perspectives regarding medical cannabis use in Australia, 2 years after the introduction of legal access pathways.
Anonymous online cross-sectional survey with convenience sample, recruited mainly through online media between September 2018 and March 2019. Participants were adults (18 years or over) residing in Australia who reported using a cannabis product for self-identified therapeutic reasons during the preceding 12 months. The survey measured consumer characteristics, indications and patterns of medical cannabis use, routes and frequency of administration, perceived benefits and harms, experiences and preferred models of access to medical cannabis.
Data were available for 1388 respondents. The main categories of condition being treated with medical cannabis were pain (36.4%), mental health (32.8%), sleep (9.2%), neurological (5.2%) and cancer (3.8%). Respondents reported using medical cannabis on 15.8 (11.2) days in the past 28, by inhaled (71.4%) or oral (26.5%) routes and spending AUD$82.27 ($101.27) per week. There were high levels of self-reported effectiveness, but also high rates of side effects. There was uncertainty regarding the composition of illicit cannabinoid products and concerns regarding their possible contamination. Few respondents (2.7%) had accessed legally prescribed medical cannabis, with the main perceived barriers being cost, disinterest from the medical profession and stigma regarding cannabis use.
Chronic pain, mental health and sleep remain the main clinical conditions for which consumers report using medical cannabis. Despite 2 years of legal availability, most consumers in Australia reported accessing illicit cannabis products, with uncertainty regarding the quality or composition of cannabis products.
The global trend towards the legalisation of cannabis for medical purposes reflects both the increased robustness of evidence supporting its efficacy  and increased interest amongst consumers in using cannabis-based therapeutics . In this rapidly changing landscape, it is important for regulators and healthcare providers to understand community use of cannabis for medical purposes, and to determine how changes in medical cannabis legislation may impact patterns of use.
In November 2016, the Australian federal government passed legislation [3, 4] enabling a range of cannabis-based products to be prescribed as unregistered medicines using the Special Access and Authorised Prescriber Schemes [5, 6], and in December 2016 the Australian Therapeutic Goods Administration (TGA) published clinical guidance  regarding their use for a range of conditions. At the time of writing, more than 30,000 official approvals have been issued to allow patients to access to more than 100 different cannabis-based products including botanical material, oils and sprays provided by government-approved manufacturers and distributors [6, 8, 9]. Special Access Scheme (SAS-B) approvals cover a wide range of conditions but by far the largest category is chronic pain [10, 11]. Any medical practitioner can apply to the TGA under SAS-B for a product to treat an individual patient. Upon approval, cannabis-based products (developed under good manufacturing practice conditions) are dispensed to patients at pharmacies licensed to hold scheduled medicines. Given that the medical cannabis is an unregistered medicine, it is not subsidised by the government via the Pharmaceutical Benefits Scheme (PBS) or private health insurance schemes, and hence the patient must bear the cost of the medication which can be significant in some cases (typically $5–15 per day) [8, 12, 13].
Immediately prior to the legislative changes allowing access, our research group conducted an online consumer survey (‘Cannabis as Medicine Survey 2016’ or CAMS-16) of Australians who had indicated use of a cannabis-based product (either legally or illegally) for the management of a health condition in the preceding 12 months . The vast majority of respondents at the time were illicitly sourcing cannabis plant matter, with smoking being the preferred route of administration. Only one respondent reported accessing medical cannabis on prescription. Mental health, chronic pain and sleep conditions were the most frequently cited reasons for medical cannabis use. Respondents generally reported high levels of clinical effectiveness, but also reported significant levels of, mostly minor, side effects.
Here, we report the results of a follow-up survey conducted approximately 2 years after the introduction of the 2016 legislative changes. The aim of the 2-year follow-up survey was to monitor changes in how Australians were accessing and using their medical cannabis following the 2016 legislative changes and the emergence, in the wake of these changes, of a more established medical cannabis environment, with increased community discussion and media attention and clearer federal guidelines to doctors around prescription and use of medical cannabis. The CAMS-18 survey, which recruited during the last quarter of 2018 and first quarter of 2019, involved many of the same questions as CAMS-16 to enable general comparisons to be made of consumer experiences over time, but also included refinement of various sections including extra questions regarding composition of cannabis products and perceptions of legal prescription cannabis models of access and care.
As with the CAMS-16 survey, the term ‘medical cannabis’ used in this paper refers to the term as understood by lay people—any licit or illicit cannabis-based product (including plant matter) used to treat or alleviate the symptoms of a self-identified health condition. This does not imply that the cannabis product was indicated or prescribed by a health professional.
The study used a cross-sectional online survey design with a convenience sample of individuals self-reporting the use of cannabis for therapeutic reasons within the past 12 months. The study was approved by the University of Sydney Human Research Ethics Committee (2018/544). Survey questions examined the following areas:
- (a)Medical conditions for which respondents reported using medical cannabis
- (b)Current and lifetime patterns of medical and non-medical cannabis use, including source, route of administration, average frequency and cost
- (c)Perceived benefits and harms associated with medical cannabis use, including side effects (symptom checklist); social and legal implications; and Patient Global Impression of Change (PGIC) , a 7-item patient-reported rating of symptom change
- (d)The cannabinoid profile that respondents thought they were using (options of tetrahydrocannabinol (THC), cannabidiol (CBD) and THC:CBD combinations)
- (e)Perspectives on accessing licit medical cannabis products—including the experiences of those who had accessed legally prescribed products, and reasons for not accessing prescribed products for respondents using only illicit products
The full CAMS-18 survey is included in online supplement 1.
Study data were collected and managed using Research Electronic Data Capture (REDCap), a secure web-based platform allowing respondents to directly enter responses online .
The CAMS-18 survey was freely accessible to any person who was supplied with the survey URL. The survey was ‘live’ online for 6 months (September 2018 to March 2019), and was promoted online using social media and consumer group webpages, and at consumer and professional forums. Eligibility criteria were (a) informed consent, (b) aged ≥ 18 years, (c) self-identified as a user of cannabis or a cannabinoid product for a medical purpose within the previous 12 months and (d) resident in Australia.
Statistical analyses were performed in R version 3.4.1  using the tidyverse , effsize , vector generalized linear and additive models (VGAM)  and rcompanion  packages. Only valid responses were analysed, with no imputation of missing data. As the number of valid responses varied across different items in the survey, categorical variable frequencies will be reported alongside the number of valid responses.
Differences between the CAMS-16 and CAMS-18 surveys were tested for several key variables, using independent samples t tests for continuous variables, chi-squared tests of independence for categorical variables and negative binomial regression for count variables. Where categorical variables had many levels, these levels were collapsed into fewer levels to aid interpretation of the chi-squared tests. Hedge’s g effects sizes were calculated for t tests (with rules of thumb: g < 0.2 = negligible, 0.2–0.5 = small, 0.5–0.8 = medium and g ≥ 0.8 = large) and Cramer’s V for chi-squared tests (rules of thumb: V < 0.1 = negligible, 0.1–0.3 = small, 0.3–0.5 = medium, V ≥ 0.5 large) [21, 22]. Due to the large sample sizes in both surveys, even very small differences between CAMS-16 and CAMS-18 were highly significant. Therefore, the results of statistical tests will be reported briefly in-text quoting effect size statistics only, with full details supplied in online supplement 2.
Patient and public involvement
The CAMS-16 survey was extensively piloted with medical cannabis users through cooperation with cannabis user organisations across Australia. CAMS-16 item selection and survey design was thus heavily informed by consumer feedback. CAMS-18 was based on CAMS-16, with minor changes, and was piloted with a group of consumers reporting medical cannabis use for user-acceptance and ease of understanding of the questionnaire.
Of the 1804 respondents who commenced the survey, 184 did not meet eligibility criteria, and 192 did not give consent. Data were excluded for 70 respondents who provided no further information beyond demographics questions, three respondents who indicated that none of their cannabis use was for medical purposes and seven who provided implausible responses to numerous questions. Of the remaining 1388 respondents, 909 (65%) completed the entire survey.
Most respondents became aware of the survey via social media: 336/1387 (24.2%) through Facebook, and 838/1387 (59.5%) through other social media (e.g. Instagram, Twitter, Snapchat, Reddit, Whirlpool, Bluelight). Others were recruited through friends (4.7%, 65/1387), medical cannabis providers (1.8%, 25/1387), the website for the Lambert Initiative of Cannabinoid Therapeutics, a philanthropically funded research centre at the University of Sydney (1.7%, 23/1387), consumer groups (0.9%, 13/1387), traditional media (TV, radio, newspaper) (0.8%, 11/1387), doctors/healthcare providers (1.0%, 8/1387), cannabis access clinics (0.4%, 6/1387) and ‘other’ sources (4.5%, 62/1387). The proportion of respondents recruited through Facebook in CAMS-18 was much lower than in CAMS-16, and the proportion through other social media was much higher (V = 0.65).
Respondents’ characteristics are reported in Table 1. Respondents’ mean (± standard deviation) age was 43.4 ± 13.9 years and the majority were male (57.6%, 799/1387). Most respondents were employed (59.2%, 821/1387) and had attained either a trade/vocational certificate or a university degree (78.7%, 1092/1387). Compared to the CAMS-16 cohort, the CAMS-18 cohort were older and had proportionally greater numbers who (i) were female, (ii) were in a relationship and (iii) had a tertiary qualification; however, these demographic differences were small (g < 0.50 or V < 0.30) except for education level where there was a medium-sized effect (V = 0.30).
Lifetime cannabis use history indicated that 19.1% (212/1109) had never used cannabis prior to using it for medical reasons, 35.7% (396/1109) reported previous non-medical cannabis use but had quit for 12 months or more prior to initiating medical cannabis use and 45.2% (501/1109) were using cannabis non-medically at the time they began using it medically. The proportion of respondents who had never used cannabis prior to using it for medical reasons was similar in both CAMS-16 and CAMS-18 (V = 0.07).
The mean estimated proportion of cannabis use for medical purposes (as a proportion of total use) was 83.2 ± 20.6% (Table 2). Respondents reported using medical cannabis on a median of 18 days in the past 28 days (IQR = 4, 28; mean = 15.8 ± 11.2).
Most respondents consumed their cannabis via an inhaled (71.4%; 788/1104) route (compared with oral [26.5%, 293/1104] or other [2.1%, 23/1104] routes); however, there was a stronger preference for oral or vaporised routes of administration over traditional smoked routes such as joints, pipes or bongs (Fig. 1). Compared to CAMS-16, a lower proportion of respondents in CAMS-18 indicated that they consumed and would prefer to consume their medical cannabis by inhalation, and a greater proportion indicated they consumed and would prefer to consume their medical cannabis orally; however, this effect was small (V = 0.15).
Compared to the CAMS-16 cohort, CAMS-18 respondents tended to (i) have started using cannabis later and used less cannabis for either medical or other reasons, and (ii) use a greater percentage of cannabis for medical purposes compared to non-medical purposes; however, these differences were all small to negligible (all g < 0.50).
Composition of medical cannabis
Respondents reported they either did not know the composition of their cannabis (25.8%, 284/1103) or that it varied significantly between batches (23.9%, 264/1103). Further, 16.4% (181/1103) reported that their medical cannabis contained approximately equal levels of THC and CBD, 21.3% (235/1103) reported that it contained predominately THC (with either no, or small amounts of other cannabinoids), 12.2% (135/1103) reported that it contained predominately CBD and 0.4% (4/1103) reported ‘other’. Most (63.4%, 699/1105) were concerned about the possibility of contaminants (e.g. heavy metals, pesticides) in their cannabis.
Conditions treated with medical cannabis
Respondents were asked to select from a structured list, up to five health conditions (‘Any condition’ column, Table 3), and the main condition that they had treated using medical cannabis. The categories most commonly endorsed for ‘Any condition’ were insomnia (41.5%, 573/1382), back pain (34.5%, 477/1382), anxiety (32.6%, 450/1382) and depression (27.9%, 386/1382). The most frequent main conditions were anxiety (12.6%, 168/1331), back pain (10.1%, 135/1331), depression (8.5%, 113/1331) and insomnia (7.1%, 94/1331).
The proportions of respondents who reported pain, mental health/substance use, sleep or other conditions as the main conditions they treated with MC were very similar across both CAMS-16 and CAMS-18 surveys (V = 0.06).
Patient reports of symptoms being managed, effectiveness, side-effects and other adverse consequences
The symptoms that respondents reported being most often managed with medical cannabis mirrored the main conditions being treated (above section): pain (48.0%, 666/1388), anxiety (44.0%, 611/1388) and sleep problems (31.3%, 434/1388). The overwhelming majority of respondents reported symptom improvement following medical cannabis use (Fig. 2).
Side effects were commonly reported (Table 4), although relatively few reported these to be severe and/or intolerable. The most common mild and tolerable side effects were dry mouth (61.5%, 601/977), increased appetite (59.2%, 578/976), drowsiness (54.7%, 534/976) and eye irritation (30.2%, 294/974). The most common severe and/or intolerable side-effects were increased appetite (4.8%, 47/976), anxiety (2.4%, 23/974), dry mouth (2.4%, 23/977) and lack of energy or fatigue (2.1%, 20/973).
Almost half the respondents (47.6%, 448/942) indicated that the cost of medical cannabis placed a significant strain on their finances, 79.7% (751/942) worried about being arrested or other legal problems and 37.5% (353/942) were worried about employment issues. Further, 9.3% of respondents (88/942) reported that they had to undergo workplace drug testing.
Accessing medical cannabis
When asked to list their main source of supply, 46.2% of respondents (482/1044) indicated that they obtained their medical cannabis from ‘recreational dealers’, 25.3% (264/1044) from friends or family, 11.6% (121/1044) by growing their own, 7.2% (75/1044) from illicit medicinal cannabis suppliers, 5.1% (53/1044) from online suppliers and 4.7% (49/1044) from ‘other’ sources. Only 2.4% of respondents (25/1044) indicated they had accessed licit medical cannabis prescribed by a doctor. These proportions were very similar to the proportions observed in the CAMS-16 survey (V = 0.14).
When asked why they had not accessed medical cannabis legally, 47.8% (433/906) of respondents indicated they did not know a medical practitioner willing to prescribe, 32.0% (290/906) were not aware they could access medical cannabis legally, 21.2% (192/906) indicated licit cannabis was too expensive, 18.4% (167/906) believed their medical practitioner was not interested or unwilling to prescribe cannabis, 12.7% (115/906) indicated they wanted their medical cannabis use to remain confidential from their healthcare providers, 9.5% (86/906) said they preferred illicit cannabis and 11.6% (105/906) gave other reasons.
One-quarter (26.2%, 289/1101) reported not paying for their cannabis, but indicated they were willing to pay a weekly mean (± SD) of AUD$38.33 ± 63.92 (median AUD$25, IQR: $10, $50) for prescribed products. Those respondents who did pay for cannabis estimated spending AUD$82.27 ± 101.27 per week (median $50, IQR: $20, $100; $12.24 less than respondents in CAMS-16, g = 0.13), and indicated that they were willing to pay AUD$68.67 ± 66.64 (median $50, IQR: $25, $100) for prescribed cannabis products.
Seeking information about medical cannabis
When asked about their decision to try medical cannabis, most (51.5%, 523/1015) indicated that they discovered the benefits on their own (using cannabis and noticed symptoms improved), 10.5% (107/1015) reported internet-based media (e.g. Facebook, Reddit), 9.9% (100/1015) by a friend or family member, 6.5% (66/1015) by a medical cannabis advocacy group, 5.6% (57/1015) by a disease-specific consumer group, 5.0% (51/1015) by a healthcare provider and the remainder (10.9%, 111/1015) from other sources.
Although the initial interest in medical cannabis was generated by sources other than health professionals, most respondents (63.2%, 641/1015) had discussed their medical cannabis use with a healthcare provider, including their GP (83.6%, 536/641), medical specialist (54.3%, 348/641), psychologist (40.0%, 256/641), nurse (17.5%, 112/641), alternative medicine provider (17.2%, 110/641) and pharmacist (12.9%, 83/641).
Accessing medically prescribed medical cannabis products
The 25 respondents who had accessed prescribed medical cannabis products had been accessing it for an average of 4.8 ± 3.8 months (median 3, IQR: 2, 6), prescribed by a medical specialist (64%; 16) or GP (36%, 9) for indications including fibromyalgia, multiple sclerosis, neuropathy, epilepsy, autism, Alzheimer’s, mesothelioma, post-traumatic stress disorder and back pain. Respondents estimated 18 ± 22.5 weeks (median 12, IQR: 4, 25) between their first cannabis-specific consultation with their doctor and receiving their first dose of medical cannabis. Although the numbers were too small to draw any firm conclusions, feedback from the 25 respondents who had accessed medical cannabis legally indicated generally positive ratings of their experience of product consistency (17 [68%] preferred licit supplies, 6 [24%] preferred illicit supplies, 2 [8%] no preference), ease of access (15 [60%] preferred licit to 7 [28%] illicit), cost (11 [44%] preferred licit to 8 [32%] illicit), effectiveness (11 [44%] preferred licit to 6 [24%] illicit), fewer side effects (13 [52%] preferred licit to 5 [20%] illicit) and legal status (20 [80%] preferred licit to 2 [8%] illicit).
Attitudes to regulation of medical cannabis
Most respondents (78.3%, 721/921) indicated that people should be able to buy and use medical cannabis without approval by a medical practitioner, 92% (850) that medical cannabis should be part of routine healthcare in Australia, 70.7% (652) that the government should subsidise the cost of medical cannabis and 91.1% (839) that medical cannabis should meet safety standards (e.g. known strength, composition and contaminant-free). Most thought that the Australian regulatory framework for accessing medical cannabis did not work well (91.0%, 838/921), that the cost of licit medical cannabis was prohibitively expensive (62.6%, 577/921) and that the current model was difficult for patients to negotiate (87.3%, 804/921).
This survey provides a number of insights into medical cannabis use within the Australian community and updates our understanding of how consumer perspectives and behaviour have changed since the introduction of legal access pathways in November 2016. In many respects, little has changed in the 2 years since cannabis was legalised for medicinal purposes in Australia: users are still largely accessing illicit cannabis, self-medicating a similar range of health conditions (chronic pain, mental health and sleep problems), with similar perceived levels of effectiveness, side effects, social and legal issues reported. The findings that pain and mental health conditions remain the most common reasons for medical cannabis use and the generally high level of perceived efficacy is consistent with similar surveys of patients in jurisdictions with more established legal medical cannabis markets (e.g. Canada and various US states) [23,24,25,26,27,28].
The current survey recruited a slightly older and more educated cohort than CAMS-16. Respondents reported using cannabis on fewer days in the past 4 weeks and spent less per week on their medical cannabis than in CAMS-16; however, overall differences in patterns of use, conditions treated and attitudes of respondents between the two surveys are minor. CAMS-18 had slightly different recruitment strategies to CAMS-16, recruiting less from Facebook and more from Twitter, in part due to recent restrictions on advertising using the term ‘cannabis’ on Facebook. It is therefore difficult to know whether the small differences in key demographics and outcomes reflect a changing profile of Australian medical cannabis users or differences in the respondents sampled.
There is little in the current survey results to suggest that 2 years of legal medical cannabis access in Australia has transformed the ‘landscape’ of medical cannabis. The vast majority of respondents had not used the legal avenues available for prescription, with many respondents perceiving difficulties in finding medical practitioners willing to prescribe, and/or citing cost and stigma as barriers. Whilst few study respondents (n = 25) had accessed legal medical cannabis, those that had generally had more favourable perceptions regarding the legal form of the drug than those who had only ever used illicit forms. Interestingly, the small number of respondents who accessed legal medical cannabis tended to prefer it to illicit cannabis for its cost and ease of access. However, cost and ease of access were both endorsed as important barriers to accessing licit medical cannabis by respondents who had never obtained medical cannabis legally. This suggests that the barriers to licit use may involve a mistaken perception amongst illicit users (perhaps due to continuing public expressions of scepticism surrounding medical cannabis by some sectors of the medical profession and cannabis advocacy groups [29, 30]), rather than being the result of actual experiences following committed attempts to obtain access through legal channels. However, it should also be noted that as cannabis is currently an unregistered, unsubsidised medicine, patients must pay out of their own pocket for medications. Until medical cannabis products are licensed as medicines with the TGA, and subsidised under the Australian Pharmaceutical Benefits Scheme, it seems likely that the cost of unlicensed cannabis-based products will continue to force many people to source their medical cannabis illicitly , especially those on low incomes.
The predominant use of illicit sources of cannabis is consistent with the relatively limited number of official approvals under the TGA SAS-B at the time the survey was conducted. In the 6 months prior to September 2018, when the CAMS-18 survey opened, fewer than 1200 SAS-B approvals had been granted across Australia, and approximately 3000 approvals were granted during the study recruitment period (September 2018 to March 2019). Notably, however, in the 6-month period following the close of the CAMS-18 survey in March 2019, a further 13,000 approvals were issued  and total approvals as of January 2020 were around 30,000, involving more than 18,000 patients [6, 9]. Future CAMS surveys will attempt to explore this significant expansion in regulatory approvals and the impact upon medical cannabis consumers.
Our findings identify ongoing concerns regarding illicit supplies. As would be predicted with illicit products, there was scant knowledge of the composition of the products being used with regard to cannabinoid content (e.g. THC, CBD). This represents a fundamental issue given that the two cannabinoids have very distinct clinical indications and therapeutic effects. Specifically, CBD-only products having no intoxicating or euphorogenic properties, and when dosed appropriately have demonstrated efficacy in treating epilepsy, anxiety and psychosis [31, 32]. Even for those who thought they knew the composition of their cannabis products, it is worth noting that there is essentially no capacity for consumers to determine the strength or composition of illicit cannabis products in Australia, with no ability for laboratory testing of illicit cannabis products. In a previous study by our group, there was considerable discrepancy between perceived and actual cannabinoid profiles of illicit cannabis supplies used for children with epilepsy . Similarly, almost two-thirds of respondents were worried about potential contaminants. Even in US states with long-established legal medical cannabis markets, recent studies suggest a disconcertingly high prevalence of inaccurately labelled cannabinoid products with significant over- and under-representation of THC and CBD content on products labels [34, 35]. Another health concern with legal medicinal cannabis products in these jurisdictions is the widespread use of ‘cannabis concentrates’ made using butane solvents and designed for ‘dabbing’ (vaporisation of a highly concentrated extract). This exposes the user to a highly potent THC levels (as high as 76%), and may also contain residual solvent . Concerns around artisanal medical cannabis vaporisation products were also raised with recent reports of lung injury caused by vaporisation of contaminated illicit cannabis-based products in e-cigarettes [36, 37]. Clearly, these are not ideal conditions for any therapeutic intervention in a modern healthcare system.
Nonetheless, the move away from smoking (joints, bongs) to non-smoked cannabis-based products (vaporised cannabis, oral products) remains a positive trend in the current survey relative to CAMS-16, and is a trend that is evident in other countries [38,39,40,41]. In one recent survey of medical cannabis patients in Canada, most patients not only reported vaporisation as their primary route of administration but also indicated a preference for non-smoked routes over smoked routes . Whilst, as noted above, vaporising does carry associated health concerns, the vaporisation of cannabis plant material is at least preferable to smoking, as the lower temperatures avoid production of the many toxic pyrolysis products that occurs when plant material is burned in joints or bongs.
Demand for medical cannabis products does not seem to be abating. The experience of consumers surveyed here suggests minimal uptake of licit and prescribed products during the first 2 years of official access in Australia, although there are indications that this is changing. The marked increase in SAS approvals since the close of this survey signals improved access to medical providers willing to engage in this area of medicine with more than 14,000 medical practitioners in Australia having now prescribed cannabis . This has coincided with the emergence of a number of private clinics specialising in medicinal cannabis, which appears to have markedly simplified access to medicinal cannabis products for many patients. Recent surveys of Australian GPs  and specialists [43, 44] indicate that many medical practitioners feel relatively under-educated regarding this area of clinical practice. Over half of psychiatrists (54%) and GPs surveyed (57%) supported the availability of medical cannabis on prescription; however, a majority of GPs (52%) felt uncomfortable discussing medical cannabis with their patients, with over two-thirds of GPs reporting that they did not have good knowledge around medical cannabis. Lack of perceived knowledge on the topic is a common barrier for medical practitioners globally [42, 45,46,47], highlighting a need for improved training of medical practitioners around medical cannabis. Finally, whilst most respondents in our survey continued to express disappointment with the legal models of medical cannabis availability, those who had actually pursued the licit avenue reported quite positive experiences.
The study design has inherent limitations, as described in our previous CAMS-16 survey . The reliance on self-report data is potentially associated with inaccurate information, such as incorrect diagnostic conditions, recall difficulties, or misinterpretation of effectiveness or adverse events. Furthermore, there is always likely to be a selection bias in any such survey towards recruiting people with favourable experiences of medical cannabis and cannabis legalisation generally. Whilst we were able to reduce the amount of missing data compared to the CAMS-16 survey, we acknowledge that valid responses to all questions were only available for 65% of respondents. Finally, the fact that CAMS-18 was recruited from a slightly different group of people to CAMS-16 makes it difficult to be sure whether the small differences in experiences relayed by the two cohorts were the result of changes in the medical cannabis landscape or simply differences in demographics.
Our survey reflects the experiences of consumers during the first 2 years following major regulatory changes permitting medical cannabis access to patients in Australia. The early experiences of the small numbers of patients who had accessed legally prescribed products appear positive, although there remain many negative perceptions of access pathways amongst the vast majority of consumers who are not yet accessing these pathways. It remains to be seen how many of the individuals using illicit cannabis products for medical reasons legally will transfer to legally prescribed products over time. Until some form of medicinal-grade cannabinoid product is added to the list of medications subsidised by government (e.g. the Pharmaceutical Benefits Scheme) or private insurance schemes, cost seems likely to remain a significant barrier to widespread use of licit medical cannabis. Another potential concern is the many individuals who reported using medical cannabis for conditions for which there is little evidence [31, 48, 49] and no clinical guidance (e.g. management of anxiety). Given that many in the community are already using illicitly-obtained cannabis to treat their anxiety, depression and insomnia, there is an urgent need for more clinical trials to investigate the effectiveness of cannabis products for these conditions.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on request.
- Australian Dollars
- Cannabis as Medicine Survey 2016
- Cannabis as Medicine Survey 2018
- Patient Global Impression of Change
- Pharmaceutical Benefits Scheme
- Research Electronic Data Capture
- Special Access Scheme
- Therapeutic Goods Administration
- Vector generalized linear and additive models
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We would like to acknowledge the important contribution of Associate Professor David Allsop to the creation of the original CAMS-16 questionnaire, upon which the CAMS-18 questionnaire was based. It seems not even death can curb Dave’s research output.
This research was supported by the University of Sydney Division of Addiction Medicine, Faculty of Medicine and Health; and the Lambert Initiative for Cannabinoid Therapeutics, a not for profit philanthropically funded research program at the University of Sydney. It received no specific grant from any funding agency in the public or commercial, or sectors.
Ethics approval and consent to participate
This study was approved by the Sydney University Human Research ethics Committee (2018/544). In order to begin the survey participants were asked to read a linked Participant Information Statement and to tick a check box giving consent for their data to be used in the study.
Consent for publication
Dr. Lintzeris reports grants from the Australian National Health and Medical Research Council (NHMRC) during the conduct of the study; grants from Camurus, personal fees from Indivior and personal fees from Mundipharma unrelated to the submitted work; and, being the Clinical Director of the Lambert Initiative in Cannabinoid Therapeutics at University of Sydney from 2015 to 2017, was involved in a number of other studies of medical cannabis unrelated to the submitted work. Dr McGregor reports grants from NHMRC and grants from Lambert Initiative for Cannabinoid Therapeutics during the conduct of the study for projects unrelated to the submitted work; Dr McGregor is a consultant to Kinoxis Therapeutics and has received speaking fees from Janssen. He reports patents to WO2018107216A1, WO2017004674A1 and WO2011038451A1 issued and licensed, and patents to AU2017904438, AU2017904072 and AU2018901971 pending. Dr Arnold reports grants from the NHMRC and the Lambert Initiative for Cannabinoid Therapeutics. He reports patents pending AU2017904072 and AU2018901971. No other authors report conflicts of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Jay-Z announces new line of cannabis products dubbed Monogram
Rapper and entrepreneur Jay-Z is launching his own cannabis brand in partnership with Caliva, the California-based weed company that hired the star as its chief brand strategist last year.
Named Monogram, Jay-Z’s line of marijuana products launched its website and social media accounts on Friday.
“Monogram marks a new chapter in cannabis defined by dignity, care and consistency. It is a collective effort to bring you the best, and a humble pursuit to discover what the best truly means,” Monogram’s website highlights.
No further information on the specific products that will be sold under the Monogram brand has been released yet.
However, according to the website, the flower used in Monogram’s products is grown in small batches, with a board of “cannabis experts” tasked with grading and hand-selecting each flower that goes into the line.
The New York rapper joined Caliva in 2019 as a brand strategist, which entailed overseeing the creative direction of the company. Furthermore, Jay was focused on Caliva’s social equity efforts as he aimed to increase economic participation of people disproportionately harmed by marijuana prohibition in the newly legal industry.
As for when consumers can expect to try Jay-Z new products, a spokesperson told the New York Daily News Monogram still hasn’t set its dispensary release schedule. The line will “definitely be available across all of California,” according to the spokesperson.
In other news, basketball star Shawn Kemp who played for the Seattle SuperSonics is also showing his love of pot. Kemp is set to open Seattle’s first black-owned marijuana dispensary this Friday. The Sonics legend named his dispensary Shawn Kemp’s Cannabis and is hoping to serve as a model for others in the black community who might be interested in foraying into the legal marijuana business in the area.
“I’m looking forward to welcoming Sonics fans on a regular basis, starting with opening day. I hope that Shawn Kemp’s Cannabis will be an inspiration for people to get involved with the legal cannabis industry, especially people of color,” the Reign Man said in a press release.
Analysis: Legal weed in Texas would generate over $500 million in tax revenue per year
Legalizing marijuana in Texas could generate over half a billion dollars in tax revenue per year and create more than 40,000 new jobs, according to the results of a report released by Vicente Sederberg LLP earlier this month.
Legal cannabis sales in Texas would reach about $2.7 billion annually based on the fact that there are more than 1.5 million residents over the age of 21 that consume pot on a monthly basis, the analysis calculated.
The estimated tax revenue was calculated under the assumption Texas would tax marijuana sales at the same rate as Colorado at 20.6%. This would amount to $1.1 billion in taxes per biennium, while Texas could collect an additional $10 million per year through the issuing of marijuana business licenses.
The report notes Colorado has raised nearly $13 million on average per year just from license and application fees. Furthermore, the report indicated that current taxpayer dollars that go towards marijuana arrests and prosecutions amount to $311 million per year – money that Texas would save should it legalize pot.
“States across the country are seeing the benefits of legalizing and regulating cannabis. It is inspiring lawmakers in prohibition states to reexamine the efficacy and costs of their current policies and take a closer look at the alternatives,” said Shawn Hauser, a partner at Vicente Sederberg.
“The goal of this report is to provide a snapshot of the economic benefits Texas would experience if it started treating cannabis more like alcohol for adults 21 years of age and older,” he commented on the new report.
Aside from the tax revenue that legal weed in Texas could generate, the report highlighted marijuana’s job creation potential. An estimated 20,000 to 40,000 new jobs would be available in the newly legal industry, with tens of thousands of additional indirect positions, the report estimated.
Hauser also pointed out the added economic benefits of legalization in Texas given current uncertainties provoked by the coronavirus pandemic.
“Texas is leaving an enormous amount of money on the table by keeping cannabis illegal,” according to him.
Texas was once known for having the strictest drug laws in the U.S., but the state has softened its stance on cannabis in recent years. A very limited medical marijuana program was established in 2015, while, more recently, cannabis possession arrests in the state have been significantly declining after hemp became legal.
Cannabis Businesses Invest in Their Futures with Political Donations
Cannabis companies have been making political donations for years, and in 2020, those donations have continued to grow. In fact, some companies are investing aggressively to shape the future of the cannabis industry either by donating directly to campaigns and politicians or through political action committees (PACs) that support cannabis-friendly candidates and legislation.
So far in 2020, the Center for Responsive Politics reports that the leading cannabis companies, cannabis-related companies, and cannabis trade associations making donations to federal candidates, parties, and outside groups are (in order of 2020 donation amounts to date):
- Canty Ventures
- National Cannabis Industry Association (NCIA)
- Have A Heart
- Beyond Broadway LLC
- Sea Hunter Therapeutics
- Cannabis Trade Federation
- Dan Kopp & Co
- Acreage Holdings
Compare that list to the list of large cannabis company donors in 2019, which included Curaleaf, Parallel Brands (formerly Surterra Wellness), Tweed Inc. (part of Canopy Growth Corporation), Canndescent, and Trulieve. Even ancillary cannabis companies like Dama Financial, WeedMaps, and Acreage Holdings donate large sums of money in 2019 according to data from the Center for Responsive Politics.
State Donations in 2020
There are a number of legalization (adult-use and/or medical use) and decriminalization measures on state ballots in 2020, and cannabis companies, ancillary companies, and professional associations have been actively donating directly to related campaigns and initiatives at the state level.
In Arizona, Harvest is the biggest donor in support of legalization (Prop. 207) followed by Curaleaf, MedMen, Cresco Labs, Copperstate Farms, Arizona Dispensaries Association, Herbal Wellness Center, and Oasis Dispensaries.
Mississippi’s medical marijuana initiative on the November ballot (Initiative 65) has received donations from the CEO of Heritage Properties (George Walker III), Ghost Management Group (which owns Weedmaps), and the owner of ABKO Labs (Robert Lloyde II).
Ghost Management Group and its Weedmaps subsidiary also donated to support Montana’s and New Jersey’s legalization initiatives. In addition, New Jersey’s legalization Question 1 on the November ballot received donations directly from The Scotts Company (the maker of Scotts Miracle Gro), Pashman Stein Walder Hayden (a New Jersey cannabis law firm), and Compassionate Care Research Institute (a New Jersey dispensary).
Keep in mind, these donations don’t include the donations that cannabis companies and ancillary businesses donate to PACs or that they invest in lobbying. The Center for Responsive Politics reports that the biggest investments in lobbying from cannabis companies, ancillary companies, and trade associations in 2020 have come from the Cannabis Trade Federation, National Cannabis Roundtable, Canopy Growth Corp, Curaleaf, Global Alliance for Cannabis Commerce, Parallel Brands, Cronos Group, Charlotte’s Web, NCIA, Acreage Holdings, Dama Financial, Trulieve, California Cannabis Association, and Oregon Cannabis Association.
Political Donations from Cannabis Interests Are Not New
One of the biggest political donation stories happened in California when cannabis businesses donated aggressively to former Lieutenant Governor Gavin Newsom’s campaign to become the state’s governor in the 2018 election. According to the Los Angeles Times, he secured hundreds of thousands of dollars in donations from cannabis cultivators, processors, and retailers.
By May 2018, Newsom had raised nearly $500,000 from cannabis companies, but he wasn’t the only politician in California to receive money from cannabis interests. At the time, the state’s Treasurer, John Chiang, and Attorney General, Xavier Becerra, also secured donations from the cannabis industry
And of course, these donation numbers don’t even include the many donations from PACs that businesses and individuals working in the cannabis industry donate to. Many of these funds go directly to specific candidate’s fundraising efforts. For example, the Coastal Pacific Political Action Committee held a fundraiser in June 2017, and six days later, the PAC donated $50,000 to Newsom’s campaign.
Another noteworthy political donation happened in Florida over the course of multiple years. The Miami Herald reported that Surterra donated $1.1 million to Florida political candidates and committees between the summer of 2016 and March 2018. Trulieve donated $564,000 during the same period, and Curaleaf donated $469,000.
In Illinois, the doors for cannabis companies to make political donations opened in March 2017 when a federal judge ruled an Illinois provision that did not allow marijuana companies to make campaign contributions in the state was unconstitutional.
According to the Chicago Tribune, the provision prevented contributions to political committees that were established for the purpose of promoting candidates for public office. Since that decision was made, cannabis companies like PharmaCann and Cresco Labs have donated significant amounts to the state’s political candidates and committees.
Business and individual donations to marijuana-friendly political candidates have also become standard in Nevada and Colorado. During the 2016 elections, dozens of marijuana cultivators, processors, and dispensaries donated $75,000 to Nevada legislators according to the Nevada Independent.
Looking back further in history, Florida Senator Rob Bradley received his first donation from a cannabis company in 2015 when Costa Farms donated $10,000 to his political committee.
Similarly, cannabis businesses have actively contributed to Colorado political campaigns for years, and many of those businesses have been holding political fundraisers to support their preferred candidates. PBS reported back in 2014 that Colorado’s congressional delegation had received $20,000 during the first nine months of 2014 from marijuana businesses. Also in 2014, a fundraiser to support political candidates that was held by Tripp Keber of Denver, Colorado’s Dixie Elixirs & Edibles generated $40,000 in donations.
What’s Next for Political Campaign Donations from Cannabis Businesses?
As the cannabis industry continues to grow and more states legalize medical and/or recreational cannabis, laws will continue to evolve. Cannabis businesses and ancillary businesses should absolutely be concerned about which politicians are making those laws.
With that said, it’s safe to assume that political donations from the cannabis industry will get larger and more frequent in the coming years. Let’s put the donations from cannabis companies to political campaigns into perspective. During the first half of 2019, the cannabis industry gave more than $200,000 to members of Congress, which was up from $248,504 donated throughout all of 2018. Compare that to the $42 million that pharmaceutical companies donated to political campaigns across the United States in 2018.
With those numbers in mind, it’s guaranteed that political donations from cannabis and cannabis-related companies will continue to grow. Savvy businesses are paying attention and getting involved in an attempt to influence the regulations that could make or break their companies’ futures.
Originally published 8/24/17. Updated 10/23/20.
Susan Gunelius, Director of Email Marketing Strategy for Cannabiz Media, is also President & CEO of KeySplash Creative, Inc., a marketing communications company offering, copywriting, content marketing, email marketing, social media marketing, and strategic branding services. She spent the first half of her nearly 30-year career directing marketing programs for AT&T and HSBC. Today, her clients include household brands like Citigroup, Cox Communications, Intuit, and more as well as small businesses around the world. She has been working with clients in the cannabis industry since 2015. Susan has written 11 marketing-related books, including the highly popular Ultimate Guide to Email Marketing for Business, Content Marketing for Dummies, 30-Minute Social Media Marketing, Kick-ass Copywriting in 10 Easy Steps, and she is a popular marketing and branding keynote speaker. She is also a Certified Career Coach and Founder and Editor in Chief of Women on Business, an award-winning blog for business women. Susan holds a B.S. in marketing and an M.B.A in management and strategy.
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