Medical cannabis identity and public health paternalism

Abstract

Objectives

State-dependent and variable lists of medical conditions granting access to medical cannabis in the United States may be an example of public health paternalism. While purporting to ensure that medical use is clearly defined, the variability of approved conditions has created an atmosphere of ambiguity and medical precarity. The purpose of this study is to examine the relationship between “state” and “self” medical cannabis user identities and the ways non-medical users understand their cannabis consumption.

Study design

This is a mixed methods study consisting of semi-structured interviews and survey data.

Methods

In Phase 1, we examined the relationship between self and state-sanctioned cannabis identity, drawing on the 2022 New Frontier Data Consumer Survey of current cannabis consumers (N = 4682). In Phase 2, we conducted eight semi-structured interviews with a separate sample of adults who use cannabis regularly but do not consider themselves “medical consumers”.

Results

Self-reported cannabis identity was significantly related to the adoption of a cannabis consumer identity. Those who self-identified as solely medical or recreational consumers were more likely to reject the identity of “cannabis consumer” than those who identified as both. Self-medical identity was overshadowed by use for “wellness” among interviewees. Most interviewees, despite not identifying as medical users, report therapeutic benefit. Their identity as a cannabis consumer, is tied to the definition of “medical cannabis patient” where they live as well as the fluctuating role of cannabis related to their well-being across their lifespan.

Conclusions

The designation of medical vs. nonmedical use of cannabis varies from state to state, which is not the case for other medicine. This highly variable designation may be paternalistic in nature as governments attempt to differentiate between “legitimate” and “illegitimate” use in the context of federal cannabis prohibition. As a result, lines between medical use and wellness are blurred, which impacts consumer self-identity.

1. Introduction

1.1. Public health and paternalism

Public health programs are charged with maintaining a balance between societal harm and personal freedom. Paternalism is defined as “the policy or practice on the part of people in positions of authority of restricting the freedom and responsibilities of those subordinate to them in the subordinates' supposed best interest” [1]. When a public health policy is out of balance and personal freedoms infringed upon, paternalism is often involved. This is the case for women's health and also for substance use [2]. Regardless of potential or realized harm to self or others, drug possession and use is a crime. Those who create drug laws claim these laws are needed to protect us from ourselves, a common theme in paternalism. For those looking to use illicit drugs for wellness, paternalistic policies around drug use intersect with those around medical autonomy and the right to use plant medicines [3]. The purpose of this study was to examine the relationship between medical cannabis identity and the imposition of public health paternalism regarding access to medical cannabis in the United States.

When policies are paternalistic in nature and simply an output from the powers that be based on personal beliefs about harm, they often appear arbitrary and without logic. A good example is state level medical cannabis laws that approve use for a limited list of conditions, regardless of what a doctor recommends. A person may be a legal patient in one state and a criminal in another simply because of the specific medical condition they are trying to treat. This can create identity confusion among people whose therapeutic cannabis use is sanctioned by some states and outlawed by others, even if their own doctor feels that their use is beneficial.

Just over 35% of the US adult population reported using cannabis in 2021 and 74% of the adult population live in one of the 39 states that allow some type of access to cannabis for medical reasons [4]. Among those states, eight do not limit the conditions for which cannabis can be obtained, and 24 have a finite list of conditions and a process for adding additional conditions which is often burdensome and lengthy [5]. Lack of standardization across states can leave patient access dependent on geography and “medicalization” ill defined [6]. Boehnke et al. found that although over 85% of qualifying conditions reported by patients in state registries had significant research evidence to support the use of medical cannabis, others had little to no evidence and for some, cannabis was contraindicated. This highlights that qualifying conditions may not be tied to actual medical efficacy. It is also possible that some conditions with medical efficacy are not on the list. Boehnke and colleagues posit that this is because the Schedule 1 status of cannabis makes clinical trials difficult, and the government has traditionally only funded research on the harms of cannabis and not its therapeutic benefits [7]. These biases create a paternalistic system where authorities make rules about access to health care based on their own agenda. Furthermore, Zolotov et al. found that physicians themselves often have inaccurate information around the use of cannabis as medicine and are impacted by their personal biases [8]. Lack of knowledge from authorities and inconsistent evidence based policies around medical cannabis access along with bias and stigmatized identity might impact a cannabis user's intention and outcome by not having accurate information, feeling afraid to seek out information, and be subject to a system of approval that does not mirror the scientific evidence on cannabis as a medicine. It should also be noted that due to public misperceptions about cannabis and a lack of information about the science on cannabis for various medical conditions, this act of paternalism may not be intentional. Indeed, those creating the laws may be reacting to the will of their constituencies and their belief systems about what is valid medical use. Concerns about public health harm and its relationship to cannabis use.

1.1.1. Cannabis use and intention

People who use cannabis as a medicine and those who use it as a recreational drug were previously considered mutually exclusive groups. However, as access to cannabis increases and stigma decreases, dual intentionality is becoming common. Fifty five percent of consumers report using cannabis for both medical and recreational purposes [4]. Furthermore, the top reason consumers report for using cannabis is relaxation, but the second through fifth reasons are all therapeutic (pain, anxiety, stress, and sleep). Sixty eight percent of consumers report that their cannabis use serves a specific purpose [4]. Askew and Williams examined enhancement substance use (i.e., using a substance for self improvement) and found three distinct intentions: transformation, healing, and productivity [9]. The commonality of dual use shows that these intentions can be met inside and outside of a state medical cannabis program. Indeed, when a state opens up adult use access, the number of cannabis patients declines [10]. Intentions are unlikely different, but they are able to be met outside of the medical framework.

1.1.2. The formation of cannabis identity

How people identify themselves among the population of cannabis consumers is impacted by both set and setting: the specific purpose for using cannabis, along with the social environment impact how consumers view their use and intentions. Identity can also impact the form in which cannabis is consumed. Forty one percent of those who consider their use “medical only” consume only non-flower products like tinctures and edibles. This is compared to sixteen percent of “recreational only” consumers [4]. The cognitive dissonance between identifying as a medical only consumer and smoking cannabis flower might influence the decision to purchase products that appear more therapeutic and less recreational, as might a doctor recommending non-smoked methods due to their own beliefs and knowledge about cigarette smoking. For those becoming medical cannabis patients in a stigmatized environment, reluctance to identify as medical cannabis consumer may delay medical treatment and result in a conscious effort by medical consumers to disassociate from the culture of “recreational use” and feel hypervigilant about appearing as a non-consumer [11].

Eighty one percent of cannabis consumers say that cannabis has had a positive impact on their life, with men and those aged 18–34 most likely to say that cannabis was an important part of their identity [4]. However, Blevins et al. found that, for emerging adults (mean age 21 years old), having cannabis as part of their identity was associated with higher rates of use, more related problems from use, and less desire to reduce their use [12]. This shows that identity as a cannabis consumer might be related to consumption patterns and products chosen.

1.1.3. Medicinal, therapeutic or recreational?

Many treatments that fall outside of the western medical paradigm or those that can produce pleasure in addition to medical benefit are touted as “recreational” or “alternative”. Massage therapy, psychedelic assisted therapy, medicinal cannabis, and sound healing all fall into this category. The inability to accept that medicine can be fun, taste good, or produce euphoria can impact how a person views their own quest for health. A pill from a doctor's office may encourage “medical use” identity more than a trip to the massage therapist. This phenomena can be observed in the perceived identity of those who consume heroin vs. those who consume pharmaceutical opiates [13]. Additionally, the process of medicalization itself shifts the locus of control onto the medical profession and into their culture and protocols. In the case of cannabis, as early cannabis policy saw use shift from criminalization to medicalization, the stigma shifted from cannabis consumers as dangerous criminals to sick people. Both stereotypes bring assumptions about morality and mental capacity [14]. The objective of this study is to examine the relationship between “state” and “self” medical cannabis user identities and the ways non-medical users understand their cannabis consumption to explore how state defined medical use is experienced by those using cannabis for both medical and non-medical purposes.

2. Methods

In order to examine both the relationship between state sanctioned medical cannabis status and identity, we conducted a secondary data analysis of the 2021 Cannabis Consumer Survey administered by New Frontier Data. To examine the process of forming of cannabis consumer identity, we followed a mixed methods explanatory sequential design using a two phased approach in which survey data from cannabis consumers was first collected and then we conducted semi-structured interviews with a subsample of survey respondents to help explain the survey findings [15]. Chi-Square tests were used to explore the relationship between state sanctioned medical cannabis identity and self-described identity. Themes related to identity from the interviews were identified by each of the three authors independently and then compared to find areas of agreement and disagreement.

2.1. Phase 1

New Frontier Data designed and conducted an online survey in 2022 to assess cannabis consumer attitudes, perceptions, and consumption across legal and unregulated markets in the United States. Survey themes included: cannabis use, purchasing behavior and decision influencers, product preferences and expenditures, beliefs about cannabis, and other consumption behaviors and self-identity. Self-identity was determined by asking respondents to identify themselves as “only medical”, “primarily medical”, “primarily recreational”, or “only recreational” consumers. Consumer was defined as someone who has used cannabis in the past and plans on using cannabis again. State-identity was determined via a question asking respondents who live in a state where medical cannabis is allowed if they currently hold a medical cannabis card in their state, have ever held a card, or have never had a card.

2.2. Sampling

New Frontier Data used quota sampling to draw a demographically representative sample of the adult population in the United States (See Appendix A for full sampling method and table). Full Circle Insights performed the data collection. Potential participants were contacted from an existing pool of potential participants who were recruited via phone. The potential participants were then sent the survey online. Potential participants were targeted to fulfill the need for a census comparable sample and compensated with an Amazon gift card. Potential participants were screened for cannabis consumption. Certain portions of the survey were only administered to a subsample of participants. Analyses were conducted among 4682 cannabis consumers – respondents who indicated that they consumed cannabis in the past, and will consume it again, as well as 1250 non consumers. The survey was conducted between January and March 2022.

2.3. Analyses

We used SPSS to examine differences between self-identified medical consumers and state-identified medical consumers by examining descriptive statistics and conducting Chi-Square tests.

2.4. Phase 2

We conducted semi-structured interviews with eight current cannabis consumers who consume at least four times per week but do not consider themselves medical cannabis consumers. Our interviews focused on the participants’ cannabis use across their lifespan and how they formed their identity as a cannabis consumer. Interviews ranged in length from 10 to 52 min with an average of 24 min. In order to protect the identity of interview participants, we use pseudonyms to reference each of our interviewees.

2.5. Sampling

We recruited eligible interview participants from respondents to an online cannabis lifestyle survey administered by Cannigma, an educational cannabis platform, in 2020. Participation was anonymous, voluntary, and non compensated. We reviewed Cannigma survey results (N = 356) and invited participants to participate in follow-up interviews if they met the following criteria:

• ●They reported using cannabis four or more times per week
• ●They did not identify as a medical consumer
• ●They indicated a willingness to be contacted for further questions and left their contact information.

We sent eligible participants (N = 15) an email invitation from Cannigma with a link to sign up for an hour long interview. Of the 10 survey respondents who agreed to be interviewed, eight completed interviews and two did not show up. We conducted all interviews via Zoom and then transcribed the interviews to identify key themes.

2.6. Analyses

We reviewed and coded the interview transcriptions independently following a grounded theory approach with a focus on how interviewees described their own cannabis use across the lifespan and the ways in which they navigated access and their own identities as cannabis users. Once we independently coded the interview transcripts for these themes, we then compared our observations in order to elucidate nuances in interviewee experiences.

3. Results

3.1. Phase 1: survey results

3.1.1. Cannabis consumer identity

As can be seen in Table 1, state patient status is significantly related to self-identity. As expected, respondent self-identity as either a medical or recreational cannabis user is significantly related to their state-defined identity as a medical cannabis patient, former patient, or never a patient, χ² (6, 4682) = 652.79, p < .001. About 70% of current medical cannabis patients consider their use only or mostly medical compared to 28% of participants who have never been medical cannabis patients.

Table 1.

Relationship between self-identity (rows) and state-identity (columns).

	Current Patient	Former Patient	Never Patient
Only Medical	28.6% (238)	11.3% (30)	9.8% (218)
Mostly Medical	40.3% (335)	44.0% (117)	18.3% (407)
Mostly Recreational	24.2% (201)	35.3% (94)	25.2% (562)
Only Recreational	6.9% (57)	9.4% (25)	46.8% (1043)
Total	100% (831)	100% (266)	100% (2230)

Self-identity is significantly related to market type, χ² (6, 4682) = 40.21, p < .001 as shown in Table 2. Medical consumers are overrepresented in medical only states and underrepresented in other markets, reinforcing their identity in relation to what is permitted where they live.

Table 2.

Relationship between market type and self-identity.

Market Type	Only medical	Primarily medical	Primarily rec	Only rec
Adult Use	44% (295)	45.5% (548)	50.1% (600)	50.9% (820)
Medical Only	31.8% (213)	28.8% (347)	24% (287)	21% (339)
Illicit	24.2% (162)	25.7% (309)	25.9% (310)	28.1% (452)
Total	100% (670)	100% (1204)	100% (1197)	100% (1611)

3.1.2. Cannabis use and identity

Table 3 shows that those who identify as only medical or only recreational consumers were significantly more likely to reject cannabis as an important part of their identity compared to those who use it for both medical and recreational purposes, χ² (6, 1019) = 57.43 (p < .001). Primarily recreational consumers were most likely to say that using cannabis was an important part of their identity (36.3%).

Table 3.

Relationship between self-Identity and cannabis identity.

Using cannabis is an important part of my identity	Only medical	Primarily medical	Primarily rec	Only rec
Agree	26% (44)	27.8% (72)	36.3% (94)	17.5% (58)
Neither agree nor disagree	28.4% (48)	44% (114)	39.8% (103)	35.5% (118)
Disagree	45.6% (77)	28.2% (73)	23.9% (62)	47% (156)
Total	100% (169)	100% (259)	100% (259)	100% (332)

When considering state sanctioned identity, consumers who were current card carrying patients were significantly more likely than former and never patients to see their consumption as an important part of their identity χ² (6, 760) = 64.93 (p < .01) as shown in Table 4. Forty six percent of current patients compared to 31% and 18% of former patients and those who were never patients, respectively, agreed that their cannabis use was an important aspect of their identity.

Table 4.

Relationship between state-Identity and cannabis identity.

Using cannabis is an important part of my identity	Current patient	Former Patient	Never patient
Agree	45.5% (85)	31.1% (19)	17.5% (83)
Neither agree nor disagree	32.6% (61)	44.3% (27)	38.4% (182)
Disagree	21.9% (41)	24.6% (15)	44.1% (209)
Total	100% (187)	100% (61)	100% (474)

3.2. Finite vs. unlimited conditions and card obtainment

Those who live in states with finite lists of conditions are significantly less likely to say they have obtained a medical cannabis card than those living in states with unlimited conditions (21.8% vs. 27.2%) χ² (3, 3180) = 15.23 (p < .001).

3.3. Phase 2: interview findings

3.3.1. Sample characteristics

Our eight interviewees ranged in age from 35 to 66 years old, with a mean of 54.3 years, and first used cannabis between the age of 12 and 32, with a mean age of initiation of 17.6 years. Most of our interviewees were female (n = 5) and white (n = 6). Interviewees resided in places that, at the time of the interviews, provided legal access to medical cannabis (Illinois, Mexico, Michigan, New York, Washington) and those that prohibited medical access (Kentucky). Although all interviewees indicated they did not consider themselves medical cannabis users in the Cannigma survey, five identified specific mental health conditions for which they used cannabis (e.g., anxiety, depression, eating disorder, or PTSD). Other interviewees reported that cannabis was a substitute for prescription drug use (n = 4) and alcohol consumption (n = 3), and all but two reported also using prescription medications. Interviewees reported using between 1 and 9 medications with a mean of 4. Most of our interviewees preferred flower (n = 6) and five reported preferring cannabis with a high THC content. Our interviewees were regular users of cannabis, with all but one reporting daily use, and half reporting using multiple times per day. The most commonly reported recreational and therapeutic motivations for using cannabis were, respectively, its relaxation benefits (n = 7) and as a sleep aid (n = 7). Finally, when asked about how they incorporated cannabis use into their daily lives, all but one interviewee made reference to how it contributes to their overall well-being.

3.3.2. Theme 1: context of use (initiation, geography, knowledge)

Initiation and development as a cannabis consumer from early experiences.

The average age of cannabis initiation is 15 for boys and 16 for girls [16]. Early experiences with cannabis have the potential to shape future identities as was described by our participants.

All of our interviewees framed their reasons for first using cannabis as recreationally rather than medically motivated. For most of the interviewees, their first introduction to cannabis occurred in their teens, and many described initiating use of cannabis while in social situations where they faced peer pressure to consume, sought social acceptance, or because it was generally normative in their social environment. For example, Phyllis began using cannabis socially as a teenager with her sisters and friends and described her experiences with cannabis as an adolescent in this way:

“It was just high school kids getting stoned. Partying and drinking were always involved at friends' houses, just doing stupid high school kid stuff. We'd get high and get drunk and whatever.”

Carolyn described her early introduction around age 12 as “a cool thing to do. I grew up in a small town and that's kind of what everybody did.” Sean shared a similar motivation, stating his first use as a 17 year old was necessary if he wanted to “be cool” and “It was one of those things that at the time was a little bit of peer pressure, because it was the 70s and that's what you did.”

For some interviewees, their initiation with cannabis was associated with positive experiences and fun. Wendy shared that she began using cannabis when she was 15 after seeing her stepmom and brother have positive experiences with cannabis and reflected, “Man, they look like they're happy.”

3.3.3. Access to and framing of informational resources on cannabis

Reliable and easily accessible information about cannabis was difficult to obtain during prohibition and before the advent of the internet. Learned experiences from cannabis in a consumer's personal environment often served as the source of information about the plant and its effects.

As Becker observed, one has to not only learn from wise others how to consume cannabis but also how to evaluate its effects as desirable [17]. For our interviewees who initiated cannabis use predominantly in their teens, the information they received about cannabis, if any, was from their peers and was focused on recreation rather than the potential medical applications of cannabis. Information obtained from public health messaging focused on the potential harms of cannabis. Tom noted that when trying cannabis for the first time, he was unaware of what he was using or how to consume it. He lacked information about cannabis other than the stigma that existed.

Even as adults, many of the interviewees struggled to find information they could trust about cannabis use. Although he first tried cannabis in his early 20s, Scott associated his real introduction to cannabis with its accessibility after he moved from New York to Seattle at the age of 32.

“It wasn't really until I had a chance to go in, talk to budtenders and understand more about the actual effects, about what cannabis can provide, about its benefits, and just really getting that one-on-on education that dispelled a lot of the myths that have built up over time.”

3.3.4. Geography: impact of legal status on medical use

If geography is understood as the “setting” in which cannabis use might occur, we can see how legal context shapes cannabis identity [18]. The legal context impacts decisions to talk to healthcare providers, as well as the sources from where cannabis is obtained. Though it is well-established that drug use disclosure to health professionals varies by legal context, the consequences of withholding drug use information are less well-understood [[19], [20], [21]].

Interviewees living in states where cannabis remains illegal shared that they were hesitant to discuss their use with medical providers. For example, Wendy is asthmatic and reported using dabs and edibles because “it helps me breathe better … because it calms me down.” However, Wendy has not shared her cannabis use with her doctor saying, “He'd probably just lecture me, because it's not legal here …”

Some interviewees reported that they sought out reliable sources in states where cannabis has been legalized for adult use. Other interviewees obtained cannabis from family or friends participating in medical cannabis programs in other states. For example, Maddie lives in a state with no legal supply of cannabis and obtains her cannabis from a licensed medical grower in another state with a legal medical cannabis industry. She reported feeling confident in the safety of the product she uses.

3.3.5. Theme 2: medical motivations among recreational users

While all of our interviewees were invited to participate precisely because they did not consider themselves medical users, most, if not all, articulated they were using cannabis to address distinct medical conditions, such as sleep, pain, depression, anxiety, stress, PTSD, and/or ADHD.

Wendy described her ongoing use of cannabis in terms of the effects she reported experiencing as a result of her cannabis use: “I wasn't sad all the time and depressed, and I was just happy and calm and more relaxed.” She shared that she also uses cannabis to help her sleep. Scott reported that he uses cannabis to help with insomnia, anxiety, and depression. For example, Scott shared that he is on “some very powerful antidepressants” yet “being able to utilize cannabis … a lot of the stresses of the world would just go away, depending on what strain I was using.”

3.3.6. Well-being as a motivation for non-medical identified use

Relaxation is the top reason reported for cannabis use in the general consumer population [4]. A broad term, relaxation can cover everything from a reduction in anxiety to an overall feeling of well-being and lack of stress.

In addition to discussing the ways in which their cannabis use addressed specific medical conditions, some of our interviewees described the general therapeutic benefits they experienced from cannabis and how it served as a vehicle for mind and body wellness as well as a means to enhance other activities. All but one interviewee expressed the belief that cannabis improved their overall well-being. Though therapeutic is typically used to describe “the treatment of disease or disorders by remedial agents or methods,” often medicinal in nature, we use the term to reference actions or agents that have “a beneficial effect on the body or mind” or produce “a useful or favorable result or effect” [22].

For example, Carolyn described how she believes cannabis enhances her focus while exercising as well as relaxes her breathing and muscles while stretching:

“I do find that I can tune into my muscles and really focus on where I need to stretch and find that internal place … I don't get the same range of motion [without cannabis]. There's no two ways about it. I don't get the same release, and in fact, everything feels more restricted. My breathing feels more restricted, the muscles themselves feel more restricted. I can't seem to connect.”

Scott described how his cannabis use has generally improved his quality of life by relaxing him and consequently preventing the onset of anxiety or depression he might typically experience as a result of stress:

“I am a generally happier person … say for instance, if I'm on a particular strain, it can have individual effects, but I also think that I am a happier, more relaxed person even when I'm not on cannabis, because cannabis is an option for me. I think just having it as an option, knowing that if need be, I can just walk into the other room and take five minutes out of my day, smoke and everything calms down, it takes a lot of the pressure off your day and puts it into perspective. My anxiety, my depression, a lot of the stress that I was feeling, would often snowball into anxiety and depressive episodes, because there wouldn't be that possibility of alleviation at the end of the day.”

As someone who now works in special education, Sean finds that cannabis also helps him maintain balance in his interactions with students, as he has a greater appreciation for their individuality:

“It helps me deal with kids nowadays, because I’m like, ‘You do you. You do you, and you do you really well, so just keep on going.’”

3.4. Substitution - recreational and recreational drugs

Over half of cannabis consumers (51%) report reducing at least some of their alcohol intake by substituting cannabis, and 57% of medical consumers report replacing at least one pharmaceutical drug with cannabis [4].

Some of our interviewees explained their use of cannabis in terms of it providing a healthier alternative to alcohol as a recreational drug. For others, cannabis was used instead of or in conjunction with pharmaceutical medications and was seen as a safer option with less side effects.

While alcohol consumption in most societies is the primary legal option for generating a drug induced, altered state of consciousness, some of our interviewees described the deleterious effects their alcohol consumption was having on their own physical health and social relationships and their decision to use cannabis instead [23]. Carolyn reflected upon how her decision to begin using cannabis regularly instead of alcohol was tied to her overall life wellness practices:

“I’m an avid weightlifter, and my second career now is I'm a personal trainer and nutritionist … I decided that alcohol wasn't really doing me any favors in terms of my health, my gut microbiome, my recovery for weightlifting, etc. Even though I will still have an occasional drink, I'll have either tequila or wine, but my husband and I were like, ‘We should start smoking weed again. It’s just natural … ’”

Sean described having legal access to cannabis during the pandemic as critical to his well-being in relation to saving him from excessive alcohol consumption:

“I can sit there and say marijuana saved my life with the pandemic, because Illinois went legal on the 1st of January 2020. I was in education, so if I had to sequester at home for 7–8 months without some kind of self-help—I kind of want to say that it saved me from becoming a drunk again.”

Sean shared that cannabis provided a far safer outlet than drinking, especially since he'd come to the point where he was “committing suicide on alcohol.”

“I realized at that point that this [cannabis] was a totally different outlet than drinking. I was more in control. I could still have a good time, and I was a sloppy drunk. To me, it was a nice alternative … Will I go back to drinking? Probably not. I am 9 years sober, sobriety agrees with me, my life is in a really good place right now, but part of it has been because I was able to rely upon cannabis instead of reverting back [to alcohol].

Scott also described his preference for cannabis over alcoholic beverages, despite it making him feel like the “the black sheep of the family”:

“There are other options available to me like wine, beer, alcoholic beverages in their forms. I'm not a huge fan of those, because of the impact it has on the liver and on your mood. Yes, cannabis does as well, but I find that dependent on the strain, it is more of a mood enhancer as opposed to, say, wine.

Many interviewees described using cannabis as a substitute for other medications. Sean found cannabis to be an alternative medication to the pharmaceuticals he had been prescribed and was concerned about becoming addicted to. While Sean found Ativan or Lorazepam effective, which was prescribed to him for his panic attacks associated with working with “highly special needs kids,” he'd need another dose after 8 h or experience a “bad crash.” Fearing he was shifting “from being an alcoholic to being a drug addict”, he began using cannabis.

Wendy explained how cannabis can enhance the effect of other medications, sharing that she takes an antidepressant in addition to her cannabis use: “I just started my Lexapro again a couple of days ago, on top of smoking … The SSRIs were helping, and I was finding happiness again, but when I would smoke and take them, it was just like a heightened happiness and calm.”

Maddie also offered that as a result of her use of cannabis, she has stopped taking ibuprofen and muscle relaxers, uses fewer pain pills, and ceased taking prescription sleep medications. Though Scott acknowledged that he used antidepressants, she finds cannabis to be “a healthy alternative” given the side effects he's experienced from prescription medications:

“I use cannabis because I find that a lot of the other methods that society uses to combat a lot of these issues—creativity, pressure, and anxiety, etc.— some of them I don’t want to use, and some of them I've just wanted to stay away from because of past experience. So for instance, I do use antidepressants as a way to combat depression and anxiety, but that has significant side effects.”

3.4.1. Use of medical language and the placebo effect

One of the possible impacts of varying lists of accepted medical conditions for which cannabis can be accessed, is confusion over what is “medical”? Language around the use of cannabis for medical purposes may appear incompatible in states where that use is not considered valid and consequently consumers may broaden their own views of therapeutic benefits.

All interviewees used words typically associated with recreational cannabis use, such as stoned and high. It is noteworthy as well that even though interviewees did not explicitly state they were non-medical users, many also explained their motivation for using cannabis by drawing on language that referenced health conditions and well-being.

Several interviewees referred to the cannabis they consumed as medicine. Carolyn shared, “my own medicine seems to fit me and allows me to have that feeling time and time again.” Even Tom, who discussed his cannabis use in almost exclusively recreational terms, stated that cannabis is a “powerful medicine” that people “take for a reason.”

Additionally, some interviewees described their use as “medicating”: Sean described his reasons for use “as a self-medicating kind of thing, to be honest with you.”

Interestingly, while interviewees noted the positive effects of cannabis on their health and well-being, some questioned whether they were real, highlighting their non-medical mindset.

For example, despite describing positive effects from cannabis on her physical recovery and sleep, Carolyn expressed uncertainty about if cannabis actually had an effect or whether it was a placebo, “Really thinking internally, because there's so much chatter about our body's ability to heal ourselves and regenerate and cellular regeneration and the intention of our own mind to make that happen, it has to be a thing, I think. Even if it's not a thing, and if it's just a placebo, isn't that a thing, too? The placebo effect? That's where my mind goes in terms of this.

Echoing Carolyn, Scott described his own convictions regarding its psychoactive effects, while postulating that such effects may be psychosomatic:

“It brings me a sense of calmness, serenity, and I'm not even high right now, but I can still feel the effect, psychosomatically. I know that’s probably a placebo effect. In some way, my brain is saying it’s mine, but when I am really stressed, it gives me a bit of a placebo to cool down.”

While most of our interviewees clearly described their cannabis use in relation to medical or therapeutic narratives, only Tom really interrogated cultural norms against recreational cannabis use. Tom described his cannabis use in this way:

“… it was just something we started as sort of a fun recreational thing to do. People don't like that term, but I think it's an okay term, because it was recreational to us. It was something to have fun doing, we were enjoying ourselves while doing it. You're recreating. I don’t understand why people have such a big problem with this word, recreational. People want to rewrite the whole language of cannabis these days. There’s nothing wrong with the word.”

4. Discussion

Data on cannabis consumers show that when given the option of self-identification beyond the dichotomy of medical vs. recreational, more than half (52%) of consumers identify as using for both medical and recreational purposes [4]. For many, cannabis consumer identity is not mutually exclusive. A strict dichotomy of medical or recreational identity may result in muddled patient identities and confusion over whether use can be considered medical or therapeutic.

Self-reported cannabis identity is significantly related to both state-identity (whether they hold a medical cannabis card) and state market type. Because the consumer does not control their qualification for a state-sanctioned medical cannabis card or their state market type, it can be hypothesized that these variables influence self-identity and not the other way around. People who define themselves as either strictly medical or strictly recreational consumers were the most likely to reject cannabis as an important part of their identity. These groups also consume less cannabis than those who identify with both groups [4]. However, when looking at state-identity, medical cannabis card holders were more likely to accept cannabis as an important part of their identity than former or those who were never card holders. This suggests that accepting a cannabis identity is related to the process of becoming a state-sanctioned medical cannabis patient. This acceptance may require overcoming stigma and using techniques like disclosure and identity formation to address internalized stigma [24].

The trajectory of identity formation expressed by the interview participants was also captured by Lankenau et al. in their work, “Becoming a Medical Marijuana User,” which highlighted that almost all users initially start with social experimentation, recognize the benefits at some point, and then decide to use it for medical purposes [25]. Today, over half of cannabis consumers report using for both medical and recreational purposes depending on intended outcome. The previously held belief that consumption was exclusively one or the other could account for some interviewees rejecting a medical identity because they had already settled on a recreational one. A large part of how substance use is perceived, (i.e., What is a drug and what is a medication and in what context?) is fluid over the life course [26]. To be a medical cannabis user may be as much about how one self-identifies as how one describes the specific contexts, motivations, and effects associated with use. Furthermore, the ability and decision to become a state-sanctioned patient is often based on factors like cost and acceptability, rather than truly defined medical need [27]. Depending on state laws, the ability to claim a medical cannabis identity might be impacted by whether such an identity allows free and open conversation with one's health care providers. In illicit markets, fear of repercussions from admitting use to a doctor might inhibit self-medical identity.

All interview participants, with the exception of one, vocalized their cannabis use in the context of therapy and well-being, even though none reported to be medical cannabis users. Their shared experience of using cannabis as a substitute for alcohol and pharmaceutical medications may further blur the line between recreational and medical, as alcohol is a recreational substance and pharmaceutical drugs are deemed medical. However, substituting for both can positively impact personal well-being, a goal that all of the interviewees embraced from their cannabis consumption. Also becoming blurred is the concept of “medication.” The use of the word “medicating” by interviewees to describe wellness-based cannabis use may suggest that the term has become untethered from its medical moorings. The use of “medicating” by our interviewees and in the general population to explain use of alcohol or other drugs to address sadness, disconnection, abusive circumstances, among other conditions COULD signal “medical use,” but could also simply be embedded in the everyday language of drug use.

5. Conclusion

Some have identified the ways in which the pursuit of an altered state of mind is not only a universal human desire, but it might also be referenced in the “pursuit of happiness” enshrined in the U.S. Declaration of Independence [13,28]. However, Protestant preoccupations with self-control, sobriety, and thrift within U.S. culture discourage drug consumption for purely recreational purposes [29]. The restrictions put in place in the form of approved conditions for medical cannabis use and general legal access have not resulted in clearly defining populations of those who need access to cannabis and those who do not. It is evident that the self-reported medical/recreational user identity does not always correlate with the state-sanctioned programs or legal market status. There are medical consumers in illicit markets and adult use markets. There are also medical consumers in medical only markets who are not able to become patients because of cost and/or have a medical need that does not align with the list of accepted conditions. Even those who reject the identity of “medical user” report positive experiences from cannabis, a contribution to their overall well-being, and the use of cannabis as a substitute for more harmful substances. This apparent tension between medical use and adopting a medical identity not only speaks to epistemological questions but also the challenges contemporary cannabis users face navigating the “post-prohibition” cultural, public health, and legal landscapes characterized by “legalization with, not after, prohibition” [30].

Ethics approval

The authors declare that they have obtained ethics approval from an appropriately constituted ethics committee/institutional review board where the research entailed animal or human participation. California Polytech, Humboldt IRB 21-077.

Funding sources

☒This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Amanda Reiman, PhD is the Chief Knowledge Officer for New Frontier Data where some of the data for this study were obtained. None of the other authors have a financial interest in a cannabis business.

Appendix A. Survey Sampling Design and Sampling Table

Data for the New Frontier Consumer Survey were collected by Full Circle. Full Circle maintains a Survey Roundtable of willing survey participants. Survey Roundtable invitations are transparent and provide as-needed information, including the generic nature of the survey topic. Information is given upfront about expectations regarding specifics such as survey length, how long the survey will be open, and incentive offers. Members must give Full Circle permission before taking any survey. An opportunity to unsubscribe from the panel is always included, as is a community feedback email address.

Regardless of sample source, panel members receive no more than eight invites a month. Full Circle also places moratoriums on participation in similar survey types or categories. Upon survey completion, respondents are asked to rate their experience satisfaction via a scale of 1–5 stars and are also offered the opportunity to provide more detailed feedback.

Full Circle's proprietary attention algorithm service, HoNoR, automatically creates an FC + Quality Score in real time for every member. This score is established via qualitative checks (i.e., analysis of open-end responses) and quantitative checks (i.e., answer selection formats). Full Circle's panelists must pass every one of our checks to proceed with any survey.

Every Survey Roundtable participant chooses surveys at their will via their account's Take A Survey page, which houses open surveys that match the information they provided in their SRT Profile. The surveys are identified by open/close dates, a generic title (i.e., Consumer Survey, Product Survey, Lifestyle Survey), a generic description (i.e., Share what you like and don't like; Take this survey any day of the week until spots fill up) and the number of SRT points they earn at completion.

The sample gathered for the New Frontier Data Consumer Survey is representative of the general population 21+ in the United States as compared to the most recently available Census data.

Sampling Table.

		Starts	Start %	Census %	Var.
Gender	Male	4093	48%	49%	−1%
	Female	4428	52%	51%	1%
	Non-Binary	0	0%
		8521
		Starts	Start %	Census %	Var.
Age	18 to 24	987	12%	12%	−1%
	25 to 34	1522	18%	18%	0%
	35 to 44	1412	17%	16%	0%
	45 to 54	1514	18%	17%	1%
	55 to 64	1457	17%	17%	0%
	65+	1629	19%	20%	−1%
		8521
		Starts	Start %	Census %	Var.
Region	Northeast	1504	18%	17%	1%
	Midwest	1800	21%	21%	0%
	South	3250	38%	38%	0%
	West	1967	23%	24%	−1%
		8521
		Starts	Start %	Census %	Var.
Income	Under $25k	1875	22%	21%	1%
	$25K to $49,999	1966	23%	23%	1%
	$50K to $74,999	1502	18%	18%	0%
	$75K to $99,999	976	11%	12%	−1%
	$100K to $149,999	1239	15%	14%	0%
	$150K	963	11%	12%	−1%
		8521
		Starts	Start %	Census %	Var.
Race	Asian, Pacific Islander, or Asian American	407	5%	7%	−2%
	Black or African American	1336	16%	15%	1%
	Native American or American Indian	113	1%	1%	0%
	White or Caucasian	6220	73%	74%	−1%
	Other	445	5%	3%	2%
		8521			0%
		Starts	Start %	Census %	Var.
Hispanic Origin	Hispanic, Spanish or Latino	1428	17%	18%	−1%
	Not Hispanic	7093	83%	82%	1%
		8521			0%