Medical Cannabis Use Patterns and Adverse Effects in Inflammatory Bowel Disease

Abstract

Goals:

To investigate medical cannabis (MC) use patterns and adverse effects in patients with inflammatory bowel disease (IBD).

Background:

MC is now legal in many states. Although previous studies suggest improvement in disease activity among IBD patients using MC, use patterns and adverse effects are unclear.

Study:

Cross-sectional anonymous survey conducted (October 23, 2020-January 24, 2021) among patients accessing MC dispensaries in New York and Minnesota. Eligibility criteria: age ≥18 years, self-reported IBD diagnosis, MC dispensary purchase. Survey questions included IBD characteristics, MC and healthcare utilization, MC effects/adverse events. Participant characteristics were analyzed with descriptive statistics. Utilization patterns and symptoms before and after MC use were compared using Stuart Maxwell test.

Results:

Of 236 respondents, overall IBD disease activity was mild-to-moderate. Most respondents (61.0%) took a biologic. Median frequency of MC use was at least once within the past week. Most respondents used products with high Δ9-tetrahydrocannabinol content (87.5%) via vape pen/cartridges (78.6%). Respondents reported less emergency room visits in the 12 months after vs. before MC use (35.2% vs 41.5%, p<0.01) and less impact of symptoms on daily life. Most respondents reported euphoria with MC use (75.4%). The other common side effects were feeling drowsy, groggy, or with memory lapses (4.2%), dry mouth/eyes (3.4%), and anxiety/depression or paranoia (3.4%).Few respondents reported MC diversion (1.3%).

Conclusions:

MC users with IBD perceive symptom benefit and report decreased emergency room visits without serious adverse effects. Further studies are needed to confirm these results with objective measures of healthcare utilization and disease activity.

INTRODUCTION

Inflammatory bowel disease (IBD) is estimated to affect 1.6 to 3.1 million Americans.^1–4 Management of IBD can be challenging with primary nonresponse to medical therapies as high as 30%.^5–7 Nonresponse to conventional therapies can lead to use of non-conventional therapies, such as cannabis. Medical cannabis is now legal in 37 states.^{8, 9} In 25 states, IBD is a qualifying condition.^{8, 9} Despite the rapid expansion of medical cannabis, few studies have examined medical cannabis use patterns and adverse effects among patients with IBD.

Cannabis use in any form is common among IBD patients. Single center and population-based surveys in the US report that 32–67% of IBD patients have used some form of cannabis for symptom control.^10–12 Perceived benefits of cannabis use among patients with IBD include improvement in pain, stool frequency, appetite, anxiety, and fatigue.¹⁰ Of IBD patients, those with Crohn’s disease (CD) and chronic pain are more likely to use cannabis.^{10, 11} Improvement in disease activity indices and a decreased need for other medications have been reported in a observational cohort study of IBD patients newly started on medical cannabis.¹³ In addition, a decreased prevalence of partial or total colectomy (4.4% vs 9.7%) and a shorter hospital length-of-stay (4.5 vs 5.7  days) in cannabis users with ulcerative colitis (UC) compared to nonusers has been reported.¹⁴

Cannabis is thought to ameliorate symptoms of IBD by modulating intestinal inflammation and reducing pain, although these effects are mostly limited to preclinical murine models of colitis.¹⁵ Clinical trials that have assessed the role of the two main cannabinoids among patients with IBD have shown mixed results. Four clinical trials reported minimal improvement in CD disease activity with cannabidiol (CBD),¹⁶ but consistent improvement with Δ9-tetrahydrocannabinol (THC).^17–19 Two other clinical trials of patients with UC reported similar findings with no difference in remission rates with CBD-rich products,¹³ but with improvement in clinical remission with THC-rich products.²⁰ Despite improvements in clinical symptoms, medical cannabis use has not been associated with a concomitant reduction in inflammatory markers or endoscopic remission.^{13, 20} This suggests that the mechanism of action of medical cannabis in IBD patients may include its psychotropic and analgesic effects.

THC and CBD are thought to influence pain perception in IBD in different ways. Because of its anti-inflammatory effects,²¹ CBD is thought to modulate pain by mediating intestinal inflammation, while THC is believed to ameliorate pain via its psychotropic properties.²² Although analgesic and anti-inflammatory effects of medical cannabis products appear to differ based on THC and CBD content, few studies have reported specific medical cannabis use patterns among IBD patients. One observational study reported a preference for higher CBD vs THC doses among medical cannabis users with IBD.¹³ Additionally, inhalation was identified as the preferred mode of consumption.¹³ However, patterns of medical cannabis use among IBD patients and the effect of medical cannabis use on healthcare utilization and adverse effects are not well documented. Because of the psychotropic effects of THC-predominant products, further assessment of adverse effects among patients who use high THC-containing products is critical.

Despite its analgesic effects, cannabis has potential harms, including misuse, diversion, and psychomotor and neurocognitive effects.^{10, 23, 24} Cannabis may confer additional risks in IBD patients, including exacerbation of disease activity resulting in escalation of IBD therapy, hospitalization, or surgery. Although some studies report cannabis to be a safe option for IBD,^{13, 16, 18} cannabis use has been associated with increased abdominal surgeries²⁵ and harmful effects on psychomotor and neurocognitive function.^{10, 24} Moreover, because of its analgesic effects, medical cannabis may mask ongoing inflammation and result in a false, perceived sense of improvement ultimately leading patients to discontinue or decrease the doses of their IBD medications. Despite the potential risks, few studies have assessed adverse events associated with medical cannabis use among IBD patients.

The overarching goal of this study was to investigate medical cannabis use patterns and adverse effects in patients with IBD.

MATERIALS AND METHODS

Study Design

We conducted a cross-sectional survey to determine characteristics of medical cannabis use among respondents with IBD. Participants were informed of the study objectives and risks and benefits of the survey and assured of anonymity. All participants provided informed consent prior to completion of the survey. As an incentive, participants were offered a gift card of $20.00 for their participation. This study was approved by the institutional review boards at both Albert Einstein College of Medicine/Montefiore Medical Center and the Renaissance School of Medicine at Stony Brook University.

Study Participants and Data Collection

The study setting was an online survey. Recruitment occurred via dissemination of an online survey link by a medical cannabis dispensary in both New York and Minnesota to all patients in their network who had previously purchased medical cannabis at one of their dispensary sites (New York 4 sites; Minnesota 8 sites). Survey responses were collected online from October 23, 2020 to January 24, 2021. Eligibility criteria included age of 18 years or older, a self-reported diagnosis of IBD, and purchase of medical cannabis from a medical cannabis dispensary at any point in time. Respondents who did not identify themselves as meeting all three of these criteria were excluded from participation.

Survey Instrument

The survey instrument included 75 questions (multiple choice, single chose, numeric, open ended) that examined the following domains: socio-demographics, IBD characteristics, IBD disease activity, pain severity, medical cannabis and non-medical cannabis utilization, healthcare utilization, effects of medical cannabis and adverse events (medical cannabis- and IBD-specific). All answers were self-reported by the participant.

Questions regarding characteristics of IBD included in the survey instrument were type of IBD (ulcerative colitis, Crohn’s disease, or indeterminate colitis), duration of IBD, presence of perianal and intra-abdominal fistulae and abscesses, prior and current medications used for treatment of IBD, and history of surgery. To determine IBD activity, participants with Crohn’s disease were directed to complete the Short Crohn’s Disease Activity Index,²⁶ while participants with ulcerative colitis were directed to complete the Simple Clinical Colitis Activity Index.²⁷ Those with indeterminate colitis completed both indices. Pain severity was determined using the Pain, Enjoyment of Life, and General Activity (PEG) scale, which is a validated measure for assessing chronic pain in primary care that assesses average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G).²⁸ Higher values indicate greater pain severity.

Participants were asked to answer questions as they pertained to both medical cannabis purchased at a cannabis dispensary and cannabis not purchased at a dispensary. General questions regarding duration, frequency, and formulation of cannabis not purchased at a dispensary were included. More detailed inquiry of medical cannabis use habits was performed, as described below.

Participants who reported purchasing medical cannabis from a medical cannabis dispensary within the prior 30 days were defined as active medical cannabis users, whereas those who had purchased medical cannabis from a medical cannabis dispensary in the past but not within the prior 30 days were defined as prior medical cannabis users. Active medical cannabis users were asked to record the name, formulation, and frequency of use of each medical cannabis product that they purchased in the prior 30 days with a maximum limit of 10 recorded products. A reference library generated by the investigators that included the THC and CBD content of every medical cannabis product available at participating medical cannabis dispensaries was then used to determine the proportion of THC and CBD content contained in each purchased product. The proportion of THC and CBD content was then used to categorize medical cannabis use in the prior 30 days as high THC content or other THC/CBD content. Specifically, these categories were defined as follows: the high THC content group included respondents who reported use of any medical cannabis product that contained predominantly THC (i.e., a higher proportion of THC vs CBD); the other THC/CBD content group included respondents who reported use of medical cannabis products that did not contain predominantly THC.

Survey respondents were asked to report on their healthcare utilization (gastroenterology and emergency room visits) in the period before compared to after initiating MC use. Additionally, they were asked to report on effects of medical cannabis use on gastrointestinal and non-gastrointestinal symptoms, including abdominal pain, diarrhea, nausea, poor appetite, fatigue, insomnia, and anxiety in the period before compared to after initiating MC.

Participants were asked about medical cannabis and IBD-specific adverse events including whether they had experienced any adverse effects and specifically whether medical cannabis use was associated with euphoria, medication non-adherence or self-de-escalation, diversion, and misuse.

Statistical Analyses

Descriptive statistics were used to analyze respondent and IBD-specific characteristics along with medical cannabis use patterns, frequency of use, formulations used, and associated adverse events. The Stuart Maxwell test was used to compare healthcare utilization patterns and symptoms respondents reported having before and after medical cannabis use.

RESULTS

Of the 296 respondents, 54 were ineligible and 6 were duplicates. Therefore, a total of 236 respondents who met eligibility and completed the survey were included in the analysis. The median age of respondents was 40 years, and 58.5% were female. (Table 1) Most respondents identified as White (80.1%) and non-Hispanic (92.0%). Of those who specified their IBD subtype, most had ulcerative colitis (44.9 %) followed by Crohn’s disease (32.9%) and indeterminate colitis (22.2%). Patient-reported clinical disease activity was in the mild-to-moderate range, and most respondents (61.0%) reported currently taking a biologic for their IBD. The median pain severity was reported as 6 out of 10.

Table 1.

Characteristics of Inflammatory Bowel Disease Patients Using Medical Cannabis

	Total N=236 (%)
Age, years†	40 (33,53)
Sex
Female	138 (58.5)
Race
Black/African American	13 (5.5)
White	189 (80.1)
Other	34 (14.4)
Ethnicity
Hispanic	19 (8.0)
Not Hispanic	217 (92.0)
IBD subtype ‡
Crohn’s disease	55 (32.9)
Ulcerative colitis	75 (44.9)
Indeterminate colitis	37 (22.2)
IBD duration, years†	9.2 (3,16)
History of IBD surgery
Total colectomy	10 (4.2)
Partial bowel resection	17 (7.2)
Other	17 (7.2)
SCDAI § †	165 (131,210)
SCCAI § †	5 (4,7)
Pain Assessment ¶ †	6 (3,8)
Current IBD Medications ●	184 (78.0)
Steroids	28 (11.9)
5-ASAs	30 (12.7)
Immunomodulators	15 (6.4)
Biologics	144 (61.0)
Health Insurance
Public (e.g. Medicaid or Medicare)	106 (44.9)
Any private	130 (55.1)
Marital Status
Married	94 (39.8)
Never married	85 (36.0)
Separated, divorced or widowed	57 (24.2)
Employment
Currently employed (full- or part-time)	147 (62.3)
Not employed (unemployed, retired, disabled)	74 (31.4)
Other	15 (6.4)
Tobacco Use
Ever (at least 100 cigarettes)	140 (59.3)
Current (every day or some days)	30 (12.7)
Last medical cannabis (MC) use
Same day as survey	121 (51.3)
Within 30 days	68 (28.8)
Within 30–365 days ago	37 (15.7)
Over 365 days ago	10 (4.2)
Active Users (MC use within past 30 days)	189 (80.1)
Last MC use (days) †	7 (2,90)
Number of MC products, last 30 days †	4 (3,7)
THC/CBD Content Δ
Any high THC	56 (87.5)
Other	8 (12.5)
MC formulations used ¶
Soft gel capsules	52 (23.6)
Capsules/tablets	106 (48.2)
Drops/oral solution/sublingual tincture	83 (37.7)
Lozenges	24 (10.9)
Oral spray	58 (26.4)
Powder	6 (2.7)
Suppositories	4 (1.8)
Vape pen/cartridges	173 (78.6)
Vaporization oil/bulk oil	80 (36.4)
Other	41 (18.6)
Asked IBD provider to certify for MC	118 (50.0)
Provider certifying MC
Pain management	106 (44.9)
Primary care provider	57 (24.1)
Gastroenterology	26 (11.0)
Other	69 (29.2)
Non-medical cannabis (NMC) use ever	140 (59.3)
NMC in last 30 days	54 (22.9)
Number of days NMC use in last 30days †	22 (10,30)

^†Median (interquartile range) |

^‡IBD subtype not specified, n=69 |

^§SCDAI, Short Crohn’s Disease Activity Index for patients with Crohn’s disease or indeterminate colitis (n=92); SCCAI, Simple Clinical Colitis Activity Index for patients with ulcerative colitis or indeterminate colitis (n=112)|

^¶Three-item scale assessing pain intensity and interference over the past week. Scores range from 0–10 with higher numbers indicating greater severity |

^●More than one medication could be selected. |

^ΔData available from 64 patients merging all products for which use was reported. High THC was defined as any use of product containing a higher proportion of THC vs CBD.

Median frequency of medical cannabis use was at least once within the past 7 days, and 80.0% of respondents used within the past 30 days. (Table 1) Most respondents used products with high THC content (87.5%). The most frequent routes of administration of medical cannabis were vape pen/cartridges (78.6%) or capsules/tablets (48.2%). Half of the respondents had asked their IBD provider to certify them for MC use. The provider ultimately certifying MC was most often a pain management specialist (44.9%) or a primary care provider (24.1%). Many respondents also reported using non-medical cannabis in the past 30 days (22.9%) for a median of 22 out of 30 days.

More respondents felt that MC always helped (57.6%) compared to those who felt that it sometimes (10.2%) or rarely (1.7%) helped. (Table 2) Most respondents reported some degree of euphoria with MC use (75.4%). The majority of respondents reported no other MC side effects (80.5%). Of those who did report side effects, the most commonly reported were feeling drowsy, groggy, or with memory lapses (4.2%), followed by having dry mouth/eyes (3.4%) or anxiety/depression or paranoia (3.4%). The remaining reported side effects were: headache, dizziness, cough, fatigue, increased appetite, and ear ringing. (Table 2)

Table 2.

Adverse Effects Among Inflammatory Bowel Disease Patients Using Medical Cannabis (MC)

	Total N=236 (%)
Experienced MC side effects †
No	190 (80.5)
Yes:	46 (19.5)
Drowsy, groggy, memory lapse	10 (4.2)
Dry mouth/eyes	8 (3.4)
Anxiety, depression, paranoia	8 (3.4)
Headache	4 (1.7)
Dizziness	3 (1.3)
Increased appetite	3 (1.3)
Cough	2 (0.8)
Fatigue	2 (0.8)
Ear ringing	2 (0.8)
Addiction	1 (0.4)
Experienced euphoria with MC use
Not at all	58 (24.6)
Somewhat	160 (67.8)
Very much	18 (7.6)
MC helps
Always	136 (57.6)
Mostly	72 (30.5)
Sometimes	24 (10.2)
Rarely	4 (1.7)
Since starting MC
Forgot to take IBD meds	26 (11.0)
Decreased/stopped IBD meds	101 (42.8)
How often IBD meds taken in last month (range 0–100%)‡	95 (60,100)
Remembered to take IBD medications in last 6 months
Always	163 (69.0)
Mostly	53 (22.5)
Sometimes	13 (5.5)
Rarely	7 (3.0)
In last 6 months †
Sold MC to others	3 (1.3)
Shared MC with others	6 (2.5)
Took more MC than instructed	26 (11.0)
Got high on MC	106 (44.9)
Took MC in ways other than prescribed	6 (2.5)
Did not take MC to use drugs or alcohol	6 (2.5)
Used drugs or alcohol on days took MC	42 (17.8)
Reaction to drugs or alcohol with MC	2 (0.9)

^†More than one option could be selected. |

^‡median (interquartile range), missing values n=115

Since starting to use MC, few respondents reported forgetting to take their IBD medications (11.0%). Less than half of respondents reported decreasing or stopping their IBD medications (42.8%) since starting to use MC. When asked how often over the past month respondents took their IBD medications, the median response was 95.0% of the time (interquartile range 60–100%). More respondents reported always remembering (69.0%) than rarely remembering (3.0%) to take their IBD medications over the preceding six months.

Few respondents reported diversion of their MC through selling (1.3%) or sharing (2.5%) with others or of MC misuse through taking more than instructed (11.0%) or taking in ways other than prescribed (2.5%). A number of respondents (17.8%) did report using drugs or alcohol on days that they used MC, although few reported experiencing an adverse reaction. (Table 2)

With respect to healthcare utilization, respondents were asked about the frequency of visits to their IBD provider in the period before compared to after MC use. The percentage of respondents reporting a visit at least or more often than every 6 months was significantly lower (59.3% vs. 40.3%, p< 0.01). The same trend was reported in the frequency of IBD-specific emergency room visits in the period before vs. after MC use. The percentage of respondents reporting an emergency room visit at least once every 6 months was significantly lower after vs. before MC use (35.2% vs. 41.5%, p< 0.01). (Figure 1) The percentage of all patient-reported symptoms having a moderate-to-major impact on daily life was significantly lower after vs. before MC use. (Figure 2) For instance, the percentage of respondents reporting a moderate-to-major impact on their life from abdominal pain and nausea was: 85.6% vs. 31.8% and 53.8% vs. 21.6%, respectively (p< 0.01).

Figure 1.

Emergency room visits for IBD evaluation before and after medical cannabis (MC) use.

*p < 0.01 for all comparisons

Figure 2.

Patient-reported symptoms before and after medical cannabis (MC) use.

*p <0.01 for all before-after comparisons.

DISCUSSION

Our study suggests that medical cannabis users with IBD perceive symptom benefit without experiencing serious adverse effects. Moreover, respondents reported a notable decrease in IBD-specific emergency room visits after initiating medical cannabis. We also found that IBD respondents who are actively using medical cannabis favor use of high THC products via inhaled routes. Importantly, we add to the existing literature with new data on adverse effects, including medication adherence and cannabis diversion and misuse among active medical cannabis users with IBD.

The IBD respondents included in our study were young with mild-to-moderate disease activity, and most were on biologics at the time of survey. Additionally, many of our respondents were active medical cannabis users, with 80% of respondents reporting cannabis use within the prior 30 days. Our cohort includes a unique group of respondents that has not been well-described in the literature. To date, the majority of cross-sectional and observational studies have queried IBD respondents on their use of any cannabis products in the past^{10, 19} without clearly differentiating between medical and recreational products.²⁹ Only one observational study has been published that has specifically assessed medical cannabis use patterns and adverse effects among active medical cannabis users. However, this study was conducted outside of the US, where use of medical cannabis may differ due to regulatory issues.¹³ Because of the rapid expansion of medical cannabis use in the US over the past decade, studying active medical cannabis users is critical to gain insight into medical cannabis use patterns and adverse effects among patients with IBD in order to assist providers in having informed discussions with their patients.

Similar to prior studies, we report inhalation as the preferred mode of consumption among active medical cannabis users with IBD.^{13, 19} This raises specific concern in IBD given the known potential harms of inhaled tobacco products among patients with Crohn’s disease. Further investigation is needed to determine the harms of inhaled cannabis in patients with IBD.

Of the respondents who did provide data on type of cannabis product used (27.1%), the majority of active medical cannabis users with IBD used high-THC containing products (87.5%). Limited data on specific medical cannabis use patterns in patients with IBD exist. One observational cohort study that assessed THC/CBD content among active medical cannabis users with IBD reported patient preference for higher doses of CBD despite the lack of psychotropic effects of these products.¹³ This observational cohort study was conducted in Israel while our study included only US patients, which may account for discordance between our results and underscores the need for additional studies that include geographically diverse groups in order to allow for generalizability of results.

We report an association between medical cannabis use and symptomatic improvement among respondents with IBD with specific improvement in abdominal pain, diarrhea, insomnia, anxiety, nausea, poor appetite, and fatigue. Our results are similar to prior observational studies^{10, 11, 13, 19, 29} and clinical trials^{16–18, 20, 24} that also report symptomatic improvement associated with cannabis use among patients with IBD. Additionally, in our cohort, patients reported fewer emergency room visits after starting medical cannabis than they did before taking medical cannabis (1 or more visit every 6 months: 10.6% vs 22.5%). Given the cross-sectional design, we are unable directly to attribute this change to medical cannabis use. However, this suggests that medical cannabis use may contribute to keeping patients feeling well and out of the emergency room.

In our study, the benefits of medical cannabis were experienced without concomitant self-reported serious adverse effects. Because of the psychotropic and analgesic effects of high THC-containing products, there has been great concern that medical cannabis can result in harms. Approximately 19.5% of our respondents did report at least one adverse effect associated with medical cannabis use; however, reported adverse effects were not serious. The most common side effects were feeling drowsy, groggy, or with memory lapses, followed by having dry mouth/eyes or anxiety/depression or paranoia. In a meta-analysis of 79 medical cannabis trials including 6,462 participants (none with IBD), side effects were common. However, similar to our study, serious adverse events were rare.³⁰ Most respondents in our study reported some degree of euphoria while taking medical cannabis (75.4%), and approximately 44.9% reported getting “high” from their medical cannabis. Despite these psychotropic effects, the majority of medical cannabis users in our cohort reported being employed, adherent to their IBD medications, and with few behaviors concerning for diversion or cannabis misuse. Approximately 17.8% of respondents reported using drugs or alcohol on the same days they took medical cannabis, which does warrant further investigation to provide insight into potential behaviors that could predispose to cannabis misuse. Similar to our study, one recently published observational cohort study did not find considerable adverse effects of medical cannabis use.¹³ This study reported stable employment and improvement in functional capacity without signs of addiction among medical cannabis users with IBD.¹³

Our study has many strengths including recruiting patients from a medical cannabis dispensary. As such, our cohort includes a group actively using medical cannabis. The data we report, therefore, truly reflect use patterns and adverse effects of active medical cannabis users with IBD. Additionally, a strength of our study is that we focused on both general and IBD-specific adverse effects of medical cannabis, which have been underreported.

We acknowledge this study also has several limitations, including the small sample size, cross-sectional study design, and predominantly White non-Hispanic population, which limits generalizability. Our respondent population was also limited to those who purchased medical cannabis from one company in New York and Minnesota. Respondents in this study are not necessarily representative of a general IBD population in which many individuals may not already use a MC dispensary. As a cross-sectional survey, a major limitation of this study is that all data were self-reported. Therefore, our findings need to be confirmed using objective measures as well as with a prospective study design that measures healthcare utilization and symptom change over time. Many respondents did not identify their IBD subtype, which prevented us from comparing medical cannabis use patterns and adverse effects between respondents with UC and Crohn’s disease. Co-morbid conditions, such as irritable bowel syndrome (IBS), were not surveyed in this study. Therefore, it is unclear whether patient-reported symptoms may have had overlapping etiologies with other conditions. Regardless of the underlying trigger of symptoms, however, this study suggests that individuals with IBD specifically ask their IBD provider to certify MC, and with use of MC, report significant GI-specific symptom improvement (e.g. abdominal pain, diarrhea, nausea). Finally, we asked respondents to provide the name of the medical cannabis products they were taking and used a reference library to accurately identify THC/CBD content of these products (rather than relying on respondents to provide details regarding the THC/CBD content of the medical cannabis products). However, many respondents did not report the name of the medical cannabis product they had purchased which limited our ability to make more inferences regarding THC and CBD use patterns in our cohort. This lack of response is itself useful, however, and should be further explored as it may suggest a lack of awareness regarding the medical cannabis products that patients are using.

In conclusion, our study reveals that medical cannabis users with IBD report symptom improvement and decreased emergency room visits following initiation of medical cannabis. We report that inhalation is the preferred mode of consumption of medical cannabis and that THC-predominant products are favored. Our study also suggests that adverse effects of medical cannabis were not severe, and that IBD medication non-adherence and cannabis diversion and misuse were uncommon. Future longitudinal studies are needed to assess variation in medical cannabis use patterns and adverse effects over time. Assessment of patient awareness regarding specific medical cannabis products used is also needed as this could present an opportunity for providers to better educate patients regarding the content and expected effects of the medical cannabis products they are using.