Abstract
Purpose:
Young adults experiencing chronic pain may self-medicate with cannabis. We examined perceived risks and benefits of cannabis use among young adult users by chronic pain status, and identified relationships among perceived risks and benefits, physical and mental health, and cannabis-related problems.
Methods:
Young adults reporting at least weekly cannabis use (N = 176, 50.9% with chronic pain) reported perceptions of lifetime risks and benefits associated with cannabis use, physical and mental health, and cannabis-related problems.
Results:
Young adults without chronic pain reported better physical and mental health than those with chronic pain. Cannabis use, problems, and risk and benefit perceptions did not differ by pain status. Risk and benefit perceptions were unrelated to physical health, perceiving fewer risks and more benefits was associated with better mental health, and perceiving more risk was associated with cannabis problems. Chronic pain status moderated the relationship between perceived benefits and outcomes, such that perceiving more benefits was associated with better physical health for those without chronic pain. Further, greater perceived benefits were associated with more cannabis-related problems for those without chronic pain but fewer problems for those with chronic pain.
Conclusion:
This study offers insight into the perceptions of risks and benefits among young adult cannabis users and associations with physical and mental health and cannabis-related problems. The effects of perceived benefits on physical health and cannabis-related problems differs for young adults with and without pain, suggesting assessment and consideration of pain status may be valuable in intervention contexts.
Keywords: Cannabis, young adults, chronic pain, risks, benefits, physical health, mental health
Introduction
Cannabis is associated with negative and positive health outcomes (Cousijn et al., 2018). Although cannabis may mitigate pain experiences (Haroutounian et al., 2016), daily use predicts poorer mental health (Lev-Ran et al., 2012) and more cannabis-related problems (e.g., withdrawal symptoms) for people with persistent pain (Perron et al., 2019). An estimated 18.3% of young adults worldwide report unspecified chronic pain (Murray et al., 2021). Young adults experience unique barriers when seeking help for pain problems (Stinson et al., 2013) and often view cannabis as an effective treatment (Chabrol et al., 2017; McKiernan & Fleming, 2018). Due to increasing availability and low perceived harm (Hasin, 2018), young adults may choose cannabis to self-medicate for pain management (Lord et al., 2011; Romero-Sandoval et al., 2018).
Perceived risks can motivate health behavior change (Salloum et al., 2018) as can perceived benefits, which are often overlooked and relevant for cannabis use decisions (Freeman et al., 2018). Examining perceptions of risks and benefits of cannabis use in chronic pain populations could identify targets for behavior change interventions (e.g., education on long-term mental health risks). Given young adults may seek cannabis to manage pain, we examined the moderating role of chronic pain status to describe risk and benefit perceptions of cannabis among young adult users and identify relationships among perceived risks and benefits, cannabis-related problems, and physical and mental health by pain status. This is a first step to identifying whether associations between perceived risks and benefits of cannabis use are associated with health outcomes, an important marker of functioning for those with chronic pain (Turk et al., 2003). Based on prior work (Bigand et al., 2019; Magnan & Ladd, 2019), we hypothesized that (1) young adults with pain will perceive more benefits and have poorer physical and mental health; (2) perceived risks will be inversely related to perceived benefits and physical and mental health, and positively associated with cannabis problems; and (3) perceived benefits will be positively associated with physical and mental health and inversely associated with cannabis problems.
Method
Data were obtained from a cross-sectional online survey of 176 young adult (18–29 years old) cannabis users as part of a larger study. Participants were Oregon or Washington state residents (USA) who reported currently using cannabis at least once a week and gave informed consent. We did not recruit on the basis of chronic pain status. Respondents received a $15 gift card for survey completion (see Fales et al. (2019) for detailed recruitment and inclusion procedures). The Washington State University IRB approved all procedures.
Measures
Cannabis use.
Participants indicated how often they typically use cannabis (0 = Less than daily, 1 = Daily, 2 = Multiple times daily).
Perceived risks and benefits of cannabis use.
Participants indicated the extent (l = Very low, 7 = Very high) to which they perceived lifetime benefits and risks due to their cannabis use (Magnan & Ladd, 2019). There was restriction of range for nearly all risk items, with no participants rating their lifetime risk above a 5 (Somewhat high) for four of the five items. See Table 1 for item means and observed ranges. Separate mean scores were calculated (benefit α =.89, risk α =.78).
Table 1.
Perceived risk and benefit item means and range.
| Mean (SD) | Observed range (of possible 1-7) |
|
|---|---|---|
| Risks | ||
| Personal harm | 1.51 (0.90) | 1-5 |
| Negative health outcome | 2.03 (1.22) | 1-5 |
| Negative mental health outcome | 2.15 (1.36) | 1-7 |
| Harming someone else | 1.20 (0.58) | 1-5 |
| Experiencing increased pain | 1.24 (0.74) | 1-5 |
| Overall | 1.62 (0.73) | |
| Benefits | ||
| Personal benefit | 4.84 (1.86) | 1-7 |
| Positive health outcome | 4.32 (1.62) | 1-7 |
| Positive mental health outcome | 4.82 (1.77) | 1-7 |
| Benefiting someone else | 4.01 (1.97) | 1-7 |
| Experiencing decreased pain | 5.88 (1.55) | 1-7 |
| Overall | 4.78 (1.46) | |
Note: Each risk and benefit statement used the following format: “What are your chances of experiencing _____ due to your marijuana use at some point in your life?” (1 = Very low, 3 = Somewhat low, 5 = Somewhat high, 7 = Very high).
Cannabis-related problems.
The Rutgers Marijuana Problem Index (RMPI; White et al., 2005) provides an overall measure of cannabis-related risk by assessing a range of negative consequences experienced in the past month with 23 items on a 1 (never) to 5 (>10 times) scale. Sample items: “Went to work or school high” and “Kept smoking marijuana when you promised yourself not to.” Responses were summed with a higher score indicating greater cannabis use severity (α =.86).
Physical and mental health.
The RAND 36-Item Health Survey 1.0 (Ware & Sherbourne, 1992) provides Physical Component Summary (α=.96) and Mental Component Summary (α=.85) scores. Sample items: “My health is excellent” (5 = Definitely true, 1 = Definitely false) and “Have you felt calm and peaceful?” (6 = All of the time, 1 = None of the time). Higher scores indicate better self-reported physical and mental health, respectively (Farivar et al., 2007).
Chronic Pain Status.
Participants indicated whether they experienced a pain problem of at least three months duration (Yes/No) and frequency of bodily aches and pains (1 = Not at all, 6 = Daily). Intensity was assessed with the Numerical Rating Scale (NRS; Hawker et al., 2011; 0 = no pain, 10 = worst pain possible). Chronic pain was defined as a pain problem lasting longer than three months and/or experiencing moderate or higher intensity pain (NRS ≥ 4) at least weekly for the past three months (Merskey & Bogduk, 1994).
Analyses
Assumptions of normality were checked - three multivariate outliers (Mahalanobis distance probability chi-square <.001; Leys et al., 2018) and one non-respondent participant were excluded listwise. Perceived risks were low (Table 1) with 41.0% perceiving the least possible risk (M = 1.00). Thus, we dichotomized perceived risks (0 = least possible risk; 1 = all others). Bivariate and point-biserial correlations (rpb) established relationships of perceived benefits and risks of cannabis use with physical health, mental health, and cannabis problems. Independent samples t-tests and chi-square difference tests assessed differences by pain status. Multiple regression examined main effects of perceived risks and benefits of cannabis use (explanatory variables) and pain status (moderator), on physical health, mental health, and cannabis problems (explained variables; Step 1) and perceived risk/benefit x pain interaction effects at Step 2. Significant interactions were probed with conditional effects analyses using bootstrapped Johnson-Neyman significance regions (Hayes, 2017).
Results
Table 2 presents sample demographics. Over 80% reported at least daily cannabis use. Young adults endorsing chronic pain (50.9%) were slightly older and more likely to be female. There was no difference in race/ethnicity, cannabis use, cannabis problems, or perceived risks or benefits of cannabis use by pain status. Controlling for age and gender did not change interpretation of outcomes, thus unadjusted outcomes are reported. Correlations of perceived benefits and risks of cannabis use, physical and mental health, and cannabis problems are presented in Table 3.
Table 2.
Demographics, cannabis use, physical health, and mental health by chronic pain status.
| Total (N = 176) |
Chronic pain (N = 88, 50.9%) |
No chronic pain (N = 85, 49.1%) |
t-test/Chi square | |
|---|---|---|---|---|
| Age | 24.08 (2.87) | 24.50 (3.05) | 23.64 (2.60) | t(174)=−2.01, p=.05, d=.30 |
| Gender | ||||
| Female (n = 83) | 47.2% | 64.8% | 30.6% | χ 2 (2)= 3.25, p< .001 |
| Male (n = 86) | 48.9% | 31.8% | 68.2% | |
| Non-Binary (n = 7) | 4.0% | 5.7% | 2.4% | |
| Race/Ethnicity | ||||
| White (N = 135) | 76.6% | 72.2% | 81.4% | * χ2(1)=2.07, p=.15 |
| Multiracial (N = 14) | 8.0% | 11.1% | 4.7% | |
| American Indian/Alaskan Native (N = 9) | 5.1% | 5.6% | 4.7% | |
| Black (N = 5) | 2.8% | 3.3% | 2.3% | |
| Asian (N = 7) | 4.0% | 3.3% | 4.7% | |
| Other (N = 6) | 3.4% | 4.4% | 2.3% | |
| Cannabis Use | 19.3% | 16.7% | 22.1% | χ2{2)=4.55, p=.10 |
| Less than daily | 33.0% | 27.8% | 38.4% | |
| Daily | 47.7% | 55.6% | 39.5% | |
| Multiple times daily | ||||
| Perceived benefits (1-7) | 4.78 (1.46) | 4.68 (1.49) | 4.88 (1.44) | t(174)=0.89, p=.37, d=.14 |
| Perceived risks (1-7) | 1.62 (0.73) | 1.62 (0.76) | 1.63 (0.71) | t(174)=0.11, p=.91, d=.02 |
| Least risk (=1) | 41.0% | 38.6% | 43.5% | χ2(1)=.43, p=.51 |
| Low risk (>1) | 59.0% | 61.4% | 56.5% | |
| Physical health (PCS) | 77.81 (30.75) | 65.17 (31.05) | 91.03 (24.33) | t(174)=6.13, p<.001, d=.93 |
| Mental health (MCS) | 59.98 (23.07) | 51.37 (21.96) | 68.99 (20.74) | t(174)=5.47, p<.001, d=.83 |
| RMPI (range 23α75) | 35.16 (10.30) | 35.64 (12.32) | 34.67 (8.27) | t(169)=−0.60, p=.55, d=.09 |
Note: Values are means (standard deviations) or percentages, d is Cohen’s d effect size. Significant tests are bolded. Least risk is percent of participants with an average mean risk response of 1.00 and Low risk is percent of participants with an average mean risk response >1.00.
Chi-square for race/ethnicity compares proportion of White participants to all other racial/ethnic groups. PCS = RAND-36 Physical Component Summary, MCS = RAND-36 Mental Component Summary, RMPI = Rutgers Marijuana Problem Index.
Table 3.
Correlations between perceived benefits, risks, health, and cannabis-related problems.
| 1. | 2. | 3. | 4. | 5. | |
|---|---|---|---|---|---|
| 1. Perceived Benefits | -- | ||||
| 2. Perceived Risks | −.22** | -- | |||
| 3. Physical Health | .12 | −.07 | -- | ||
| 4. Mental Health | .23** | −.18* | .80** | -- | |
| 5. Cannabis-Related Problems | −.07 | .21** | −.13 | −.11 | -- |
Note: Bivariate and point-biserial correlations.
Denotes significant effects p < .05.
Denotes significant effects p <.01.
Physical health
There was no significant effect of perceived benefits of cannabis use (B = 0.06, 95% CI: −0.03, 0.11, p = .30), but there was a main effect of pain status (B = −0.62, CI: −1.27, −0.86, p < .001) and a benefit X pain interaction (B= −0.18, CI: −.29, −.01, p = .04, R2Δ = .015) on physical health. Those without pain who perceived more benefits reported better physical health; those with pain reported no difference in physical health regardless of perceived benefits. This effect was significant at nearly all levels of perceived benefits (≤1.18, CI: −1.07, 0.00; Figure 2). For the perceived risk model, there was no main effect of perceived risk of cannabis use (B = −0.06, CI: −0.27, 0.15, p = .56), a significant main effect of pain status (B = −1.07, CI: −1.28, −0.87, p < .001), and no risk X pain interaction (B = 0.33, CI: −0.09, 0.74, p = .12) on physical health.
Figure 2.
Chronic pain status X perceived benefits on Rutgers Marijuana Problem Index (RMPI) summary score.
Mental health
There were main effects of perceived benefits of cannabis use (B = 0.19, CI: 0.03, 0.19, p = .006) and pain status (B = −0.36, CI: −0.96, −0.50, p < .001) on mental health, but not a significant benefit X pain interaction (B = −0.13, CI: −0.26, 0.05, p = .19). Similarly, there was a significant main effect of perceived risk of cannabis use (B = −0.27, CI: −0.50, −0.03, p = .03) and pain status (B = −0.74, CI: −0.97, −0.51, p < .001) on mental health but no risk X pain interaction (B = 0.36, CI: −0.10, 0.83, p = .13).
Cannabis-related problems
The main effects of benefits of cannabis use (B = −0.50, CI: −1.61, 0.60, p = .37) and pain (B = 0.66, CI: −2.57, 3.88, p = .69) on RMPI were nonsignificant. However, there was a significant benefit X pain interaction (B = −4.24, CI: −6.36, −2.12, p < .001, R2Δ = .045). Significant differences emerged between pain groups at low (≤ 3.76, CI: 0.00, 9.82) and high levels of perceived benefits (≥ 6.71, CI: −13.48, 0.00; Figure 3). Among participants who perceived high benefits, those with chronic pain reported fewer cannabis problems (Mhigh = 32.70, Mlow = 40.09) while those without pain reported more cannabis problems (Mhigh = 37.50, Mlow = 33.38).
There was a main effect of risk of cannabis use on RMPI (B = 4.19, CI: .98, 7.40, p = .01), but no main effect of pain (B = 0.56, CI: −2.60, 3.73, p = .73). Participants who perceived less risk reported fewer cannabis problems (M = 32.73, SD = 8.77) than those who perceived greater risk (M = 36.95, SD = 11.03, d = .43). The risk X pain interaction was non-significant (B = 1.26, CI: −5.18, 7.70, p = .70).
Discussion
Participants perceived low risks associated with their cannabis use and moderate benefits. Overall, risk and benefit perceptions of cannabis use were unrelated to physical health, while perceiving fewer risks and more benefits was associated with better mental health. Although few young adults perceived risks of their cannabis use, those who did were more likely to report poorer mental health and, similar to adult users (Magnan & Ladd, 2019), experience more cannabis problems. As expected, young adults with chronic pain reported worse physical and mental health than those without; although the mean physical and mental health of the overall sample was somewhat lower than would be expected for healthy young adults (Jenkinson et al., 1993). Contrary to expectations, chronic pain status was not associated with perceived benefits of use, nor with any other cannabis-related measures (use, problems, perceived risks). Interestingly, the relationship between perceived benefits, but not perceived risks, and multiple health outcomes was moderated by chronic pain status.
Young adults with pain who perceived more benefits of cannabis use were less likely to experience cannabis problems. Although we cannot identify the temporal direction of these relationships, cannabis may mitigate experiences of pain and benefit mental health for those with chronic pain (Bigand et al., 2019) without causing related cannabis problems. Perceiving more benefits of use was not associated with better physical functioning. Future work should examine the relationship between self-evaluated and objective physical health, as increasing physical functioning is an important pain management outcome (Harding et al., 1994).
For young adults without pain, perceiving more benefits of their cannabis use was associated with better mental and physical health and more current cannabis problems. Positive expectations in combination with daily use is associated with cannabis problems (Englund et al., 2017; Stone et al., 2012); however, this relationship may be obscured by adequate physical and mental health. Public education regarding cannabis lags behind legalization (Kruger et al., 2020; Lamonica et al., 2016). Our results suggest young adults could benefit from education on cannabis risks and that correcting overvaluation of benefits may be a target in harm-reduction interventions for young adults without pain who use cannabis.
Based on homogeneity of low-risk responses, future assessments should add “no risk” as an option. This younger sample may not have experienced many problems related to cannabis use, which could limit accurate assessment of lifetime risk. Additionally, generalizability of the findings may be limited as participants were mostly White, heavy users, and resided in U.S. states where recreational and medical cannabis use is legal, which is associated with lower perceived risks (Zamengo et al., 2020).
This preliminary investigation offers novel insight into cannabis use, perceptions, and health for young adults with pain, who may be particularly motivated to use cannabis (Haroutounian et al., 2016) and are often overlooked in the scientific literature and medical system (Twiddy et al., 2017). Our findings suggest the effects of perceived benefits of cannabis use on physical health and cannabis-related problems may differ for young adults with and without pain, despite minimal differences in cannabis consumption. This could have important implications for education, prevention, and treatment. For example, assessing pain status and pain-related motivations for use in young adult cannabis users could be used to differentially target beliefs about the effects of cannabis to promote well-being. Future research should explore the temporal relationship of perceived benefits of cannabis use, mental and physical health, and cannabis problems.
Figure 1.
Chronic pain status X perceived benefits on RAND-36 Physical Component Summary score.
Acknowledgements
This research was supported by a Grand Challenges Seed Grant awarded by Washington State University (PI: Fales) and Dr. Shorey Fennell is supported by the NIH T32 Behavioral Oncology Training Program at Moffitt Cancer Center (T32CA090314-18, PIs: Brandon, Vadaparampil). We wish to thank Thomas Hefter for assistance with data collection.
Footnotes
Disclosure of interest
The authors report no conflicts of interest.
Data availability statement
The data presented in this article are available by request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data presented in this article are available by request from the corresponding author.