Cancer Patients' Experiences with and Perspectives on the Medicinal Cannabis “High”

Abstract

Background:

Patients with cancer employ medicinal cannabis for poly-symptom management and as cancer-directed therapy. Little is known about their perspectives on the medicinal cannabis “high.”

Methods:

Qualitative interviews across eight states with medicinal cannabis users with physician-verified cancer diagnoses (n = 24).

Results:

Every participant referenced and 15 spoke in depth about the medicinal cannabis “high.” Antitheticals characterized it: sleepiness versus heightened attention; calm versus “agitation.” The intensity of the “high” served as a proxy metric by which participant's judged medicinal cannabis' cancer-directed therapy and symptom management efficacies. Overall, however, study participants viewed the “high” as a barrier to medicinal cannabis use and worked to avoid experiencing for prolonged periods.

Conclusions:

The “high” is central to the manner with which patients with cancer experience medicinal cannabis. Clinicians should be aware that patients may struggle to fine-tune medicinal cannabis dosing in the setting of the “high,” and this challenge should be included in clinical discussions regarding oncological medicinal cannabis use.

Introduction

Medicinal cannabis refers to nonpharmaceutical, herbal cannabinoid products that patients use with medicinal intent, often with health care professional approval and in compliance with state law. Across the 36 state medicinal cannabis laws in the United States, malignancy is one of the two medical conditions that most frequently qualifies for medicinal cannabis access.¹ Evidence suggests that one in four patients in a comprehensive cancer center use cannabis, predominantly with medicinal intent.² Cannabis activates brain reward centers, and qualitative work with individuals using cannabis in a nonmedicinal context has linked the “high” experience with changes in mood, sensation, and thinking.^3,4

In the context of medicinal cannabis, evidence suggests that the medical establishment mainly regards the “high” as an untoward side effect. For instance, in medicinal cannabis clinical trial design, the “high” is frequently characterized as an adverse event; and interviews with key informants at the intersection of cannabis and oncology have suggested that such professionals are more likely to view the cannabis “high” as a nonmedical rather than a medicinal phenomenon.^5,6

Little is known about patient perspectives on the medicinal cannabis “high.” Results of a focus group study have suggested that patients with cancer using medicinal cannabis seek to avoid the “high.”⁷ The article notes that a sense of stigma and a prohibitive federal legal climate may play a role.⁷ The following analysis explores in greater depth patients with cancer experiences with and views of the medicinal cannabis “high.”

Methods

Through a convenience sample of medicinal cannabis dispensaries across eight U.S. states (states/districts: AZ, CA, FL, IL, MA, OR, NY, DC), we recruited participants (n = 24) with physician-confirmed cancer diagnoses and state/district authorization to use medicinal cannabis.⁸ At checkout, participating dispensaries offered all clients, regardless of diagnoses, study fliers introducing study rationale, eligibility criteria, and compensation ($75). Researchers phone-screened interested individuals and mailed a written informed consent to those who met eligibility. Study participants consented to allow researchers to: (1) contact their physician to verify their cancer diagnosis and (2) audio-record the telephone interview.

Between April 2017 and March 2019, recruitment occurred in phases to ensure adequate capture of emergent themes. We developed a semi-structured interview guide to explore the experiences and practices of participants using medicinal cannabis. An interview probe regarding the “high” was: “Tell me what the ‘high’ feeling is like and how long does it last?” A single qualitative research expert (M.M.N.) conducted audio-recorded phone interviews ranging in length from 60 to 90 minutes. Interviews were transcribed and analyzed using applied thematic analysis facilitated by NVivo 12. An initial article based on these data was published in 2020.⁸ A word frequency query (word cloud) for the term “high” and associated terms (e.g., anxious, calm, doped, effect, enjoy, euphoria, giddy, goofy, happy, mind, nice, relax, stoned, stupid, tired, and wonderful) was next generated.

A text query was conducted of entire transcripts using these specific terms. Key themes were extracted from transcripts and discussed by members of the study team to reconcile discrepancies. This approach was guided by the consolidated criteria for reporting qualitative research (COREQ).⁹ This study was approved by the Dana-Farber Cancer Institute Institutional Review Board. Additional methodological details are published elsewhere.⁸

Results

As previously reported, 67 individuals expressed interest in study participation; 17 of whom did not meet the eligibility criteria; 18 of whom lived in states already heavily sampled; two of whom were lost to follow-up; two of whom ultimately declined; three of whom could not be reached; and one of whom died before interview.

Reference to the medicinal cannabis “high” existed in all 2 dozen transcripts, with 15 participants discussing the phenomenon in depth. Among the 15 participants (Table 1), the median age was 58 years (range 35–65 years). Three-quarters were female and 80% Caucasian. Regarding cancer stage, 40% had early disease and 60% advanced disease (defined as “Stage IV” or “metastatic”).

Table 1.

Self-Reported Characteristics of Participants Who Spoke at Length on the Medicinal Cannabis High (N = 15)

Characteristic	Number (%) or median (range)
Gender
Female	11 (73)
Age, years	58 (35–65)
Ethnicity
Non-Hispanic/Non-Latino	12 (80)
Hispanic/Latino	3 (20)
Race
Caucasian	12 (80)
African American	1 (7)
Native Hawaiian/Pacific Islander	1 (7)
More than one race	1 (7)
Education
Some college or more	9 (60)
High school or less	6 (40)
Work status
Disabled	7 (47)
Working	3 (20)
Retired/unemployed	5 (33)
Marital statusa
Married/cohabitating	7 (47)
Divorced/widowed/single	7 (47)
United States region
Eastern	7 (47)
Western	3 (20)
Midwestern	5 (33)
Cancer stageb
Early stage	6 (40)
Advanced stage	9 (60)

^aOne person declined to answer this item.

^bAdvanced stage = stage IV or metastatic.

Theme 1: The medicinal cannabis “high” was described in antitheticals

While the most common medicinal cannabis “high” descriptor was “sleepy,” and some participants reported dissociation from reality, others described the opposite: a heightened sense of focus and awareness. One, for instance, who employed medicinal cannabis as cancer-directed therapy, undertook meditative “visualiz[ation of] cancer cells dying” when “high.” While many described a sense of relaxation, others reported the “high” phenomenon as existing proximal to or comingling with a heightened anxiety (“agitated”) state. Finally, several described a sense of disinhibition (“goofy,” “giddy,” “inebriated,” “waving at the International Space Station”).

Theme 2: Participants regarded the intensity of their “high” as a proxy for the strength of their desired therapeutic medicinal cannabis effect

Of the 15 participants, two-thirds described employing the “high” phenomenon as a medicinal cannabis titration metric, some titrating to, others past, the onset of the “high” phenomenon. This emergent theme was most pronounced among the 6 participants (of 15 total) targeting a Rick Simpson Oil (RSO) protocol, an Internet-based recipe with an antineoplastic claim, calling for high daily cannabinoid doses.¹⁰ Many of these individuals viewed the “high” as an indication that they had achieved therapeutic antineoplastic dosing. However, the theme of “high”-as-titration metric also appeared in transcripts of participants targeting symptom management with their medicinal cannabis use. In fact, a couple of individuals who used medicinal cannabis to treat specific cancer-related symptoms (e.g., pain or nausea) employed the “high,” rather than relief from those specific symptoms, to dose the botanical. In other words, the intensity of the high served as a proxy for the strength of the intended therapeutic effect.

Theme 3: Overall, study participants viewed the “high” as a barrier to—rather than a facilitator of—medicinal cannabis use

Most participants who discussed the “high” viewed the phenomenon as a barrier to medicinal cannabis use, often because the “high” was viewed as intense or tinged with anxiety; or because participants wished to remain in full possession of their faculties. Less than a handful perceived it to be therapeutic in its own right. In fact, participants employed a variety of maneuvers to avoid experiencing the “high” in a prolonged or intense manner. For instance, most participants timed their medicinal cannabis use to coincide with sleep. Some used cannabidiol-predominant products to counteract the intense sense of intoxication due to delta-9-tetrahydrocannabinol. Others described deliberately selecting routes of cannabis administration that prolonged time to peak concentration (e.g., edibles). Still others discussed gradually titrating daily medicinal cannabis dosing over several weeks to avoid experiencing the “high” (“going low and slow”).

Discussion

In one of the first scientific reports to examine cancer patients' experiences with and perspectives on the medicinal cannabis “high,” we found the phenomenon to be a prominent component of medicinal cannabis use. Participants described the experience of being “high” using sharply contrasting terms: sleepiness versus heightened attention; calm versus “agitation.” A theme that emerged in the transcripts was of participants using the intensity of their “high” as a proxy metric for the strength of the intended therapeutic medicinal cannabis effect. This finding held true for both those participants using medicinal cannabis as cancer-directed therapy and for those targeting symptom management.

For instance, a participant seeking analgesia might titrate medicinal cannabis based on the intensity of the high rather than pain intensity. Even so, overall, study participants viewed the “high” as a barrier to medicinal cannabis use, rather than a facilitator, and went to lengths to avoid experiencing the phenomenon for prolonged periods. These exploratory findings indicate that the “high” may be a salient issue in medicinal cannabis use and that clinicians should ask their patients about this facet of the use experience. Our findings also suggest dualities in the ways patients with cancer experience the medicinal cannabis “high” and that, from a patient perspective, the “high” may not always equate to an adverse event in the strict sense of a clinical trial definition, nor does it equate precisely with euphoria typically targeted by nonmedical use of cannabis.

Our findings do not illuminate whether individuals with other health conditions using medicinal cannabis have experiences with the medicinal cannabis “high” similar to those of the cancer patient. For two reasons, we suspect that the oncological population may be unique. First, a substantial proportion of cancer patients seem to use medicinal cannabis as cancer-directed therapy.⁸ In the absence of robust clinical research in this domain, cancer patients typically turn to nonmedical sources for their antineoplastic recipes, including the RSO protocol, which calls for high daily cannabinoid doses.¹⁰ Individuals using this protocol may be at higher risk for toxicity since they target a dosage rather than a subjective effect.

Second, in the times between tumor surveillance testing (e.g., scans or tumor markers assessments), individuals with cancer commonly gauge the efficacy of their cancer-directed treatments by the intensity of treatment side effects.¹¹ Perhaps this common practice explains the tendency for participants in this sample to titrate medicinal cannabis according to the intensity of the “high.” For all these reasons, additional exploratory research into the meaning of the “high” is necessary in nononcology populations using medicinal cannabis.

There are several limitations to this study. The fact that the study utilized a small convenience sample opens it to potential bias. Participants who enrolled in the study were, by definition, willing to discuss their medicinal cannabis use. Individuals who did not enroll may have had experiences and perspectives not represented in this sample. The fact that our study employed a geographically diverse sample, participants with physician-confirmed cancer diagnoses, and near equal numbers of participants with early disease compared with those with advanced disease certainly strengthens the generalizability of our findings to the U.S. population of individuals with cancer using medicinal cannabis.

In conclusion, our preliminary findings suggest that the role of the medicinal cannabis “high” is more nuanced than traditionally depicted in the clinical trial literature and central to the manner with which individuals with cancer approach medicinal use of the botanical. As such, the medicinal cannabis “high” should be scientifically investigated in greater depth. Our study should be followed by a rigorously conducted quantitative study in a population-based sample of cancer patients to understand the true prevalence of the medicinal cannabis “high” among oncological users and its associations with target indications for medicinal cannabis use (e.g., symptom management vs. as cancer-directed therapy).

These findings could inform development of a psychometrically tested instrument to gauge medicinal cannabis “high” intensity for clinical and research purposes. In addition, qualitative work around the MC “high” should be carried out in other illness populations, for instance, in individuals with chronic pain. Our study should also inform clinical care of individuals with cancer using medicinal cannabis. Based on the initial analyses of our data, we know that health care professionals tend not to conduct discussions or guide care around oncological cannabis use and that this represents a gap in care.⁸ In the current exploratory analysis, we glean that the role of the “high” in MC use may be one important facet to include in such discussions as individuals with cancer may struggle in the finetuning of this nuanced effect.

Authors' Contributions

I.M.B., M.M.N., and J.T. conceived the study and obtained ethics approval and funding for the study. M.M.N. conducted interviews. S.C.T., M.M.N., P.R.C., T.S.S., M.Y., and I.M.B. conducted data analysis. S.C.T. and I.M.B. assembled the draft article. All authors provided substantial key feedback for the final submitted version. S.C.T. and I.M.B. take responsibility for the final article as a whole.

Funding Information

This project is funded through the Hans and Mavis Lopater Foundation.

Author Disclosure Statement

I.M.B. is funded by the Hans and Mavis Lopater Foundation and participates in preclinical research funded through a structured research agreement with Cannex Scientific. M.M.N. is funded through the Hans and Mavis Lopater Foundation and the Gloria Spivak Faculty Advancement Fund. P.R.C. is funded by NIH K23DA044874, R44DA051106, MA Consortium on Pathogen Readiness, eInk Corporation.