THE ROLE OF CANNABIS IN PAIN MANAGEMENT AMONG PEOPLE LIVING WITH HIV WHO USE DRUGS: A QUALITATIVE STUDY

Abstract

Introduction

People living with HIV who use drugs commonly experience chronic pain and often use illicit opioids to manage pain. Recent research suggests people living with HIV use cannabis for pain relief, including as an adjunct to opioids. This underscores the need to better understand how people living with HIV who use drugs use cannabis for pain management, particularly as cannabis markets are undergoing changes due to cannabis legalisation.

Methods

From September 2018 to April 2019, we conducted in-depth interviews with 25 people living with HIV who use drugs in Vancouver, Canada to examine experiences using cannabis to manage pain. Interviews were audio-recorded, transcribed and coded. Themes were identified using inductive and deductive approaches.

Results

Most participants reported that using cannabis for pain management helped improve daily functioning. Some participants turned to cannabis as a supplement or periodic alternative to prescription and illicit drugs (e.g. benzodiazepines, opioids) used to manage pain and related symptoms. Nonetheless, participants’ access to legal cannabis was limited and most continued to obtain cannabis from illicit sources, which provided access to cannabis that was free or deemed to be affordable.

Discussion and Conclusions

Cannabis use may lead to reduced use of prescription and illicit drugs for pain management among some people living with HIV who use drugs. Our findings add to growing calls for additional research on the role of cannabis in pain management and harm reduction, and suggest the need for concrete efforts to ensure equitable access to cannabis.

INTRODUCTION

Advances in antiretroviral therapy have dramatically altered the course of HIV infection for many with consistent access to HIV treatment and care, transforming it into a manageable, chronic condition [1]. However, people living with HIV (PLHIV) have a significantly lower quality of life than the general population [2]. Pain plays a major role in reducing the quality of life for PLHIV [3]. A recent systematic review focusing on PLHIV reported a pain prevalence of 54% to 83% [4]. It is common for PLHIV to experience pain at various sites and severity at one time, suggesting that their pain results from several different pathological processes [4]. PLHIV experience moderate to severe pain [4]. Their pain can arise from HIV itself, as well as opportunistic infections and antiretroviral therapy-related side effects [4]. It can also derive from a variety of concurrent chronic conditions, which is a growing concern as PLHIV are living longer and aging with multiple comorbidities [5]. Pain is not only a difficult physical experience, but can also have adverse consequences on daily life functioning and psychological wellbeing for PLHIV [6]. For example, untreated pain can contribute to suboptimal adherence to antiretroviral therapy and missed HIV-related clinic visits [7, 8]. Moreover, pain in PLHIV is associated with higher rates of mental illness, including anxiety, depression and suicidal ideation [9–11]. Managing pain among PLHIV is critical to improving their health and quality of life.

While non-opioid treatments are available for pain, given the intensity of pain experienced by PLHIV, opioids, both from regulated and unregulated sources, are commonly used analgesics among PLHIV [12, 13]. Furthermore, given the often chronic nature of their pain, long-term opioid therapy is common among PLHIV [12]. However, long-term opioid use in PLHIV is complex due to adverse effects from drug–drug interactions between antiretroviral drugs and opioid analgesics, including methadone, buprenorphine and fentanyl, among others [14–16]. There is also emerging evidence to suggest the impact of opioid use on virologic failure and acceleration of HIV disease progression through disruption of gut homeostasis among PLHIV [17, 18]. Furthermore, opioid use carries inherent risk for opioid use disorder and overdose, particularly with high doses and long-term use [19]. Given the rise in opioid-related overdoses across the USA and Canada, policy interventions, including revised clinical practice guidelines, focused on reducing opioid prescribing have been introduced in recent years [20, 21]. Unfortunately, this has resulted in untreated pain for many individuals with chronic and serious illness as they are now unable to obtain or fill opioid prescriptions, or have had their opioid dose abruptly lowered or discontinued [13, 22, 23]. Lack of access to adequate pain relief has forced more individuals to self-medicate and turn to drugs from an unregulated and increasingly fentanyl-adulterated illicit drug market, raising concerns of increased overdoses and exposure to other drug-related harms [13, 22, 23].

PLHIV use illicit drugs at a higher rate and are more likely to have a history of substance use disorder than the general population [24, 25]. In one study, PLHIV with a history of substance use disorder reported more pain, use of prescription opioids not as prescribed, and prescription opioid use specifically for pain management compared to those without such histories [26]. Previous research has identified that despite the use of prescription opioids, PLHIV with a history of substance use disorder continue to experience persistently high levels of pain, highlighting the inadequacy of current pain management approaches in this population [26, 27]. Due to differences in underlying neurophysiology, PLHIV with a history of substance use disorder have been reported to require higher doses of opioid analgesics to achieve pain relief compared to those without such history [28]. Yet, changes to prescribing practices that have resulted in limiting access to, or the de-prescribing of, high doses of opioids likely limit the ability of this population to access adequate treatment.

Recent studies from the USA and Canada report that 23% to 39% of PLHIV use cannabis [29–33], and there is emerging evidence to suggest that cannabis may be used to manage pain and serve as an adjunct to or substitute for legal and illicit opioids [29, 34]. While existing studies, including a few randomised controlled trials, have provided encouraging evidence to suggest that cannabis may be used for pain relief among PLHIV [35, 36], research in this area of study as it relates to PLHIV who use drugs remains limited despite high levels of pain. Given the critical need for non-opioid pain relievers, cannabis holds promise for effective therapeutic treatment to manage pain among this population. Further research is needed to better understand this dynamic, particularly as cannabis markets are undergoing changes via varying forms of cannabis legalisation.

We undertook this study to explore how cannabis use affects pain management among PLHIV who use illicit drugs after cannabis legalisation in Vancouver, Canada. In the early 2000s, Canada’s court systems recognised the constitutional right of individuals to purchase, possess and use cannabis for medical purposes, and directed the federal government to create a system for individuals to fulfil those rights [37]. In 2018, Canada became the second country following Uruguay to legalise cannabis for non-medical use at a national level [38]. With the introduction of non-medical cannabis legalisation, the Cannabis Act came into force and replaced the previous Access to Cannabis for Medical Purposes Regulations [39]. Under the current system, individuals with authorisation to use medical cannabis from their health-care provider can purchase cannabis directly from a licensed producer or grow their own [39]. Given recent concerns over the potential implications of legalisation on access to cannabis among structurally vulnerable PLHIV [40], we also sought to understand access to cannabis through legal and illicit channels in the period immediately following legalisation among PLHIV who use drugs.

METHODS

We draw upon in-depth, semi-structured interviews conducted with PLHIV who use drugs in Vancouver, British Columbia. This descriptive analysis of cannabis use and its role in pain management was undertaken to develop a more nuanced understanding of how this structurally vulnerable population consume cannabis for therapeutic purposes. The study was approved by the University of British Columbia/Providence Health Care Research Ethics Board.

To be eligible for the interviews, an individual had to be 18 years of age or older, conversant in English, living with HIV and at least one comorbidity, and self-reported using cannabis as well as other illicit drugs regularly (i.e. at least once within the last week). Participants were recruited by one of two strategies to diversify the sample. First, participants were recruited at the Dr. Peter Centre (n = 12), an integrated HIV care facility in Vancouver’s West End neighbourhood that operates under a harm reduction approach. Participants were recruited through clinician referral or in-person outreach by research coordinators. Potential participants were screened for eligibility by the research coordinators and scheduled for interviews. Second, participants were recruited through AIDS Care Cohort to Evaluate exposure to Survival Services (ACCESS; n = 13), an open prospective cohort study of PLHIV who use illicit drugs operating in Vancouver’s Downtown Eastside neighbourhood. ACCESS cohort study participants must be 18 years of age or older, live in Greater Vancouver and have used illicit drugs other than cannabis in the previous month, and are recruited through word of mouth, street outreach and referrals [41]. For the current study, cohort participants were screened for eligibility during their routine cohort study interviews and then, if interested in participating, scheduled for interviews for this study.

Participants were interviewed where they were recruited (Dr. Peter Centre or cohort study office). Interviewers explained the study procedures and obtained written informed consent prior to the interviews. The interview guide included questions to facilitate discussion on a range of topics, including: (i) the use of cannabis for pain and symptom management; (ii) interaction with care providers regarding cannabis; and (iii) access to cannabis through legal and illicit channels following legalisation. During the interviews, a pain scale with a range of 0 (no pain) to 10 (most severe pain) was also used to elicit responses about the level of pain participants experienced on an average day. Interviews were conducted beginning in September 2018, 1 month before cannabis legalisation on 17 October 2018, and concluded in April 2019. Interviews were between 19 and 56 min in length, audio-recorded and transcribed verbatim. Participants each received a CAD $30 honorarium following the completion of their interview.

Interview transcripts were imported into NVivo qualitative data analysis software program and analysed using a qualitative descriptive analysis approach [42]. Members of our research team each reviewed a selection of transcripts and then met as a group to develop the initial coding framework based on the interview guide as well as emerging themes from the data. The data were then coded independently by two team members. The research team met regularly during data coding and analysis to discuss developing themes in the data and established a comprehensive data coding framework. Once final themes were established, data were recoded to ensure consistency and trustworthiness in coding across all transcripts. The same two team members involved in the initial coding recoded the transcripts, resolving any discrepancies in coding through discussion and establishing inter-coder reliability.

RESULTS

A total of 25 participants were interviewed (Table 1). Fifteen were women and 10 were men. The largest racial/ethnic group was Indigenous followed by White. Many participants reported crack cocaine or heroin as their drug of choice. At the time of the interviews, a large majority of participants reported smoking cannabis on a daily basis. Twenty-one participants reported pain, which were attributed to a range of conditions, including neuropathy, arthritis, osteoporosis and cancer. The majority of these participants experienced chronic pain and they described how chronic pain affected various regions of their bodies, with legs, back, hip and stomach being most common.

Table 1.

Background characteristics of sample (n = 25)

	Total	%
Age, years
30–39	4	16
40–49	3	12
50–59	15	60
60–69	3	12
Sex
Female	15	60
Male	10	40
Race/ethnicity
Indigenous	16	64
White	8	32
Asian	1	4
Drug of choice
Heroin	6	24
Crack cocaine	6	24
Crystal methamphetamine	5	20
Cannabis	4	16
Fentanyl	1	4
MDMA	1	4
Cocaine	1	4
Alcohol	1	4
Frequency of cannabis use
Daily	20	80
3–4 times a week	3	12
≤ once a week	2	8

Four key themes emerged that describe participant experiences of cannabis use for pain management after cannabis legalisation: (i) cannabis use for pain management and daily functioning; (ii) cannabis as a supplement or alternative to other drugs for pain and symptom management; (iii) limited access to Canada’s legal medical cannabis program; and (iv) greater access to non-medical cannabis through illicit sources.

Cannabis use for pain management and daily functioning

Across our sample of participants reporting pain, the majority of participants expressed how pain shaped their daily lives, and commonly described using cannabis for pain management. For these participants, smoking a joint or pipe was a more familiar practice and preferred over other methods of cannabis consumption. They preferred smoking because of its rapid onset, allowing them to more easily find the effective dose compared to edibles and capsules, which they indicated could be ‘intense’ and ‘overwhelming’. Participants commonly indicated their preference for ‘indica’ varieties (e.g. Purple Kush), which are known for their more sedative effects, and high Tetrahydrocannabinol (THC) strains, though most reported that they usually consumed whatever cannabis strain they could access.

Among participants reporting pain, average level of pain experienced based on the 10-point pain scale ranged from 4 to 10, with an average of 6. All of these participants reported experiencing reduction in pain levels after cannabis use, with the majority reporting a reduction of two or three points. The duration of pain relief from cannabis varied among participants, ranging from 1 to 6 h following consumption. Many participants attributed improvements in daily functioning to improved pain management through the use of cannabis. For several participants, more effective pain management through the use of cannabis improved their energy levels and mobility, making it easier for them to engage in often physically challenging income-generating activities (e.g. ‘binning’ or informal recycling) available to them within the context of employment discrimination and poverty [43]. For example, the following excerpts illustrate how participants experienced greater mobility through improved pain management:

‘I can move. When I don’t smoke […] I can’t move. I’ll start popping and cracking when I’m trying to move.’

(43-year-old Indigenous woman)

‘It [cannabis] gives me a whole new … wow, it’s enjoyable. With the leg pain and all that, we all sit outside and smoke [cannabis], because we’re all suffering from the same thing. And we’re all like wow, and we get up and we go binning and it gets you going again.’

(55-year-old White man)

One participant reported that cannabis reduced his pain level from five to three and a half and explained that using cannabis for pain management improved his ability to engage in the kind of physical exertion needed to access his antiretroviral medications. When asked how cannabis use impacts his engagement in HIV treatment and care, he responded:

‘Sometimes, yeah, it helps, right? Because I know I need to smoke for the pain, which I do first. […] You smoke it and it helps you to go get your meds. Seriously.’

(54-year-old South Asian man)

Cannabis use played an important role in improving pain management and engagement in daily activities across our sample of PLHIV who use drugs.

Cannabis as a supplement or alternative to other drugs for pain and symptom management

Among participants experiencing pain, most described how cannabis use led to reduced use of prescribed or illicit drugs for management of pain and related symptoms (e.g. difficulty falling asleep and staying asleep). Some participants used cannabis in place of or in conjunction with prescribed gabapentin and benzodiazepines (e.g. diazepam, clonazepam) used for pain management purposes. These participants explained that they used cannabis because gabapentin and benzodiazepines were inadequate or ineffective at relieving their pain. For example, one participant reported that cannabis could reduce pain level from seven to four and described how he used cannabis when pain management with clonazepam along with gabapentin alone was insufficient:

Interviewer: ‘Do you ever use cannabis in combination with painkillers?’

Participant: ‘Well, I use it with my clonazepam and my gabapentin. Yeah. But I know for a fact it’s not the gabapentin and stuff like that, because there are days when I take just gabapentin and my clonazepam and nothing’s helping me. On those days, I use marijuana.’

(55-year-old White man)

Some participants turned to cannabis as an adjunctive therapy to extend analgesic effects of prescription or illicit opioids or periodically as an alternative to these drugs to assist with chronic pain management. Among these participants, cannabis use was attributed to inadequate pain management by physicians and related issues in accessing prescription opioids following restrictions put in place due to the overdose crisis. For example, one participant described how he was tapered down involuntarily to a lower dose of oxycodone by a physician following changes to prescribing guidelines and how he began to use cannabis to assist in managing his injury-related chronic knee pain:

‘I was taking Percocet until the opiate scare, so I can’t take that … So now I use weed now and that helped. […] You know, my doctor was giving me two Percocets, right, where I should be taking actually four for the whole day. I was taking two and the pain was still coming back, right? Like one in the morning, I should say, and one in the evening. […] That morning dose would last only ‘til lunch. It wouldn’t be the full day. […] So I’d be in pain. The pain would slowly start, you know, building up, slow. That’s where I would smoke a really strong joint to myself.’

(54-year-old South Asian man)

Many participants had described accessing illicit opioids to manage chronic pain, especially when prescription pain medications were withheld or discontinued, and noted that cannabis provided them with another therapeutic option for managing their pain alongside illicit opioids. One participant who reported that cannabis could reduce their pain level from seven to four described using cannabis after smoking heroin to further manage her lower back pain, as heroin alone was no longer effective:

‘Usually, when I’m smoking some down [heroin] or whatever, then right after I smoke down, I smoke pot and that seems to help ‘cause the heroin’s not even helping the pain anymore. So the marijuana just seems to ease it.’

(55-year-old White woman)

Other participants described using cannabis in combination with other drugs to relax the mind and take their attention off of pain. For example, one participant living with osteoporosis who used crack cocaine and heroin supplemented with cannabis to manage severe pain:

‘I think I try to use the hard stuff like the crack and the heroin and that’s if it gets really severe. […] Yeah, because it numbs it, right. For a while anyway. And then I use cannabis. […] Well cannabis is mostly for me to relax and try to get my mind off the pain.’

(50-year-old Indigenous woman)

Participants turned to cannabis as a supplement or periodic alternative to prescription and illicit drugs used to manage pain, suggesting the potential utility of cannabis as a harm reduction strategy.

Limited access to Canada’s legal medical cannabis program

Although the majority of participants reported symptoms or conditions which could lead providers to authorise access to cannabis through Canada’s medical cannabis system (e.g. pain, depression), few participants reported accessing medical cannabis. Participants reported that they were unaware about their eligibility for authorisation for legal medical cannabis, had not discussed it with their physicians and their physicians had not brought the program up with them. While some participants, many of whom reported otherwise good relationships with their physicians, reported feeling generally comfortable speaking with their physicians about cannabis use and requesting written support for authorised access, those requesting support for medical authorisation encountered reluctance among physicians. One participant described how her physician was supportive of cannabis use, but unwilling to sign her application for authorised access:

‘I’ve asked her but she [physician] is not on the same boat. […] She was all for it [cannabis use] but she didn’t want to sign the letter.’

(35-year-old Indigenous woman)

Other participants emphasised that their physicians needed to be convinced of the need for medical cannabis before signing off on their request, often in ways that de-centred their health experiences. One participant with chronic pain related to rheumatoid arthritis explained that her daughter needed to attest to the therapeutic benefits of cannabis for her physician to provide medical authorisation:

‘It took him [physician] a year to do it. And he was very old school, but he was my doctor for over 20 years. So I told him, I said I don’t want to take these pills that you guys give me. I’d rather just smoke weed. So he says well why don’t you try this and I said okay. I didn’t get upset. I tried whatever he wanted first and then about a year later, I said, so Dr. [physician’s name], have you given any more thought about signing this paper for me. And my daughter was in there with me and so he said does it really help you, and she said yes, it does. It helps with the sleep. It helps for pain. Then he signed it.’

(60-year-old Indigenous woman)

Participants reported that they were usually the ones to initiate a conversation with their physicians regarding the use of cannabis for pain management and other therapeutic purposes. Several participants indicated that their physicians had limited practical knowledge regarding the therapeutic uses of cannabis and described experiences of being put in a situation that required them to educate their providers. This was the case for a participant whose physician was initially wary of and reluctant to support their application to access cannabis for medical purposes. For example:

‘Well, they [physician] were kind of at first a little bit wary of it. They weren’t really going to go for it, but because I was HIV, I was like one of the big ones, like the big ones they want: cancer, HIV. Those two, and you’re in. But they were … she was pretty reluctant at first. […] I don’t think these doctors are up-to-date on it. I really don’t. […] I’m not blaming her or anything like that; that’s just the way she was taught.’

(55- year-old White man)

Regardless of the source, medical and non-medical cannabis are the same product. Some participants deliberately chose not to obtain authorised access through the federal medical cannabis program. These participants were perplexed about the benefits of obtaining federal authorisation as a medical cannabis patient, particularly as, in the wake of non-medical cannabis legalisation, cannabis could now be legally purchased for their use, directly from retail stores without medical documentation, or obtained through the illicit market or cannabis distribution programs in their neighbourhood that dispense free unregulated cannabis to people who use drugs. As one participant (55-year-old Indigenous man) put it: ‘I don’t know why I would get a prescription now it’s all legal.’ Despite the benefits of cannabis for pain management, participants’ access to and use of the legal medical cannabis program was limited.

Greater access to non-medical cannabis through illicit sources

Although Canada legalised cannabis for non-medical use close to the beginning of our data collection, this appeared to have little impact on how the participants in our study accessed it. Participants told us that they looked to source cannabis from illicit markets, including unlicensed retail dispensaries. Alongside cannabis retail stores licensed by provincial and municipal regulators, local cannabis dispensaries operating outside of Health Canada’s federal license program provided participants with access to their preferred cannabis strains and cannabis they deemed to be of higher quality than that obtained from other illicit market sources. As one participant explained:

‘They [dispensaries] are really careful about what they bring in. They check it for, for mold and all that stuff. […] making sure that it was not contaminated with the pesticides and stuff like that.’

(55-year-old Indigenous man)

Prior to legalisation, Vancouver was well known for its extensive network of illicit cannabis dispensaries. In response to the proliferation of these storefronts in 2015 up until 2018, the City of Vancouver granted numerous dispensaries with temporary business licenses, which were then given an additional 1-year post-legalisation to obtain their legal license from the province or face closures. This meant that cannabis continued to be accessible through these channels post-legalisation. Nevertheless, some participants described that legalisation resulted in overly restrictive regulations for operating licensed cannabis retail stores and closure of multiple unlicensed dispensaries, posing a new challenge to cannabis access. For example:

‘I know they’re trying to shut them [dispensaries] all down though, right. I know in our area there on [a major street in downtown Vancouver] they shut quite a few of them down. Yeah. Cause they weren’t obeying by the government standards. […] And it’s been much harder to get. […] I get upset of course. You know, especially when I need it.’

(50-year-old Indigenous woman)

High cost prohibited many participants from obtaining cannabis from legal retailers. In contrast, illicit sources provided participants with cannabis that was deemed to be free or affordable. As one participant who obtained cannabis from the Cannabis Substitution Project, a local free cannabis distribution program operating in Vancouver’s Downtown Eastside [44], described:

‘Substitution program. That’s the only place I get it because it’s free. And those gummy bears are not cheap. I priced them out in the store just for the little ones. They’re 12 bucks. And we get those and the stronger ones and, you know, a joint, and a capsule, you know, whatever he has. […] It’s a blessing, let me tell you. I don’t have to buy it, first of all, and that it’s there available and I know where to get it. That’s, to me, is like wow. I couldn’t ask for any more.’

(60-year-old Indigenous woman)

Several participants procured cannabis from their local medical cannabis dispensaries and expressed satisfaction with the affordable and consistent pricing. For example:

‘It’s less expensive where I go, yeah. Because it’s the $5 gram, right. And then all day every day it’s $5. It doesn’t change and whatever strain it is they have, it’s $5 and that’s prime.’

(43-year-old Indigenous woman)

In addition to the pricing, participant narratives also highlighted how illicit cannabis dispensaries provided a sense of community along with unique aspects, such as the provision of credit when participants did not have enough funds to complete their purchases, enabling immediate access to cannabis when it was needed:

‘After being a member there for a year and buying some amount, I was able to take some [cannabis] home and pay them on cheque day. Things like that, right? And people, it was great.’

(54-year-old South Asian man)

Even after the legalisation of non-medical cannabis, most continued to obtain cannabis from illicit sources, highlighting the need to improve access for low-income individuals.

DISCUSSION

This study explored experiences of cannabis use for pain management among PLHIV who use drugs in Vancouver, British Columbia shortly after legalisation of non-medical cannabis. Most participants reported using cannabis for pain management. Some participants turned to cannabis as a supplement or alternative to prescription and illicit drugs used to manage pain and related symptoms. Nonetheless, participants’ access to legal medical and non-medical cannabis was limited and most continued to obtain cannabis from illicit sources. These alternate sources provided participants with access to cannabis that was free or deemed to be affordable.

Our study adds to the growing evidence base suggesting the therapeutic role of cannabis in pain management among PLHIV and other chronically ill populations [45, 46] by providing an emergent understanding of the experiences of PLHIV who use drugs and how they describe cannabis use for alleviating pain and improving their daily functioning. We also demonstrated that PLHIV who used cannabis reported reduced use of other prescribed and illicit drugs. Previous studies have shown that daily cannabis use is associated with significantly lower odds of daily illicit opioid use among people who use drugs for pain, suggesting that cannabis may be used to alleviate pain and potentially reduce resulting opioid use [29, 47]. Our qualitative account extends these insights, and suggests that cannabis use may play a role in reducing pain and drug-related risks not only from illicit and prescribed opioids but also illicit and prescribed gabapentin and benzodiazepines among PLHIV who use drugs. Recent research suggests that an increasing number of people are being prescribed gabapentin and benzodiazepines for chronic pain [48, 49]. However, similar to opioids, benzodiazepines pose serious health risks, including addiction and overdose [50]. Furthermore, both gabapentin and benzodiazepines have been suggested to significantly increase the risk of opioid-related overdose [51, 52]. Given that drug overdose is a leading cause of accidental death among PLHIV, our finding is particularly relevant to harm reduction for this population [53].

Despite the therapeutic potential of cannabis, our findings suggest that access to legal cannabis, both medical and non-medical, is inadequate among PLHIV who use drugs. High cost alongside other barriers, such as the need for identification, restricts access through the legally-regulated system, particularly for structurally vulnerable populations [44]. Further, access to legal medical cannabis requires authorisation from a health-care provider. Yet, perhaps unsurprisingly, we found that in the first few months immediately following legalisation in Canada, provider-related barriers previously reported to restrict access to legal medical cannabis among people who use cannabis for therapeutic purposes extend to the experiences of PLHIV [54, 55]. Cannabis stigma and provider belief that cannabis is only a ‘recreational’ drug has previously been identified as a significant patient barrier to obtaining authorisation for medical cannabis [55]. Further, lack of provider knowledge has been reported as a challenge and hindrance to patients seeking authorisation [54]. Provider-facilitated access to medical cannabis provides a critical opportunity for individuals to receive guidance on strain selection, dosing, administration and safety. Education may assist providers in identifying patients who may benefit from access to legal medical cannabis.

Previous research has reported that a substantial number of chronically and seriously ill people in Canada access cannabis for therapeutic purposes from illicit sources [45]. To our knowledge, however, this is the first study to examine the experiences of cannabis use with PLHIV who use drugs within the context of legal access to non-medical cannabis. We found that most PLHIV who use drugs continued to obtain cannabis from illicit sources following legalisation, even when they were authorised through the federal medical program, primarily as these alternate sources provided access to cannabis that was free or deemed to be affordable. Nevertheless, we also found that legalisation resulted in closure of multiple illicit dispensaries, posing a new access barrier for PLHIV who use drugs. These low-cost illicit outlets are the target of enforcement actions by provincial and municipal governments and will likely be forced to close under legalisation. Policy change is needed to ensure that legalisation is equitable and does not hinder access to cannabis for therapeutic purposes among PLHIV who use drugs and other structurally vulnerable people living with chronic illness. For example, insurance coverage and subsidies to cover medical cannabis expenses for low-income individuals should be protected and scaled up.

This study has some limitations. First, the voluntary nature of study participation may have introduced selection bias that favoured recruitment of a sample of participants with stronger views on the topic. While our findings highlight how participants who are PLHIV who use drugs describe the potential benefits of cannabis use for pain management, further controlled studies remain needed to determine the impact of cannabis use on such outcomes. Furthermore, as the legalisation of cannabis was introduced in October 2018, our findings may reflect the growing pains of a newly regulated landscape. More research is needed to understand the long-term experiences and structural contexts of cannabis use and access post-legalisation.

CONCLUSIONS

Cannabis use is one strategy PLHIV use to reduce their use of prescription and illicit drugs. Our findings add to growing calls for additional research on the role of cannabis in pain management and harm reduction, and suggest the need for concrete efforts to ensure equitable access to cannabis for this population.