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. Author manuscript; available in PMC: 2024 Feb 1.
Published in final edited form as: Exp Clin Psychopharmacol. 2022 Jan 13;31(1):14–22. doi: 10.1037/pha0000542

Differences in Cannabis Use Characteristics, Routines, and Reasons for Use Among Individuals With and Without a Medical Cannabis Card

Benjamin L Berey 1, Elizabeth R Aston 1,2, Nioud Mulugeta Gebru 3, Jennifer E Merrill 1,2
PMCID: PMC9276841  NIHMSID: NIHMS1783210  PMID: 35025588

Abstract

As recreational and medical cannabis use increases in the U.S., the proliferation of novel cannabis products is expected to continue. Understanding cannabis product preferences and use patterns may inform public health and policy decisions. This study investigated similarities and differences in cannabis use patterns, product preferences, and beliefs about cannabis’ subjective effects and therapeutic benefits among individuals with and without a medical cannabis card (MCC). Participants with an MCC completed individual interviews (N = 25; 40% male). Participants without an MCC completed focus groups (N = 31; 6–7 participants/group; 72% male). All sessions followed a semistructured agenda. Participants were queried about their use routines, reasons for using cannabis, and perceptions and experiences of subjective cannabis effects. Thematic analysis of coded transcripts revealed that MCC participants had structured, daily cannabis use routines whereas non-MCC participants’ use routines were less structured. Product information including strain and cannabinoid composition were important to MCC participants whereas non-MCC participants primarily evaluated quality based on perceptual (e.g., olfactory) cues. Regardless of MCC status, participants reported misconceptions about cannabis’ therapeutic benefits and agreed that the two primary cannabis strains—Indica and Sativa—produced primarily sedative and stimulant effects, respectively. Results have clinical, public health, and policy implications surrounding cannabis recommendation guidelines and ways providers can relay accurate information to patients seeking medical cannabis. Future research assessing demographic and geographic differences in cannabis product preferences and beliefs about medical cannabis use is warranted. Further, quantitative research is needed to evaluate whether cannabis’ therapeutic value differs across products.

Keywords: medical marijuana, Indica, Sativa, qualitative, cannabinoid

Following the 2020 election, 36 states in the U.S., plus the District of Columbia, have passed legislation permitting medicinal and/or recreational cannabis use. Further, the cannabis industry manufactures myriad cannabis products varying in formulation (e.g., flower, concentrates) and administration mode (e.g., inhalation, oral ingestion; Spindle et al., 2019). Contemporaneously, cannabis potency and rates of use are increasing whereas perceptions of harm are decreasing (ElSohly et al., 2016; Hasin & Walsh, 2021) and over four million people are estimated to have a medical cannabis registration card (National Conference of State Legislatures, 2020). Recent research indicates differences in sociodemographic and cannabis use patterns between individuals who use cannabis for medical or recreational purposes (Camsari et al., 2019; Gunn et al., 2019; Loflin et al., 2017; Sznitman, 2017; Turna et al., 2020). However, it remains unclear whether individuals with or without a medical cannabis card (MCC) use or prefer specific products for certain reasons or various medical conditions, information that has important policy and public health implications.

The growing list of qualifying conditions for medical cannabis essentially signals to the public that cannabis is an effective treatment for many medical conditions despite mixed evidence for efficacy (Abrams, 2018; Whiting et al., 2015). Although cannabis produced beneficial therapeutic effects for chronic pain and chemotherapy-induced nausea, evidence for several other currently approved conditions (e.g., Posttraumatic Stress Disorder, seizures) was limited or insufficient (Abrams, 2018; National Academies of Sciences, Engineering, and Medicine, 2017). It is important to understand whether certain cannabis products are perceived to promote optimal effects, and the extent that such beliefs differ among individuals based on MCC status.

Cannabis types are typically distinguished based on two cannabis plant species (i.e., Indica, Sativa; Piper, 2018; Small & Cronquist, 1976), which are often marketed as producing divergent effects. Retailers are more likely to recommend Indica strains for insomnia and anxiety (Haug et al., 2016); Sativa strains are reported to engender predominantly stimulant effects and are recommended for conditions like depression and appetite stimulation (Haug et al., 2016; Piper, 2018). Despite the Indica/Sativa dichotomy, the current system for classifying cannabis has received scrutiny (e.g., Piomelli & Russo, 2016) and the debate continues as to whether a verifiable difference exists between the two strains (Hazekamp et al., 2016). More research is needed to identify whether misconceptions around Indica and Sativa products exist among individuals with and without an MCC, including instances when one strain is preferred over another.

Various administration modes exist but inhalation of combustible whole-plant cannabis (e.g., joints) remains most common (Schauer et al., 2016; Singh et al., 2016). Vaporization and oral forms (e.g., edibles, beverages) have also gained popularity (Borodovsky et al., 2016). However, it is unclear what impact administration mode has on cannabis use patterns or therapeutic outcomes. For example, vaporizing cannabis concentrates may be optimal for decreasing headache severity (Cuttler et al., 2020) but may also produce severe pulmonary injuries (Anderson & Zechar, 2019; He et al., 2017). As such, additional research is needed to understand why, and in which contexts, individuals with and without an MCC may prefer distinct administration modes.

The present study aimed to explore similarities and differences in cannabis use patterns and preferences between individuals with and without an MCC. As legislation permitting recreational and medical cannabis use continues to increase and more individuals start to use cannabis for medical and nonmedical purposes, it is vital to ascertain consumers’ beliefs about cannabis products that they use to help inform future prevention, intervention, and policy efforts. Qualitative data were used to characterize use patterns, determine whether certain products were preferred for specific reasons or health conditions, and understand beliefs surrounding the effects of different cannabis products.

Method

Participants

We report how we determined our sample size, all data exclusions, all manipulations (not applicable), and all measures in the study. Individuals were recruited from Rhode Island (RI) and Massachusetts (MA) in 2015–2016. Individuals with an MCC (n = 25, Mage = 46.96 year, 60% female, 68% Caucasian) and without (n = 31, Mage = 26.10 year, 29% female, 54.8% Caucasian) participated in semistructured individual interviews and focus groups, respectively. Throughout data collection, medical cannabis use was legal with an MCC and recreational use was illegal but decriminalized in RI and MA. In RI, specific conditions qualified for an MCC (e.g., cancer, epilepsy; see Mercurio et al., 2019) per the patient’s certifying healthcare provider (i.e., Doctor of Medicine, Doctor of Osteopathic Medicine, Physician Assistant, Advanced Practice Registered Nurse). In MA, those same conditions plus any debilitating condition qualified for an MCC per the patient’s certifying healthcare provider (i.e., Doctor of Medicine, Doctor of Osteopathic Medicine).

Non-MCC participants met the following inclusion criteria for focus groups, which were matched to the associated laboratory cannabis administration study: ages 18–50, English speaking, past-month cannabis use ≥ four times, past 6-month use ≥ monthly, not currently seeking treatment for, or attempting to quit, cannabis, and past 6-month cannabis purchase ≥ twice. MCC participants met identical inclusion criteria as listed above except that the age range was expanded to 70 given that MCC participants did not complete the laboratory cannabis administration study and the prevalence of medical cannabis use among older adults has increased. The present study’s sample size included all available data from participants who met inclusion/exclusion criteria. This study was not preregistered and no manipulations were implemented.

Procedure and Measures

All study procedures were approved by the University’s Institutional Review Board (Protocol #: 1502001185; Behavioral Economic Analysis of Demand for Marijuana). After consenting, participants provided information on sociodemographic characteristics and completed the Marijuana History and Smoking Questionnaire (Metrik et al., 2009) to assess average use days per week, duration of regular use (in years), frequency of use for medical purposes, and typical administration mode (for full review of procedures, see Aston, Scott, & Farris, 2019). Interviews and focus groups were moderated by the principal investigator (E.R. Aston); a trained research assistant attended sessions for purposes of note-taking. Participants were asked: “Tell me about your cannabis use routine,” “What do you know about the cannabis you are buying?,” “What are the reasons for using different strains of cannabis?,” and “Are certain strains marketed for certain effects?.” Interviews and focus groups were audio recorded and captured via observational notes. Interviews and focus groups lasted approximately 60 and 75 min, respectively, and proceeded until achieving data saturation (i.e., new or relevant data ceases to arise). Participants were compensated $40. For additional data and study materials, please contact the second author.

Data Analysis Plan

Independent samples t-tests and chi-square tests were used to determine whether sociodemographic or cannabis use variables differed between groups (Table 1). Interviews and focus groups were transcribed verbatim and identifiers were removed. A qualitative coding structure was developed from the semistructured agenda and refined throughout coding to include emergent topics. Transcripts were coded separately by two research assistants using an open-coding process (Glaser & Strauss, 1967). Codes were subsequently entered into NVivo qualitative data analysis software for thematic analysis.

Table 1.

Sample Descriptive Characteristics

General characteristics; M (SD), range Combined sample (n = 56) MCC participants (n = 25) Non-MCC participants (n = 31)
Age, in years*** 35.41 (14.12), 18–67 46.96 (11.86), 24–67 26.10 (7.20), 18–41
Education levela 3.68 (1.05), 1–5 3.68 (0.95), 1–5 3.68 (1.14), 1–5
Individual annual incomeb 1.42 (1.86), 0–7 1.40 (2.02), 0–7 1.43 (1.76), 0–6
Employment (n, % employed)*** 36 (64.3) 9 (36.0) 27 (87.1)
Sex (n, % male)* 32 (57.1) 10 (40.0) 22 (71.0)
Ethnicity (n, % Hispanic) 10 (17.9) 3 (12.0) 7 (22.6)
Race (n, %)
 American Indian/Alaskan Native 1 (1.8) — 1 (3.2)
 Asian 3 (5.4) 1 (4) 2 (6.5)
 Black* 6 (10.7) — 6 (19.4)
 Multiracial 8 (14.3) 5 (20) 3 (9.7)
 Native Hawaiian/Pacific Islander 1 (1.8) — 1 (3.2)
 White 34 (60.7) 17 (68) 17 (54.8)
 Other 3 (5.4) 2 (8) 1 (3.2)
Cannabis-related variables
 Past-month use days/week* 5.54 (2.06), 1–7 6.20 (1.78), 1–7 5.00 (2.15), 1–7
 Duration of regular cannabis use, in years** 12.57 (13.75), 0–49 19.56 (16.98), 0–49 6.94 (6.05), 0–22
 Frequency of use for medical purposesc,*** 2.84 (1.66), 0–4 3.92 (0.28), 3–4 1.97 (1.80), 0–4
 Usual cannabis mode(s) of administrationd (n, %)
  Combustible 25 (44.6) 11 (44.0) 14 (45.2)
  Edible** 34 (60.7) 20 (80.0) 14 (45.2)
  Vaporization 25 (44.6) 14 (56.0) 11 (35.5)
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Note. MCC = medical cannabis card.

a

Mean education level equivalent to GED or some college.

b

Mean income equivalent to $30,000–49,999.

c

Non-MCC mean equivalent to daily or almost daily, MCC mean equivalent to monthly, 0 = never, 1 = less than monthly, 2 = monthly, 3 = weekly, 4 = daily or almost daily.

d

Participants could select all applicable modes of administration.

*

p < .05.

**

p < .01.

***

p < .001 for comparisons between MCC and non-MCC participants.

After the initial open-coding review of transcripts was complete, relevant content then underwent secondary coding and analysis. Final codes were reviewed and summarized to identify key themes reported herein. Themes are described but data are not quantified as this would not accurately reflect the prevalence of a given behavior or belief (Hannah & Lautsch, 2011). Each quote includes the assigned participant study number and group (i.e., MCC status) in parentheses. Illustrative quotes were selected to reflect the most accurate representation of each theme, and are presented across groups to compare themes for each topic (Table 2).

Table 2.

Study Themes and Representative Quotes Concerning Use of Cannabis Products and Reasons for Use Among Individuals With and Without a Medical Cannabis Card (MCC)

Subtheme Group ID Quote
Mode of administration
Non-MCC #19
I prefer … a joint. But the thing is, is that I don’t always have them. So I’m normally smoking out of a bowl, that’s my second … preference
MCC #41
Just a glass pipe. The only other way is topical which is basically safe oils that they use, they’re edible oils in the drinks as well. … I just rub it [cannabis oil] all over where the pain is
MCC #44
I don’t know if it so much a preferred way [smoking cannabis]. It’s just that most of the time that’s the way I do it, but I also use edibles and vape
MCC #45
I usually roll either [sic] joint or blunt. … I’ve used pipes and I do make edibles for a friend. … I also used … Dabbs or shatter or the wax … too
MCC #46
I smoke it and I use it in candy form. … I smoke it in a joint … but I do like the candy form, I currently use the candy form right now and I feel like I have more control
MCC #47
I’m using … the oil to help fight my cancer directly as an edible and then I [sic] for the flower to help relieve anxiety and. … general attention
Time of administration
Non-MCC #3
Not every day, but … usually … once on the weekend, uh, vaporize, and then … if it’s a particularly light week, then I’ll … vaporize a couple times … in the evening … during that week
Non-MCC #11
I smoke every day. When I wake up in the morning, like 15 minutes … and then I smoke … in the afternoon. And then I smoke … before bed or before I watch my TV shows … to relax
Non-MCC #18
I like to get all the important stuff out of the way. So like I’ll work or go to school and at the end of the night or whatever, you’re watching a movie with a friend or roommate and spark a bowl. … But that’s about it. There are some days, though, that we’ll wake up and smoke, but that’s … not preferable, cuz you kinda get like sluggish and … don’t wanna carry on with the rest of your day
Non-MCC #21
I have a pretty busy schedule through the week with school, and [when I use cannabis] it’s usually anytime … after … my full day of what I do, or after work
Non-MCC #29
If I’m at school, then, typical day, wake up, get the kids to school, get myself where I need to be, so I’m not … driving under the influence. And then I just smoke at school, and then I’m at school for like the whole day. And then, again … a few hours before I go to bed
MCC #41
I smoke before I eat. So whatever time of the day I eat and then I smoke before sleep … If it’s one or three times, I smoke before or after … I usually try to go for like one gram a day, and it’s very routine. Morning and the night, definitely, and before I eat
MCC #50
I’ll wake up, usually I’ll go on the back porch and have a bowl. Come back in the house do my chores, laundry, dishes stuff like that, household duties. Then I’ll go out smoke another bowl and that’s basically how my day goes. I’m smoking like every couple of hours
MCC #51
Well usually I have like a joint and a cookie in the morning. I get up, like some people have their cigarette with their coffee, I’ll have a marijuana cigarette with my coffee and then either a muffin or a cookie with it … I would say depending on the strength of the product I’m using, it could be every couple of hours or it could be an hour
MCC #55
At least an hour before I go to bed … I use it and then I usually relax maybe an hour. TV and then I go to bed
MCC #57
Once my son goes to bed and I have some time to unwind I’ll smoke and watch a little TV and then I’ll go to bed
Symptom management
Non-MCC #2
If you’re a medical user, then you would use a different strain depending on … what condition you have, but if you’re using it recreationally … there’s not that much difference
Non-MCC #9
That’ll [referring to Indica strains] be good if I wanna sleep or something, but that’s about it
Non-MCC #11
Yeah [there are different reasons for using different strains], because some are better for pain and some are better for anxiety, … you can look it all up
Non-MCC #19
It’s like you can still go and do stuff, but it [cannabis] takes away your pain at the same time
Non-MCC #24
Normally, because I have insomnia, I’m like always like up and agitated and whatever, so [cannabis] just calms me down … so I can go to bed
MCC #35
My cancer that I had was skin cancer. So I didn’t take anything to alleviate nausea or anything like that. … But really what I really use it [cannabis] for is … to manage like any kind of depression or anxiety. It really helps me take the edge off, but I can still think and do what I need to do
MCC #36
I’ve, I needed it [cannabis] since I was 17. … I dealt with … bipolar and major depression … and I would be not alive without it
MCC #37
I was titrating to figure out from this batch … what I was aiming for, that same type of pain relief. … Because if I have a migraine … I’ll take the edible if I can even get it down. … [Cannabis] give [sic] me a little extra boost for the pain
MCC #41
It [cannabis] gets me … less anxious … it helps you … hone in on yourself
MCC #42
Blue dream [specific cannabis strain] is very much a medical reliever, it’s one of the top medical cannabis variety [sic] for any condition. Don’t ask me why, but it just works
MCC #43
I find … it [cannabis] definitely helps with pain because if you are really stressed, especially with like an [sic] MS and stuff, the fact that it just relaxes you at all, not just your muscles but it relaxes your mind enough where, you can let some of that go
MCC #45
Baking [cannabis], that type of method … It’s more relaxing. That will actually … make you more tired. So that’s better for the evening, when you’re trying to fall asleep
MCC #46
I’m going to get more pain relief, I’m going to get that relax [sic] feeling, that sleepy feeling, it’s going to help me get a better sleep, my muscles are going to stop spasm [sic]
MCC #51
While they’re [different cannabis strains] all good for pain, some are just better than others
MCC #53
Especially since I have Bipolar. So I go up and down so it keeps me level throughout the day. … It [cannabis] helps with stress. It helps to keep my mind focus [sic] and with anger issues
MCC #54
When … my core muscles and stomach … were really cramped and sore. I smoked them [cannabis] and that helped me. That relieved the issue
MCC #56
For the nausea I smoke or vaporize because it’s immediate and if I feel like I’m about to start vomiting I want to stop it immediately
MCC #57
When I did have endometriosis, I smoked [cannabis] a lot. Like if I was having an episode I was smoking nonstop. … If I was in that much pain I would just stay home and smoke all day
MCC #58
The nausea relief is almost instant [when using combustible forms of cannabis]. The cramping takes about 5 to 10 minutes to relieve.
MCC #58
If it’s more of a GI issue, I will take an edible. Edibles will help me more. The effects are just longer so I don’t like to use an edible before work
Budtender/dealer recommendations
Non-MCC #1
I typically know who … grew it [cannabis the participant purchased] and … he’ll tell me the strain name, … any details about it that I want to know, like, if it’s an indica/sativa hybrid
Non-MCC #7
I don’t really know much about the weed that I smoke. Just gotta trust your dealer
Non-MCC #9
It’s usually just if I go to a person’s place to … buy it, it’s like whatever I see. … I can tell if it’s good or not, but … there’s usually not a lot of choice in the matter. … Just, like, whatever’s available
Non-MCC #16
But I mainly know that … it [cannabis the participant purchases] comes from the dispensary most of the time. … It shows the percentage of THC in there
Non-MCC #27
I know everything about it [cannabis the participant purchases]. I mean I get it from a grower, so I … know the percentage and all that stuff
Non-MCC #28
A lot of the time, if like you ask a dealer who doesn’t grow their own stuff what the strain is, sometimes they’ll just make something up on the spot, like, Oh, yeah, this is that OG pineapple. It’s the best shit ever … but … most of the time, they just don’t know … or … the guy who sold it to ‘em just made up a strain and told them
MCC #35
I’ve gone to [the dispensary] and I say is there anything that you can recommend … that’s good for anxiety and sleep. And then they’ll say, yeah right now we have “blah, blah, blah.” Or I’ll say, uhm, do you have anything … that’s good for more of a creative high. I need to write and they’ll say, yeah this. And sometimes I agree with them and sometimes I think it’s just good weed and I don’t agree with them. So this is what I mean by subjective, like, it could be the mood I’m in. If I smoked other weed before that. It could even be what did I eat, did I not eat? Did I sleep well?
MCC #36
If you go in there and ask the budtender, uhm, they’ll like try and lean you in a direction. But usually they say Sativa is more energizing, Indica is more for sleep and relaxation … I’ve seen on some menus on the other dispensaries, they’ll say great for depression and other stuff. And they did that on the menu at the [dispensary]
MCC #41
They [dispensary staff] said … “I have some problems too and … I’ve tried this and I found out that this helps [with relaxation].” And I was like, I’ll try it. And I started off with a little bit and it really does [help]. … They’re very good at those dispensaries. … They’ll tell you … if you’re feeling like nauseous or hyper or this or that, maybe you should try something lower or higher [in reference to cannabis strain]
MCC #46
They [dispensary staff] are trying to get people to understand that the sativa is more, we say sativa-sun. So it’s daytime and in Indicia [sic] where you say in the couch
MCC #50
They go over everything with you. So you getting [sic] what you need and what you want
MCC #52
I don’t think they [dispensary staff] market it [cannabis], they gather information about it and when you ask they tell you what it is and what it’s good for. But they don’t push it on anyone. Like they don’t say you should try this you should try that. They give me the information and let me decide
MCC #55
They [dispensary] gave me a form and it had … Sativa. You know, it increases your creativity and all that and your energy level. … I told them I needed it strictly for pain and so I can sleep more than an hour … And [dispensary staff] suggested a high concentrated CBD
Prophylactic use
MCC #41
However many times I eat. … I smoke before or after … so I don’t get nauseous
MCC #43
This morning I knew I was going to be doing yard work, then coming here, then going home to do more yard work later, so I had some [cannabis-infused] honey … The regular honey is one thing, that’s like, if I know … I [sic] going to have like a lot of physical … things going on its kinda like a … pregame thing. … If I have that for … the day it will like avoid all the … crap that I will usually wake up with … tomorrow
MCC #53
I usually smoke before I go especially if I have to drive. It’s hard for me to sit for a long time. So if I have to sit for a long period of time or something … I would smoke a little something and then drive. Not enough that’s going to impair me but just enough to be able to turn the wheel
MCC #56
I will normally eat an edible while making dinner and that will allow enough time for it to set in and to begin getting ready for bed and I use it because I find that it’s more preventive than anything like I normally get flare ups during the day, of pain, and as long as I take it at night the next day I can generally be pain free
Indica
Non-MCC #21
Best description I had in Colorado is they called … Indica “in-da-couch.” … So if you smoke that kind of variety you’re not gonna wanna be doing things actively. It’s gonna be more of a sedative
Non-MCC #29
I’ll use an Indica if I need … pain management and energy, so I focus on studying
MCC #37
For my day time, for what I call my day time—go to work, do numbers, that kind of stuff would always be a blueberry [names of cannabis strain]. Which they say is an Indica but somehow has [sic] different effect on me
MCC #40
I wouldn’t want a Sativa if I’m looking for pain relief but then again if I’m looking for mood enhancement, I’m not gonna consume an Indica. So there are different products … that will obtain different results.
MCC #43
Get yourself like something that’s all 90% Indica and not its 8:30 in the morning and you have a million thing to do and you decide, I’m going to medicate, yeah right, I’ll see you at noon
MCC #44
I use Indicas for pain reliever [sic]
MCC #45
[Indica strains] are better for the evening because they’ll actually do more, you know. It’s more body heavy, you want to kinda just relax
Sativa
Non-MCC #1
I’m a musician personally, so … I tend to like the sativa when I’m playing cuz it makes me feel … more creative. I feel like I can think of more interesting ways to play
Non-MCC #2
Sativa will give you … a head high, it’s more … like, a thinking sort of high. You have more thoughts. Typically you’re more creative
Non-MCC #9
I usually prefer to … be functional after smoking, so … a Sativa’s much better for that because you don’t wanna just … sit somewhere and … not do anything
Non-MCC #21
Sativa, on the other hand, which I prefer … doesn’t bring you down, energy-wise. It’s more of um … makes you think more rather than just kinda turning [you] to a vegetable
MCC #36
So if it’s … in the morning I usually use Sativa so I’m not sleepy
MCC #44
Sometimes the pain … is so intense that it’s [Indica strains] really not cutting through it, and at that point I need to look for something that’s more cerebral and that’s Sativa. I may still have the pain but … it [sativa] gives me inspiration, or the mindset that masks the pain
MCC #46
High sativa is … more stimulating, it’s more thought provoking and I’ll think more like “What do I want to do tomorrow.” Or “What research papers should I work on. … High sativa … really helps me with the day. And it really helps me stay super focused. But I have that energy … We say sativa-sun. So it’s daytime.”
MCC #48
I like the sativa during the day. High Sativa strains during the day, that wakes you up and gives you alertness
(Un)Importance of cannabis strain
Non-MCC #4
If I need the information [on strain or cannabinoid composition] … I can get it, but … I don’t really care to ask. It doesn’t really matter cuz … if it tastes good and … it’s gonna get me high, I’m happy
Non-MCC #9
If I go to a person’s place to … buy it, it’s like whatever I see. … I can tell if it’s good or not, but … there’s usually not a lot of choice in the matter
Non-MCC #18
I don’t see a reason, personally, for me [for using different cannabis strains]. … As long as it does the job. … As long as I smoke a bowl and I feel all right, then that’s all right with me. … I don’t go out of my way to find a … specific strain, you know?
Non-MCC #19
Like medical marijuana users obviously … want specific types and strains. Most recreational users will smoke anything
MCC #36
A lot of times I’ll mix a Sativa, a strong Sativa in with CBD and smoke them together. … That just adds a huge benefit to it. I never get like, feeling uncomfortable. You can use as much [cannabis] as you need but you never feel uncomfortable when I [sic] add the CBD to it
MCC #40
If you use a product a product and it works for you and you don’t know what the [cannabinoid] concentration is. Doesn’t matter. … Like myself and my patients, we don’t test the product if it works, it works. If it doesn’t, it doesn’t matter what the numbers say
MCC #41
The reason I … purchase two eighths is … If I have to get one [cannabis strain] that’s like 90 [percent] Sativa, I will get like the highest Indica so I can mix them
  MCC #45
It all depends on what that THC level is in it. But again depending on the strain you can something with 12% THC that works a lot better than something what 23% THC. It depends on the strain. Depends on how your body reacts to it
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Results

Qualitative Themes

Cannabis Use Routines

Mode of Administration.

MCC participants typically endorsed a preferred administration mode, but most used several modes. Combustible methods and edibles were most common. Many MCC participants also reported vaporization, and fewer reported using tinctures administered sublingually, cannabis-infused topicals, and concentrates. Conversely, most non-MCC participants preferred combustible modes. Further, while non-MCC participants were familiar with vaporization (see Aston, Farris, et al., 2019), few endorsed this as a primary or adjunct mode.

Timing of Administration.

Most MCC participants reported using cannabis consistently throughout the day and had routine medication schedules (#41, MCC). Participants with an MCC reported cannabis use was intertwined with other regular activities and helped them transition from one task to another. Further, almost all MCC participants reported using cannabis as part of evening or nightly routines, and that using cannabis helped them to relax or unwind (#55, #57, MCC).

Conversely, most non-MCC participants reported use routines that were less strict and influenced by day of week or other contextual factors, for example, workload (#3, #21, Non-MCC). Further, non-MCC participants infrequently reported using cannabis prior to completing daytime responsibilities (#18, Non-MCC). Yet, the majority reported using cannabis during the afternoon and/or evenings. Similar to MCC participants, non-MCC participants also discussed using cannabis at night to relax (#11, #29, Non-MCC).

Reasons for Using Cannabis Products

Symptom Management.

MCC participants generally believed that cannabis could effectively manage numerous symptoms and conditions (#42, MCC) ranging from bipolar disorder (#36, #53, MCC) to endometriosis (#57, MCC). Several MCC participants indicated that edibles optimally managed inflammatory diseases, for example, Crohn’s disease (#42, MCC), provided longer effects, and more pain relief than other formulations/modes (#37, #42, #51, #58, MCC). Many participants noted cannabis effectively treated pain from various sources (#42, #43, #45, #46, #54, #57, #58), but some believed certain strains were better for pain (#51, MCC). Others perceived that combustible forms effectively treated nausea due to rapid antiemetic effects (#56, MCC).

Perhaps unsurprisingly, few non-MCC participants used cannabis to manage psychiatric and/or physical symptoms; those that did described how cannabis helped with managing pain and/or mitigating anxiety (#11, #19, #29, Non-MCC). Further, some participants believed individuals who use cannabis for medical purposes would prefer certain strains based on medical conditions (#2, Non-MCC). Participants with and without an MCC agreed cannabis was an effective sleep aid, noting it helped them to relax so they could fall and stay asleep (#24, Non-MCC). Moreover, participants agreed that Indica strains were better able to engender sleep than were Sativa strains (#9, Non-MCC; #43, MCC).

Dispensary/Dealer Recommendations for Specific Cannabis Products.

Many MCC participants described receiving recommendations for cannabis products at dispensaries, but experiences varied. In some cases, participants described a personalized experience (#50, #55, MCC). Others described how staff recommendations were based on patient-reported symptoms, such as anxiety and/or pain (#41, #46, #50, #55, MCC). In other instances, participants indicated dispensary staff would make broader recommendations based on strain (#36, #46, MCC) or cannabinoid composition (#35, #55, MCC). Notably, a few participants expressed skepticism about the accuracy of dispensary staff recommendations and perceived the information to be subjective (#35, MCC).

As expected, most non-MCC participants described a dissimilar experience when purchasing cannabis from illegal suppliers (i.e., dealer). They described receiving minimal information about available products prior to purchasing and some expressed skepticism about the details of certain cannabis characteristics (e.g., strain name; #7, #28, Non-MCC). However, some explained that they had considerable knowledge regarding their cannabis because their dealers grew their own products (#1, #27, Non-MCC) or purchased diverted cannabis from retail dispensaries (#16, Non-MCC).

Prophylactic Use.

Several MCC participants used cannabis to prevent certain symptoms, such as pain (#43, MCC) or nausea (#41, MCC), and described how using cannabis before physical activity helped mitigate experiences of pain (e.g., intensity) later. Conversely, non-MCC participants did not discuss using cannabis prophylactically.

Perceived and Experienced Subjective Effects

Indica.

Participants perceived Indica strains most often produced pleasurable, relaxing, and sedating effects (#21, Non-MCC; #43, MCC). Many also discussed perceived analgesic effects of Indica strains (#29, Non-MCC; #40, #43, #44, #45, MCC). However, beliefs about sedating effects of Indica strains were not universal. Some participants noted using Indica strains for energy (#29, Non-MCC) or while engaging in daytime tasks (e.g., work; #37, MCC).

Sativa.

Participants agreed Sativa strains produced stimulating subjective effects such as enhanced mood (#40, #45, MCC) and increased focus (#46, #48, MCC). Accordingly, participants primarily used Sativa strains during the day (#36, #46, #48, MCC) and perceived them to be less impairing than Indica strains (#9, Non-MCC). Multiple participants conveyed feeling more creative after using Sativa strains (#1, #2, Non-MCC). Others noted Sativa strains permit altered mindset to help tolerate pain (#44, MCC).

(Un)Importance of Cannabis Strain.

Many, but not all, MCC participants indicated it was important to know characteristics about their cannabis, such as strain or cannabinoid composition (e.g., THC:CBD ratio), because it denoted expected subjective effects for a given product and informed purchasing decisions (#36, #41, MCC). However, some MCC participants noted strain was less relevant due to individual differences and that symptom reduction should be the driving factor rather than strain (#40, #45, MCC).

Alternatively, non-MCC participants evaluated cannabis quality based more on physical sensory aspects (e.g., taste, smell, visual; #4, Non-MCC) and rarely noted strain or cannabinoid composition as important factors influencing purchase or use. Indifference toward strain may be attributed to general apathy toward strains or cannabinoid compositions (#18, #19, Non-MCC) or access constraints, as most were using cannabis obtained illegally (#9, Non-MCC).

Discussion

In the present study, MCC participants reported frequent use of multiple cannabis products, whereas non-MCC participants reported less frequent, more opportunistic use. No consensus emerged among participants regarding specific cannabis characteristics that were preferred for certain conditions. Rather, a general belief persisted that cannabis effectively treated many physical and psychiatric symptoms, including conditions with moderate to limited evidence of efficacy (Abrams, 2018). Accordingly, consistent informational campaigns are needed to accurately educate all consumers about cannabis’ ability to treat medical conditions and to counteract widespread misperceptions about cannabis’ therapeutic and subjective effects.

Individuals who use cannabis must rely on subjective input from dealers, dispensary staff, or “trial and error” approaches to determine if product information is accurate or certain dosing regimens are effective (Mercurio et al., 2019). Oftentimes, non-MCC participants had minimal information on products they used. While dispensary staff helped inform product selection for many MCC participants, they are allowed to make recommendations without medical education (Haug et al., 2016), including unsubstantiated claims that directly contradict established medical consensus (Dickson et al., 2018). Thus, more precise guidelines are needed so individuals can make informed decisions about the products they purchase. While participants generally agreed that Sativa and Indica strains engendered distinct subjective effects, it is unclear to what extent differences were due to expectancies. Indeed, misconceptions surrounding cannabis’ therapeutic benefit are pervasive among individuals regardless of MCC status (e.g., that Indica strains reliably produce sedative effects). Identifying misconceptions about cannabis’ medical benefits may inform future prevention/intervention efforts.

This study was not without limitations. Participants were classified based on MCC status, however, non-MCC participants also endorsed infrequent cannabis use for medical purposes, on average. Further, some participants may have obtained an MCC to facilitate nonmedical use, but this theme did not emerge during individual interviews. Regardless, a meaningful and parsimonious way to distinguish between people who use cannabis only recreationally versus only medically remains elusive (Budney, 2021). Second, participants were required to have their MCC card registered in RI/MA. Recreational cannabis use was illegal during data collection but is currently legal in MA. Thus, generalizability may be limited due to potential differences in legal status or accessibility. However, all participants reported near-daily cannabis use, and while MCC participants preferred more administration modes than non-MCC participants, participants across groups indicated usual use of many different administration modes. Further, use and/or access to various cannabis products is not required for individuals to hold specific beliefs about their subjective effects or medical benefit. Additionally, there were some notable differences between the groups; those in the MCC group were older with more years of regular use, and it is possible that these differences or other underlying factors (e.g., tolerance) influenced thematic group differences. However, study themes remained consistent when comparing the top versus bottom three quartiles of participants based on age/duration of regular use (i.e., oldest participants and participants with the longest duration of use versus younger participants and participants with a shorter duration of regular use). Finally, data collection methods differed between groups that may have elicited different responses. The interactive component of focus groups can elicit a broader range of beliefs and ideas (Agar & MacDonald, 1995; Powell & Single, 1996), whereas interviews can provide more nuanced information about one’s personal beliefs and feelings (Knodel, 1993; Morgan et al., 1998).

Altogether, it is critical to understand differences in cannabis use patterns, perceptions about different products, and purchasing behaviors among individuals with and without an MCC. Given misperceptions of cannabis’ ability to treat medical conditions among individuals regardless of MCC status, these beliefs may be beneficial intervention targets. Additional research is also needed to establish evidence-based guidelines for medical cannabis dosing regimens.

Public Health Significance.

This study demonstrated that individuals with and without a medical cannabis card believed cannabis, in general, effectively treated myriad physical and psychiatric conditions and that Indica and Sativa cannabis strains produced primarily stimulating and sedating subjective effects, respectively. However, access to objective information about different cannabis products was limited and support when deciding which products to use for medical purposes was lacking.

Acknowledgments

Funding for this research, including participant compensation and author effort, was supported by the National Institute on Drug Abuse grant K01DA039311 (Elizabeth R. Aston), National Institute of General Medical Sciences Center of Biomedical Research Excellence grant P20GM130414 (Elizabeth R. Aston), National Institute on Alcohol Abuse and Alcoholism grant T32AA0 07459 (Benjamin L. Berey), and National Institute on Alcohol Abuse and Alcoholism grant F31AA028751 (Nioud Mulugeta Gebru). All funding sources had no other role in study design or manuscript preparation other than financial support. All authors contributed to the data analysis and interpretation and have read and approved the final manuscript.

Footnotes

The authors have no conflicts of interest to disclose.

This study was not preregistered. For additional data and study materials, please contact the second author.

The findings appearing in the manuscript were previously disseminated at the American Psychological Association Society of Addiction Psychology (APA Division 50) Collaborative Perspectives on Addiction conference in March, 2021.

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