Access to Cannabis for Medical Purposes in Canada: Gathering information on views and practices of patients and health care practitioners

Executive Summary

Prepared for Health Canada

Supplier Name: Phoenix SPI

Contract Number: HT372-214981/001/CY

Award Date: 2022-01-07

Contract Value: $249,429.53 (including applicable taxes)

Delivery Date: 2022-10-24

Registration number: POR 093-21

For more information on this report, please contact Health Canada at: hc.cpab.por-rop.dgcap.sc@canada.ca

Ce rapport est aussi disponible en français.

Access to Cannabis for Medical Purposes in Canada:

Gathering information on views and practices of patients and health care practitioners

Executive Summary

Prepared for Health Canada

Supplier name: Phoenix Strategic Perspectives Inc.

October 2022

This public opinion research report presents the results of two online surveys: one conducted with individuals who have used cannabis for medical purposes since legalization in Canada and the other conducted with medical doctors and nurse practitioners from a specialized panel who have authorized cannabis for medical purposes since legalization or who have discussed, treated or referred a patient in relation to cannabis for medical purposes.

This publication may be reproduced for non-commercial purposes only. Prior written permission must be obtained from Health Canada. For more information on this report, please contact Health Canada at:

HC.cpab.por-rop.dgcap.SC@canada.ca or at:

Communications and Public Affairs Branch

Health Canada

200 Eglantine Driveway, Jeanne Mance Building

AL 1915C, Tunney's Pasture

Ottawa, Ontario K1A 0K9

Catalogue number:

H14-422/2022E-PDF

International Standard Book Number (ISBN):

ISBN 978-0-660-46221-9

Related publications (registration number: POR 093-21):

Catalogue number (Final report, French) H14-422/2022F-PDF

ISBN 978-0-660-46222-6

^© His Majesty the King in Right of Canada, as represented by the Minister of Health, 2022.

Cette publication est aussi disponible en français sous le titre : Accès au cannabis à des fins médicales au Canada : renseignements sur les perspectives et les pratiques des patients et des professionnels de la santé

Executive Summary

The Cannabis Act and Cannabis Regulations came into force on October 17, 2018. Health Canada commissioned Phoenix Strategic Perspectives Inc. (Phoenix SPI) to conduct baseline surveys on access to cannabis for medical purposes.

1. Research Purpose and Objectives

The primary objective of this research is to gather evidence on the state of access to cannabis for medical purposes in Canada. The target populations were:

• Individuals, of any age, who have used cannabis for medical purposes since the legalization of cannabis (October 17, 2018). This includes adults who are responsible for a person who uses cannabis for medical purposes and who completed the survey on their behalf.
• Health care practitioners (HCP)s, defined as doctors or nurse practitioners who have the legal authority to authorize cannabis for medical purposes, and who have had patients disclose use of cannabis for medical purposes since the legalization of cannabis (October 17, 2018).

Specific objectives for each target population were as follows:

• Individuals who have used cannabis for medical purposes since legalization[1]: Understand the socio-demographic profile of those who use cannabis for medical purposes; determine whether the legalization and regulation of cannabis in Canada is perceived as having benefited those who access cannabis for medical purposes, and if it is, how it benefits them; collect information on use patterns for medical purposes as well as on how cannabis for medical purposes is accessed (e.g., medical sales licence holder, provincial retail store); and identify any barriers to accessing cannabis for medical purposes.
• Health care practitioners: Understand the socio-demographic profile of HCPs; gather information on their knowledge, perceptions, and informational sources regarding cannabis for medical purposes, and how these factors affect their attitudes towards cannabis for medical purposes; gather information on HCPs who support cannabis for medical purposes, including, for example, details regarding their authorization experiences; and better understand if the legalization of cannabis has changed the way in which they perceive or authorize cannabis for medical purposes.

2. Methodology

Two surveys were administered as follows:

• A 20-minute online survey was administered to a non-probability sample of 1,205 Canadians aged 16 and older who have used cannabis for medical purposes since it was legalized on October 17, 2018). The sample was drawn from the Leger Opinion panel (LEO) and the fieldwork was conducted from May 5 to May 13, 2022. The survey data have been weighted by region, age, and gender of those who use cannabis for medical purposes using figures from the government of Canada's 2021 Canadian Cannabis Survey.
• A 15-minute online survey was administered to a non-probability sample of 823 medical doctors and nurse practitioners who have had experiences with patients accessing or inquiring about cannabis for medical purposes since legalization. The sample was drawn from MD Analytics proprietary panel of Canadian health care professionals and augmented by a small sample of nurse practitioners drawn from a provincial health regulator. The fieldwork was conducted from May 19 to July 12, 2022. The survey data have been weighted by region and type of HCP using figures from the Canadian Institute for Health Information (CIHI) Health Workforce data.

3. Key Findings

Key Findings from the Patient Survey

Legalization improved access, information sharing, and reduced stigma associated with cannabis.

• Just over half (53%) of the patients surveyed said they used cannabis for medical purposes prior to the broader legalization of cannabis for non-medical purposes in Canada. Conversely, 46% started using cannabis for medical purposes only following legalization of cannabis for non-medical purposes on October 17, 2018.
• More than half of the patients surveyed (58%) who were motivated to start using cannabis for medical purposes following its broader legalization said this is because cannabis became more accessible and easier to buy. Half made the decision because more information about cannabis for medical purposes became available (49%), and half because legalization reduced the stigma associated with cannabis use (49%).
• Over two-thirds (71%) of respondents who use cannabis for medical purposes have also used cannabis for non-medical purposes in the past three years.

The majority consulted a medical doctor or nurse practitioner prior to using cannabis for medical purposes. Those who didn't consult felt apprehension surrounding discussions about cannabis with health care providers.

• A majority (66%) of patients discussed the use of cannabis for medical purposes as a potential treatment option with a medical doctor and/or nurse practitioner.
• One-third (34%) of patients did not discuss the use of cannabis for medical purposes with a medical doctor or nurse practitioner. Patients who did not discuss the use of cannabis with a practitioner provided a variety of reasons for not doing so. Fear and apprehension were common themes among many of these patients – 22% feared the medical doctor or nurse practitioner would not be willing to talk about cannabis as an option, 21% feared being judged, and 18% were just not comfortable asking about cannabis.

Half of patients who discussed using cannabis for medical purposes with their HCP received a medical document authorizing them to use cannabis for medical purposes. Among those who discussed using cannabis for medical purposes with an HCP, but who did not receive a medical document, the majority said they did not ask their HCP for a medical document.

• Half (53%) of patients who discussed using cannabis for medical purposes with a HCP received a medical document. Conversely, more than one-third (38%) did not receive a medical document.
• Of those who discussed using cannabis for medical purposes with their HCP, and who did not receive a medical document (n=298), the majority (73%) said it was because they did not ask for one. Only one in five (20%) asked for a medical document and were refused one by their HCP. Reasons for refusing to issue a medical document included that the health care provider does not authorize cannabis for patients (38%), that there is a lack of evidence to support cannabis as a treatment option (31%), or that the health care provider did not know enough about the use of cannabis for medical purposes (29%).

• Recommendations regarding the appropriate levels of THC and CBD received by patients varied. About one-third (31%) said they were recommended higher levels of CBD with lower levels of THC. One-quarter (24%) said they were recommended cannabis containing equal levels of THC and CBD, 19% were recommended CBD only, and 17% were recommended higher levels of THC and lower levels of CBD.
• According to patients, the most common type of cannabis recommended to them is cannabis oils and extracts (42%), followed by edibles (26%), capsules (24%), and dried cannabis (23%).

Among patients with a medical document, the majority are either registered with a licensed seller or authorized to produce their own cannabis. Those with Health Canada authorizations found them lengthy or complicated to complete.

• Approximately one-third of respondents who have a medical document authorizing their use of cannabis obtain their cannabis via a licensed seller (37%) or are authorized by Health Canada to produce their own (33%). Fewer are authorized to designate someone else to produce cannabis for them (13%).
• Those registered with Health Canada to produce cannabis for themselves were asked what issues they may have encountered when applying to Health Canada; one-third said the application process took a long time (37%) or was complicated (31%), although 26% indicated that they did not experience any issues. Among those authorized to designate someone else to grow cannabis on their behalf, 38% found the registration process took a long time, and one-third (32%) said the process was complicated.
• Among those who access cannabis for medical purposes through a licensed seller, many said the cannabis from these sources is more expensive (34%). Beyond cost, a common theme among these patients included logistical issues in receiving the cannabis. For example, patients found issue with the following: the need to buy cannabis online with no physical store (27%), and an inability to get their cannabis immediately (24%). Others found they could not always get their preferred products (27%) or had issues with the registration process – 16% say registration was complicated, and 13% say it took a long time.
• Patients who do not buy cannabis through a licensed seller most often said this is because it is more expensive (27%).

More than one-third use cannabis for medical purposes daily; most others do so several times a week. Smoking cannabis is the most common method of consuming cannabis for medical purposes, while the preferred ratio of THC and CBD levels in cannabis products varies by patient.

• In a typical month, 39% of patients said they use cannabis for medical purposes daily or almost daily. Most others use cannabis several times a week (21%), with fewer using cannabis once a week (14%), or several times a month (10%).
• Although respondents' preferred methods of consuming cannabis for medical purposes vary, three methods were noted with higher frequency. Forty-four percent of patients smoke cannabis, 34% prefer edibles, while nearly one-third (31%) ingest cannabis extracts or oils.
• Most patients prefer cannabis products that include both THC and CBD, but there is no consensus on the preferred ratio of THC to CBD. Similar proportions prefer higher levels of THC with lower levels of CBD (27%), higher levels of CBD with lower levels of THC (30%), or equal levels of both THC and CBD (28%). Fewer patients (13%) prefer a product containing only THC.

In terms of outcomes, nearly half feel better in general using cannabis for medical purposes; one-third noted a symptom improvement and increased ability to function. Few patients surveyed experienced negative effects, and most of those who did, said the negative effect they experienced was not serious.

• More than three-quarters (78%) of respondents reported a positive outcome of using cannabis for medical purposes. Many (45%) said that using cannabis for medical purposes has helped them feel better in general. Following this, one-third say their symptoms have improved, and 31% said they are able to function better. One in five mentioned that their condition has improved or resolved altogether (21%) and that they have been able to decrease the use of other medications (19%) because of using cannabis for medical purposes.
• Fewer patients noted negative or neutral outcomes from their cannabis use. These include feelings of intoxication (10%), lack of improvements to symptoms or conditions (10%), or adverse or negative effects (9%). Among those who did experience a negative reaction or side effect from using cannabis for medical purposes, two-thirds (68%) said this experience did not require medical attention or result in hospitalization.
• Symptoms of nausea (61%), sleeping problems (53%), and lack of appetite (51%) were among the symptoms for which patients reported improvements.

Six in 10 patients feel the broader legalization of cannabis in Canada in 2018 has positively impacted medical access to cannabis. Many find better product variety, availability, and stigma reduction.

• Six in 10 (60%) patients said that the broader legalization of cannabis in Canada has improved their access to cannabis for medical purposes. Among the patients who said legalization has had a positive impact on their access to medical cannabis, half said there are more (52%) or better quality products available (50%). Similarly, nearly half feel that there is less stigma surrounding the use of medical cannabis, that there are more sources to purchase from (49%), and that it is now easier to find information on cannabis prodcuts (47%).

Key Findings from the Health Care Practitioner Survey

The vast majority of HCPs surveyed believe there is therapeutic value in the use of cannabis at least some of the time.

• Nearly half of practitioners (49%) said there is therapeutic value in the use of cannabis, while most of the rest (45%) indicated that there is value at least some of the time.
• Of those who said there is therapeutic value to the use of cannabis at least some of the time, three-quarters cited clinical examples that suggest cannabis can have therapeutic value to explain why, while just over half (59%) said that the intolerability or ineffectiveness of other treatments for some patients presents cannabis as a reasonable treatment option in these situations.
• Among those who said there is therapeutic value to the use of cannabis at least some of the time, the vast majority (89%) identified CBD as the part of the cannabis plant that has therapeutic value. Furthermore, 44% identified THC, 13% identified other cannabinoids, and 9% identified terpenes.
• There was widespread agreement among HCPs that CBD has therapeutic value (90%), and that there are risks associated with the use of THC for medical purposes (85%).

Many practitioners have been asked by patients for information about cannabis for medical purposes and have demonstrated a willingness to consider cannabis as a treatment option for patients.

• Nine in 10 (92%) practitioners have been asked by patients for information about using cannabis for medical purposes.
• Nearly two-thirds (64%) of HCPs said they have treated a patient who uses cannabis for medical purposes without recommending it, while smaller majorities have referred a patient to a colleague who is an expert on the use of cannabis for medical purposes (55%) or recommended to a patient that they use cannabis to treat their symptom or disease (53%).

Practitioners are most likely to recommend patients access cannabis for medical purposes via a legal storefront or legal website. Among those who recommend sources of cannabis for medical purposes, the top reason for doing so is product safety.

• Asked where they recommend that their patients access cannabis for medical purposes, health care providers were most likely to say they recommend legal storefronts or provincially authorized retailers and legal websites at least some of the time. Specifically, 70% said they recommend legal storefronts at least sometimes while 60% said this about legal website for cannabis for medical purposes. Fewer HCPs recommend that patients access cannabis for medical purposes from the hospital or via Health Canada.
• Among those that recommend patients access cannabis for medical purposes from select sources, two-thirds (66%) said they recommend the sources because of the safety of cannabis products, while (62%) said they recommend sources because of the consistent quality of cannabis products.

Higher CBD or CBD-only suggested by most when recommending cannabis for medical purposes. Of those who recommend a daily maximum THC dose, the majority recommended 10 mg or less, whereas maximum CBD amounts recommended were more varied.

• Of the practitioners who have recommended the use of cannabis or provided medical documents to access cannabis, most were likely to suggest cannabis that is higher CBD, lower THC (53%) or CBD-only (38%) when making recommendations.
• When asked about whether they provide recommendations on a daily maximum dose not to exceed, many practitioners (57%) said they do not. Although the survey did not ask why these practitioners do not recommend, results show that those who are comfortable talking to patients about cannabis for medical purposes, as well as those who have good or very good knowledge about cannabis for medical purposes are more likely to provide recommendations on a maximum daily amount.
• The most frequently cited way practitioners who have recommended the use of cannabis or provided medical documents to access cannabis determine dosages is using titration, with nearly half (49%) doing so.

Lack of evidence about efficacy and lack of information about dosage are the main reasons why HCPs do not recommend cannabis for medical purposes. When it comes to issuing a medical document, lack of familiarity with the process and not being well enough informed about the uses of cannabis for medical purposes are also issues.

• Among the practitioners who have not recommended that patients use cannabis to treat symptoms or diseases/disorders, many pointed to a perceived lack of evidence about the efficacy of cannabis (58%) or lack of information about appropriate dosage (55%) to explain why. In addition, nearly half said that they are not well enough informed about the uses of cannabis for medical purposes (48%) and that there are side-effects to using cannabis (47%) to explain why they do not recommend cannabis.
• Nearly half (47%) of practitioners who have not given a patient a medical document to access cannabis to treat their symptom or disease/disorder said they are not familiar with the process of providing a medical document to patients for the use of cannabis for medical purposes. Furthermore, identical proportions (40% in each case) cited the lack of information about appropriate dosage and not being well enough informed about the uses of cannabis for medical purposes as reasons for not providing a medical document to a patient.

Since the broader legalization of cannabis, the majority of HCPs have received more inquiries from patients about cannabis for medical purposes and are noticing changes in how patients access cannabis. HCPs are also generally more supportive of using cannabis for medical purposes post-legalization.

• Almost two-thirds of practitioners (64%) said that since legalization patients have asked questions more often about using cannabis for medical purposes.
• Six in 10 (60%) said that they have noticed changes in the ways in which patients are accessing cannabis for medical purposes since the broader legalization of cannabis in Canada. Among HCPs who have noticed changes, nearly all (94%) said more patients seem to be accessing cannabis from a provincially authorized retailer, while 43% said that fewer patients appear to be using illicit sources now.
• Practitioners were asked if they are more or less supportive of the use of cannabis for medical purposes since its legalization. A majority (58%) said they are more supportive, although practitioners were much more likely to be 'somewhat more supportive' (45%) than 'much more supportive' (13%). Very few (6%) described themselves as less supportive, whereas over one-third (35%) said there was no change in their views on the use of cannabis for medical purposes. While support has increased, HCPs were evenly split when it came to changes in their practices for recommending cannabis: 50% said their practices in relation to cannabis have not changed and 50% said there have been changes.

4. Limitations of the Research and Intended Use of the Results

The results of these surveys are not statistically projectable to the target populations because the sampling method used does not ensure that the sample represents the target population with a known margin of sampling error.

The research findings will be used to better understand the different experiences of 1) individuals who access cannabis for medical purposes and 2) the perspectives and practices of HCPs regarding cannabis for medical purposes.

5. Contract Value

The contract value was $249,429.53 (including applicable taxes).

6. Statement of Political Neutrality

I hereby certify as a Senior Officer of Phoenix Strategic Perspectives that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Communications Policy of the Government of Canada and Procedures for Planning and Contracting Public Opinion Research. Specifically, the deliverables do not contain any reference to electoral voting intentions, political party preferences, standings with the electorate, or ratings of the performance of a political party or its leader.

Alethea Woods

President

Phoenix Strategic Perspectives Inc

[1] This includes adults and guardians who are responsible for a person under the age of 18 who uses cannabis for medical purposes