Medical cannabis-related stigma: cancer survivors’ perspectives

Background Although the vast majority of medical cannabis laws in the USA includes cancer as a qualifying condition and medical cannabis-related stigma influences decision-making regarding the botanical, few studies have explored the phenomenon in oncology. Early findings indicated oncologic cannabis-related stigma to be quite widespread. Methods Semi-structured interviews with 24 adults with cancer histories using medical cannabis were analyzed using the Health Stigma and Discrimination Framework. Results Sixteen out of 24 participants discussed medical cannabis-related stigma in some depth. The phenomena emerged as more pervasive in medical than personal/professional domains and was internalized as well as experienced directly. It led some participants, but not others, to practice partial or complete secrecy. Discussion Taken together, our findings suggest that, while medical cannabis-related stigma remains widespread and led some study participants to alter behavior, an early shift in ethos towards greater medical cannabis acceptance could be underway. If so, this transition may be occurring more rapidly in non-medical than in clinical settings. Conclusion Cancer survivors may experience heightened medical cannabis-related stigma in the clinic as compared to their personal/professional lives. Healthcare providers who depend on patient transparency when gathering medical histories and devising care plans may wish to neutralize perceptions of medical cannabis-related stigma.


Introduction
Medical cannabis is nonpharmaceutical, herbal cannabinoid products that individuals use for medical purposes, sometimes authorized by clinical professionals in compliance with state laws. Thirty-seven states in the United States (U.S.) permit medical cannabis use and a cancer diagnosis qualifies for medical cannabis in nearly every such state law. For this reason, understanding the role medical cannabis plays in oncology should be of import to all clinicians. Defined as a social process of stereotyping, labeling and grouping, stigma triggers loss of social status and discrimination, which in turn influences health and other outcomes [1,2]. Although stigma associated with medical cannabis may influence decision-making regarding the botanical, only one stigma-related study (to our knowledge) has focused on an oncologic population. In it, stigma emerged as a significant barrier to medical cannabis use by cancer survivors [3].
Anna Revette and Manan M. Nayak are considered joint first authors 1 3 Outside of oncology, the limited number of studies examining medical cannabis-related stigma have suggested that the phenomenon is pervasive, if gradually shifting [3][4][5][6][7][8][9]. Testimony from individuals using or considering use of medical cannabis indicated a perception that their communities view the practice as deviant and that stigma exists in an internalized form (e.g., assumed) in addition to an externalized (e.g., directly experienced) one [2]. Both forms seem to impact patient transparency about use with healthcare teams, as well as with social networks [1,3,4].Of note, a recent study (out of Canada) identified less stigma than earlier investigations. The paper's authors attributed the finding to liberalization of Canadian medical cannabis laws, allowing medical cannabis use greater social acceptance and legitimacy [5,10].
The studies above were conducted regionally (e.g., Canada/Israel/California) and differing cultural norms across geographies may have limited generalizability. Our study aimed for broader applicability by including a geographically diverse U.S. sample as well as individuals across the disease trajectory and aimed to understand the drivers and facilitators of oncologic cannabis stigma, guided by the Health Stigma and Discrimination Framework [11]. This multidimensional, theory-and evidence-based framework was selected to allow exploration of medical cannabisrelated stigma at an individual as well as macro levels.

Materials and methods
Complete methodology is described in the initial paper [12]. In brief, researchers selected eight geographically/ culturally diverse states/districts with legal medical cannabis: Arizona, California, Florida, Illinois, Massachusetts, Oregon, New York, and the District of Columbia. Through state-sanctioned medical cannabis dispensaries, researchers recruited 24 individuals 21-years or older, certified to use medical cannabis and with physician-verified cancer histories. Participants received $75 honoraria for approximately 45-min interviews. Written informed consent enabled confidential, audio-recorded phone interviews which adhered to a semi-structured interview guide that included prespecified inquiries pertaining to stigma: Have you experienced stigma around [medical cannabis]? If yes, from where/ whom? How, if at all, has stigma affected your decisions around using [medical cannabis]? Between April 2017 and March 2019, recruitment occurred in phases to ensure adequate capture of emergent themes. A qualitative research expert (AR) coded and analyzed transcripts using a multistage thematic analysis that combined prefigured and emergent codes and incorporated aspects of grounded theory, more applied framework analysis and a Health Stigma and Discrimination Framework [11,[13][14][15][16]. Each stage of coding/analysis was iteratively designed and discussed by an interdisciplinary research team (I. M. B., M. M. N., A. R.) to address trustworthiness in approach/interpretations and resolve conflicts. Recruitment ceased following achievement of thematic saturation. The Dana-Farber Cancer Institute Institutional Review Board approved this study (Protocol 15-449).

Medical cannabis-related stigma more pervasive in the medical than personal/professional domain
Manifestations of stigma experiences and practices frequently emerged unprompted during interviews (Table 1). Participants noted the phenomenon in two arenas: the medical (which we will define as organized provision of healthcare to individuals or a community) and the personal/professional (which we will define as private life, relationships, career). While nearly all participants perceived some level of medical cannabis-related stigma in at least one of these domains, stigma in medical settings was considerably more pervasive.
Nearly half of participants discussed stigmatization in the medical domain. Sub-themes included the seemingly "taboo" nature of medical cannabis in the clinical setting ("It's all hush hush [in the doctor's office]") and unwillingness of healthcare providers to engage in in-depth medical cannabis discussions. For instance, one participant expressed frustration over a medical professional labeling them as a "substance abuser" without further exploration of their medical cannabis use; another experienced "giggling" at a medical conference when they publicly disclosed medical cannabis use. Social judgment and prejudice emerged as powerful drivers for medical cannabis stigma and, notably, no participant denied such stigma in the medical setting.
Most participants perceived stigma in the personal/professional domain. Those who did noted a mixed response among friends and family, with some in their social network supportive of and others standing in opposition to their use. Those disapproving were seen to define medical cannabis as a "gateway drug" and its use as a substance use disorder, again suggesting social judgment and prejudice as powerful drivers. Some participants indicated a "no-drug-use policy" from family members. Unlike in the medical arena, however, a quarter of participants-all from the Eastern United Statesexplicitly reported the absence of medical cannabis-related stigma in their personal and professional lives. In fact, a few noted that perceptions of medical cannabis were shifting and that the door to medical cannabis acceptance was "creaking open" suggesting that cultural norms were increasing less of a facilitator of stigma. Of note, stigma was perceived across the cancer trajectory including among those undergoing and those in the surveillance stage of cancer treatment.

Some medical cannabis-related stigma internalized rather than directly experienced
While some manifestations of stigma were external, an emergent theme across both personal/professional and medical domains was that of internalized stigma. For instance, in the personal/professional domain, one participant noted:

[My family] probably thinks … I'm a junkie.
In the healthcare domain, another participant assumed their medical team's response to medical cannabis use would be negative:

I didn't want to hear [from providers], 'well that's foolish or you can't plan [medical cannabis] to work.'
Yet, another reported:

While many responded to medical cannabis-related stigma with secrecy, some were impervious
Common strategies among participants to mitigate stigma included sharing partial truths and being judicious about with whom to self-reveal. While all participants were open about medical cannabis use in the medical setting to some degree, most discussed medical cannabis with healthcare providers only generally, without disclosing full details (e.g., mode of consumption; types of medical cannabis products used). Many shared their medical These health/social impacts of stigma seemed ubiquitous in that judiciousness with one's medical cannabis history was equally common among participants in active cancer treatment as those in the surveillance stage of cancer care.

Discussion
In exploring whether individuals with cancer histories using medical cannabis experience stigma around this practice, we learned that medical cannabis-related stigma was perceived in medical and personal/professional domains but seemed more prevalent in the former. In fact, a quarter of those interviewed-all from the Eastern U.S.-denied any stigma in their personal lives. A sizeable proportion of the stigma discussed was presumed rather than directly experienced. While many participants responded to stigma with partial or complete secrecy, a few reported being impervious, altering neither transparency nor behavior, in other words, endorsing few health or social impacts. Taken together, these findings suggest that, as articulated by a study participant, the door to medical cannabis acceptance may be creaking open but seems to be doing so more gradually in the medical realm as compared to the personal/professional one.

Clinical implications
Our findings extend those of earlier research investigations that pointed both to widespread medical cannabisrelated stigma, as well as to possible early shifts in culture around medical cannabis. The fact that participants in our study frequently reported presumed stigma suggested that historic antecedents served as facilitators. The finding of regional differences in medical cannabis-related stigma is also of interest, particularly since this is, to our knowledge, the first study of medical cannabis-related stigma to capture a geographically diverse U.S. sample. One could hypothesize that local variations in legal/cultural/ informational milieus might underlie these differences. Our study should be followed by a quantitative, longitudinal assessment of oncologic medical cannabis-related stigma in the U.S among patients, caregivers, and clinical care teams, in order to quantify regional differences, their etiologies, and trends over time. To fully capture the experiences of affected populations, a more comprehensive study should include individuals with cancer acquiring cannabis from medical cannabis dispensaries, adult use dispensaries as well as informal sources. If quantitative assessments support our findings, greater medical cannabis-related communication in the clinic may be necessary to improve transparency on the part of individuals with cancer histories regarding decisions about whether to use medical cannabis, modes of self-administration, ratios of active ingredients, target indications, potential risks, and adverse events, etc. One could imagine that an important component for improved communication would be strengthened cannabinoid therapeutics education for clinicians [10,17].

Study limitations
This study has important limitations. It is cross-sectional, a weakness given the rapid pace of change regarding state cannabis legalities. The sample, which consisted of individuals state-sanctioned to use medical cannabis, might differ in viewpoint from those accessing cannabis from adult use dispensaries or sans state approval. Our study specifically evaluated medical cannabis perceptions among individuals with cancer histories. Levels of perceived stigma may differ among individuals with other illnesses turning to medical cannabis.

Conclusions
Our study also has important strengths. We achieved thematic saturation suggesting that our sample size did in fact allow for broader perceptions of medical cannabis-related stigma among cancer patients to be reflected. The study's wide geographic sampling also strengthened its generalizability as compared to earlier studies on this topic. Finally, its key findings-that medical cannabis-related stigma, while highly prevalent, exists more in medical than in personal/professional domains and often leads to a degree of secrecy-will be of considerable interest to healthcare providers who depend on patient transparency when gathering medical history and in the devising optimal care plans.
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