Family attitudes about and experiences with medical cannabis in children with cancer or epilepsy: an exploratory qualitative study.

BACKGROUND: Cannabis is legal for recreational and medical use in Canada. Our aim was to explore family experiences using medical cannabis for children with severe conditions in the context of legalization. METHODS: We conducted a qualitative study using semistructured interviews between April and July 2019. Participants were parents of children attending BC Children's Hospital oncology or palliative care clinics, recruited through posters, emails or referral. Participants were included if they spoke English and their child used any type of cannabis for medical purposes. Interviews included open-ended questions about the child's cannabis use. Interviews were recorded and transcribed, and thematic analysis was performed using qualitative description. RESULTS: Ten interviews were completed with 9 mothers and 1 mother-father pair. The age range of the children was 22 months to 16 years. The primary reasons for cannabis use were epilepsy (6 children) or chemotherapy management (4 children). Five major themes were identified. 1) Child and family context, and cannabis as a last resort: children were seen as severely ill; parents sought cannabis out of desperation and responsibility to their child. 2) Varied information sources informed decision-making: parents lacked resources from health care providers and sought support from social media, industry and other families. 3) Cannabis as an ambiguous medicine: cannabis was viewed as both a serious drug that doctors should prescribe and as a natural alternative health product, safe to pursue alone. 4) Perceived effects: parents perceived medical benefits with few concerns about adverse effects. 5) Legal and financial challenges: parents were willing to obtain cannabis despite high costs and uncertain legality. INTERPRETATION: Parents of children with severe conditions pursued medical cannabis despite obstacles and needed unbiased information to access alone. Scientific investigation is needed to develop pediatric medical guidelines to inform decisions.

Barriers in accessing medical cannabis for children with drug-resistant epilepsy in Canada: A qualitative study.

INTRODUCTION: The use of medical cannabis to treat drug-resistant epilepsy in children is increasing; however, there has been limited study of the experiences of parents with the current system of accessing medical cannabis for their children. METHODS: In this qualitative study, we used a patient-centered access to care framework to explore the barriers faced by parents of children with drug-resistant epilepsy when trying to access medical cannabis in Canada. We conducted semistructured interviews with 19 parents to elicit their experiences with medical cannabis. We analyzed the data according to five dimensions of access, namely approachability, acceptability, availability, affordability, and appropriateness. RESULTS: Parents sought medical cannabis as a treatment because of a perceived unmet need stemming from the failure of antiepileptic drugs to control their children's seizures. Medical cannabis was viewed as an acceptable treatment, especially compared with adding additional antiepileptic drugs. After learning about medical cannabis from the media, friends and family, or other parents, participants sought authorization for medical use. However, most encountered resistance from their child's neurologist to discuss and/or authorize medical cannabis, and many parents experienced difficulty in obtaining authorization from a member of the child's existing care team, leading them to seek authorization from a cannabis clinic. Participants described spending up to $2000 per month on medical cannabis, and most were frustrated that it was not eligible for reimbursement through public or private insurance programs. CONCLUSIONS: Parents pursue medical cannabis as a treatment for their children's drug-resistant epilepsy because of a perceived unmet need. However, parents encounter barriers in accessing medical cannabis in Canada, and strategies are needed to ensure that children using medical cannabis receive proper care from healthcare professionals with training in epilepsy care, antiepileptic drugs, and medical cannabis.

Medical cannabis in the UK: From principle to practice.

BACKGROUND: In the UK, medical cannabis was approved in November 2018, leading many patients to believe that the medicine would now be available on the NHS. Yet, to date, there have been only 12 NHS prescriptions and less than 60 prescriptions in total. In marked contrast, a recent patient survey by the Centre for Medical Cannabis (Couch, 2020) found 1.4 m people are using illicit cannabis for medical problems. AIMS: Such a mismatch between demand and supply is rare in medicine. This article outlines some of the current controversies about medical cannabis that underpin this disparity, beginning by contrasting current medical evidence from research studies with patient-reported outcomes. OUTCOMES: Although definite scientific evidence is scarce for most conditions, there is significant patient demand for access to medical cannabis. This disparity poses a challenge for prescribers, and there are many concerns of physicians when deciding if, and how, to prescribe medical cannabis which still need to be addressed. Potential solutions are outlined as to how the medical profession and regulators could respond to the strong demand from patients and families for access to medical cannabis to treat chronic illnesses when there is often a limited scientific evidence base on whether and how to use it in many of these conditions. CONCLUSIONS: There is a need to maximise both clinical research and patient benefit, in a safe, cautious and ethical manner, so that those patients for whom cannabis is shown to be effective can access it. We hope our discussion and outlines for future progress offer a contribution to this process.

Exploring medicinal use of cannabis in a time of policy change in New Zealand.

AIMS: To explore patterns of medicinal cannabis use prior to implementation of the new Medicinal Cannabis Scheme (MCS) in New Zealand. METHODS: An anonymous online convenience survey of 3,634 last-year medicinal users of cannabis promoted via Facebook™ from May to August 2019. RESULTS: Fifty percent of the sample were female, 18% were Maori and the median age was 38 years. The medical conditions for which cannabis was most often used were pain (81%), sleep (66%) and mental health conditions (64%). Respondents perceived cannabis to be an effective therapy and reported reducing use of other pharmaceutical medicines. Fifty-two percent reported side effects from cannabis use, including increased appetite (29%), drowsiness (12%), eye irritation (11%), dependency (10%), memory impairment (10%) and lack of energy (9%). Smoking was the dominant route of administration. Nearly half (47%) had discussed their use of cannabis with a medical professional in the previous year, while 14% had requested a prescription and 5% accessed a prescribed cannabis-based product (mostly oral CBD). CONCLUSION: Respondents self-medicated with cannabis to treat a wide range of health complaints. Only half discussed medicinal cannabis use with their medical professional, and a minority requested a prescription and used a prescribed cannabis-based product.

"You have to make some money before you can do some good": Balancing the commercial, social and public health objectives in a "community enterprise" regulatory model for alcohol and cannabis.

INTRODUCTION: New Zealand's alcohol licensing trusts are social enterprises that operate retail alcohol outlets in their districts and distribute profits back to the community. There have been calls for a similar "social enterprise" approach to legal cannabis sales. However, social enterprises face unique challenges in balancing commercial and social objectives. AIM: To explore mechanisms that support the balancing of commercial, social and public health objectives in alcohol trusts and identify learnings for cannabis reform. METHOD: Thematic analysis of interviews with 16 internal and external key informants (trust board members, trust retail managers, community activists, law enforcement) from two alcohol trust districts. RESULTS: Key informants overwhelmingly conceptualised alcohol trusts as business entities, but commercial success was also seen as a means to help the community. Interviewees' perceptions of trusts' social mission ranged from simple "corporate social responsibility" to a "genuine" community orientation. Despite a near-monopolistic market position, forces within and outside the trusts create pressures to conform to standard commercial behaviour, including strategic placement of alcohol outlets. Participants attributed the potential public health benefits of the trusts to reduced density of alcohol retail outlets and ease of enforcement. The pragmatic political goal of maintaining a favourable public image (to secure survival of the trust and re-election of individual trustees) was the key mechanism balancing commercial and social objectives. Ethical dilemmas related to the sale of alcohol and conflicts of interest in allocating community funds were evident. Discord was "negotiated" with the community via the public discussion and voting, providing opportunity to correct mission drift. CONCLUSIONS: The need to maintain a positive public image (to ensure favourable electoral results) was a key mechanism helping to balance the commercial and social goals of alcohol trusts. A community trust model for retail cannabis sales could similarly provide constraints on commercial behaviour while funding community services.

Understanding motivations for large US cannabis firms' participation in the cannabis space: Qualitative study exploring views of key decision-makers.

INTRODUCTION AND AIMS: Large for-profit firms supply the majority of US state-legal cannabis stores and some firms have attempted to shape cannabis-related policies. Understanding firms' motivations for participation in the cannabis space is critical, given firms' possible links to cannabis usage patterns. Key decision-makers (KDM) in the cannabis space may have information unavailable to lower ranking staff, and may influence firm decision-making and consequently US cannabis usage practises. We present the findings of a qualitative study investigating the views of KDMs in the cannabis market, on large cannabis firms' motivations for participation in the space. DESIGN AND METHODS: Data were collected through 37 semi-structured interviews with a convenience sample of KDMs in the US cannabis space, representing both for-profit and non-profit organisations. Thematic analysis, with an inductive approach, was used to analyse the data. RESULTS: KDMs reported three non-exclusive motivations for large cannabis firms' participation in the space; to seek profit, to mitigate social inequity and to provide cannabis as medicine. Within the theme relating to profit, findings suggest that for-profit and non-profit organisations in the space may be cognisant of the other's goals, representing a symbiotic relationship. DISCUSSION AND CONCLUSIONS: We suggest that firms may have reasons to enter the space not necessarily centred on increasing use. Although non-profits and for-profits have different agendas, the bottom line for both groups is to expand access. Policy-makers should be aware of that fact, and set policies which consider the two groups as a unified whole.

Out-of-state cannabis purchases in the United States.

BACKGROUND: Cannabis legalization at the US state level may have implications for cross-border purchases and diversion of legal products. The current study examined the association between out-of-state purchases and 1) cannabis regulations; and 2) the length of time a state has had recreational retail sales. METHODS: Data come from US respondents who participated in Wave 1 of the International Cannabis Policy Study (ICPS), conducted in August-October 2018. Respondents were aged 16-65 years who had used cannabis in the past 12 months (n = 4320). Respondents were recruited using the Nielsen Consumer Insights Global Panel. Binary logistic regression models examined likelihood of any out-of-state cannabis purchases in the prior year, including differences by cannabis regulations, and time since recreational cannabis retail sales began. RESULTS: Overall, 15.0 % of US cannabis users had made any out-of-state cannabis purchases in the past 12 months. Respondents in states where recreational cannabis was legal were less likely to make any out-of-state purchases than respondents in states where only medical cannabis was legal (AOR = 0.45, 95 % CI: 0.34-0.60, p < 0.001) and where all cannabis was prohibited (AOR = 0.36, 95 % CI: 0.26-0.50, p < 0.001). Among respondents in 'legal' states, a longer history of legal sales was associated with a lower likelihood of out-of-state cannabis purchases (AOR = 0.82, 95 % CI: 0.72-0.93, p = 0.002). CONCLUSION: The findings demonstrate that consumers in states where recreational cannabis is legal were less likely to purchase cannabis out-of-state than consumers in states where recreational cannabis is not legal. Future research should examine which states people travel to purchase cannabis and why.

[Cannabis-derived medicines for the treatment of chronic pain : Problems resulting from medical appraisals in the experience of the Medical Advisory Board of the Statutory Health Insurance Funds North]. / Cannabispräparate für die Therapie chronischer Schmerzen : Problemfelder bei medizinischen Begutachtungen aus der Erfahrung des MDK Nord.

BACKGROUND: On March 10th 2017, the law amending narcotic and other regulations was expanded, thereby allowing physicians, irrespective of their specialization, to prescribe cannabis-derived medicines as magistral formulas or proprietary medicinal products at the expense of the German statutory health insurance (GKV). First prescription requires approval from the respective health insurance, which in turn commissions the Medical Advisory Board of the Statutory Health Insurance Funds (MDK) to prepare a medico-legal report. OBJECTIVES: Since § 31 Para. 6 of the German Social Code, Book V (SGB V) came into effect, a multitude of imponderables have been reported regarding reimbursement. Based on the experience of the MDK Nord, problems within the fields of patients, physicians and cannabis-derived medicines are illustrated. MATERIAL AND METHODS: Considering current literature, a retrospective review was conducted including approximately 2200 applications for reimbursement received in 2018 from patients residing in Hamburg and Schleswig-Holstein. RESULTS: A relevant problem within the field of patients resulted from the lack of a specific definition of the term "severe (chronic) disease". Although this term is mentioned several times in SGB V, it is not put into concrete terms. Circumstances like multimorbidity are not taken into account. Another problem consisted in an irreproducible anticipation of treatment with cannabis-derived medicines. Within the field of physicians, a major problem was caused by missing, fragmentary or inconsistent information regarding disease and/or therapy. Hence, initially, almost one-third of all applications could not be appraised. Amongst various cannabis-derived medicines, dried flowers were found to be the most problematic regarding doses and effective levels. Notably, a marked increase in numbers of applications for reimbursement of therapy with pure cannabidiol was noted. DISCUSSION: Numerous problems reported elsewhere and relating to prescription of cannabis-derived medicines were also observed by the MDK Nord. Many prescriptions reflected an uncertainty regarding therapeutic use of cannabis-derived medicines. Thus, one should consider restricting the prescription of cannabis-derived medicines to selected specialists. It should be noted that, in individual cases, e.g., patients suffering from neuropathic pain, treatment with cannabis-derived medicines seems to be a reasonable therapeutic option taking into account the risks and benefits.

The impacts of potency, warning messages, and price on preferences for Cannabis flower products.

BACKGROUND: Recreational cannabis has been legalized in 11 states and Washington DC in the US. However, little is known about individual preferences for legal cannabis products. This study estimated the impacts of tetrahydrocannabinol (THC), cannabidiol (CBD), warning messages, and price on preferences for cannabis flowers. METHODS: A cross-sectional online survey with discrete choice experiments was implemented in October 2017. A sample of 2400 adults aged 21 years or older were recruited from 6 US states with recreational cannabis legalization, consisting of 1200 past-year nonusers and 1200 past-year users. Each respondent was randomly assigned to 12 discrete choice scenarios, each asking them to choose from an opt-out option and 3 cannabis flower products with varying levels in THC, CBD, warning messages, and price. The impacts of product attributes on individual choices were analyzed with nested logit regressions. RESULTS: Both cannabis nonusers and users preferred higher CBD and lower price. Users also preferred higher THC. The results on warning messages were mixed: graphic warning on drugged driving and text warning message had positive impacts on nonusers' and users' preferences for cannabis flowers, respectively, whereas FDA disapproval disclaimer had negative impacts on nonusers' preferences. Heterogeneities in preferences were revealed among nonusers by former use status and among users by reason of use. Particularly, medical cannabis users were not as responsive to THC as recreational cannabis users or dual users were. Regarding relative importance of the attributes, all respondents but medical cannabis users perceived price as the most important attribute (relative importance 51-64%), whereas medical cannabis users perceived CBD as the most important attribute (relative importance 47%). CONCLUSION: The findings indicated that product characteristics may have influences on US adults' choices of legal cannabis flower products and may deserve consideration for cannabis regulatory framework.

[High-dose dronabinol treatment vs. medicinal cannabis flowers]. / Hochdosisdronabinoltherapie vs. Medizinalcannabisblüten.

This article reports a case of pronounced, chronic lumboischialgia, which was not satisfactorily controlled by conventional analgesic treatment. The level of pain under high-dose dronabinol treatment with oral and inhalative administration as well as the way to reimburse the cost of medicinal cannabis flowers, the treatment success and criteria of the economic prescription procedure are presented.

Cannabis-based medicines for chronic pain management: current and future prospects.

PURPOSE OF REVIEW: The medicinal use of cannabis has recently become the focus of much medical, as well as political, attention. This reality of growing use but limited evidence creates unique dilemmas for the prescribing clinician. The purpose of this review is to explore current evidence and gaps in knowledge and offer some practical considerations. RECENT FINDINGS: There is robust preclinical data regarding the relevance of the endocannabinoid system to many pain-relevant processes. However, evidence to support cannabis-based medicines clinical use is still lacking. The best evidence to date is in managing neuropathic pain, although whether effects are clinically significant remains undetermined. However, the safety profile of cannabinoids seems favorable, especially by comparison to other medications used for pain control. SUMMARY: The endocannabinoid system is undoubtedly a new and exciting pharmaceutical target for chronic pain management, but transition from preclinical to clinical studies has so far proved difficult. Although it is reasonable to consider cannabinoids for otherwise unresponsive pain, care should be taken in frail clinical populations. As this has become a socioeconomic and political issue in which agendas often take precedence over due diligence, there is a pressing need for unbiased empirical data and high quality evidence to better inform prescribers and patients.

Decision Models for Assessing the Cost Effectiveness of Treatments for Pediatric Drug-Resistant Epilepsy: A Systematic Review of Economic Evaluations.

BACKGROUND: Drug-resistant epilepsy affects about one-third of children with epilepsy and is associated with high costs to the healthcare system, yet the cost effectiveness of most treatments is unclear. Use of cannabis-based products for epilepsy is increasing, and the cost effectiveness of such strategies relative to conventional pharmacologic treatments must be considered. OBJECTIVE: The objective of this systematic review was to identify economic evaluations of cannabis-based treatments for pediatric drug-resistant epilepsy. We also sought to identify and appraise decision models that have been used in economic evaluations of pharmacologic treatments (i.e., antiepileptic drugs) in this population. METHODS: Electronic searches of MEDLINE, EMBASE, and the Cochrane library, as well as a targeted grey literature search, were undertaken (11 June 2018). Model-based full economic evaluations involving cannabis-based treatments or pharmacologic treatments for drug-resistant epilepsy in children were eligible for inclusion. Two independent reviewers selected studies for inclusion, and study quality was assessed by use of the Drummond and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklists. Study findings, as well as model characteristics, are narratively summarized. RESULTS: Nine economic evaluations involving children with drug-resistant epilepsy were identified; however, none involved cannabis-based treatments. All studies involved pharmacologic treatments compared with other pharmacologic treatments or non-pharmacologic treatments (i.e., ketogenic diet, epilepsy surgery, vagus nerve stimulation). Few studies have assessed the cost effectiveness of pharmacologic treatments in specific drug-resistant epilepsy syndromes, including Dravet and Lennox-Gastaut syndromes. Five included studies involved use of Markov models with a similar structure (i.e., health states based on seizure frequency relative to baseline). There was a wide range of methodological quality, and few studies fully addressed context-specific issues such as weight gain and treatment switching. CONCLUSION: Whether cannabis-based treatments for pediatric drug-resistant epilepsy represent good value for money has yet to be investigated. Economic evaluations of such treatments are needed and should address issues of particular importance in pediatric epilepsy, including weight gain over time, switching or discontinuation of treatments, effectiveness of interventions and comparators, and long-term effectiveness beyond the duration of available clinical studies. PROSPERO REGISTRATION: CRD42018099591.

Price elasticity of illegal versus legal cannabis: a behavioral economic substitutability analysis.

BACKGROUND AND AIMS: The evolving legal status of cannabis world-wide necessitates evidence-based regulatory policies to minimize risks associated with cannabis misuse. A prominent concern is the impact legalization may have on the illegal cannabis market, including whether illegal cannabis will serve as a substitute for legal cannabis. Empirical data on this issue are virtually non-existent. This study used behavioral economics to investigate substitutability of legal and illegal cannabis in legalized catchment areas in the United States. DESIGN: A substitution-based marijuana purchase task assessed estimated cannabis consumption from concurrently available legal (a dispensary) and illegal (a dealer) sources. Prices of the two options were reciprocally either held constant ($10/gram) or escalated ($0-$60/gram). SETTING: US states with legalized recreational cannabis. PARTICIPANTS: Adult cannabis users who were at least 21 years old (n = 724; mean age = 34.13; 52% female; 74% Caucasian) were recruited using online crowdsourcing. MEASUREMENTS: Mean consumption values were used in demand curve modeling to generate indices of price sensitivity and elasticity. Differences in demand indices were compared using extra sums-of-squares F-tests. FINDINGS: Both legal and illegal fixed-price cannabis options had significant positive cross-price elasticities (Ps < 0.001), indicating that higher prices motivate substitution irrespective of legality. However, the presence of a legal alternative had a substantially greater effect on consumption and elasticity of illegal cannabis (∆elasticity  = 0.0019; F(1,37)  = 160, P < 0.0001) than the presence of an illegal alternative on demand for legal cannabis (∆elasticity  = 0.0002; F(1,37)  = 48, P < 0.0001), indicating asymmetric substitution. Demand for legal cannabis was significantly greater than for illegal cannabis (P < 0.0001). CONCLUSIONS: Cannabis users treat legal cannabis as a superior commodity compared with illegal cannabis and exhibit asymmetric substitutability favoring legal product. Cannabis price policies that include somewhat higher consumer costs for legal cannabis relative to contraband (but not excessively higher costs) would not be expected to incentivize and expand the illegal market.

Recreational marijuana legalization and prescription opioids received by Medicaid enrollees.

OBJECTIVES: Medical marijuana use may substitute prescription opioid use, whereas nonmedical marijuana use may be a risk factor of prescription opioid misuse. This study examined the associations between recreational marijuana legalization and prescription opioids received by Medicaid enrollees. METHODS: State-level quarterly prescription drug utilization records for Medicaid enrollees during 2010-2017 were obtained from Medicaid State Drug Utilization Data. The primary outcome, opioid prescriptions received, was measured in three population-adjusted variables: number of opioid prescriptions, total doses of opioid prescriptions in morphine milligram equivalents, and related Medicaid spending, per quarter per 100 enrollees. Two difference-in-difference models were used to test the associations: eight states and DC that legalized recreational marijuana during the study period were first compared among themselves, then compared to six states with medical marijuana legalized before the study period. Schedule II and III opioids were analyzed separately. RESULTS: In models comparing eight states and DC, legalization was not associated with Schedule II opioid outcomes; having recreational marijuana legalization effective in 2015 was associated with reductions in number of prescriptions, total doses, and spending of Schedule III opioids by 32% (95% CI: (-49%, -15%), p = 0.003), 30% ((-55%, -4.4%), p = 0.027), and 31% ((-59%, -3.6%), p = 0.031), respectively. In models comparing eight states and DC to six states with medical marijuana legalization, recreational marijuana legalization was not associated with any opioid outcome. CONCLUSIONS: No evidence suggested that recreational marijuana legalization increased prescription opioids received by Medicaid enrollees. There was some evidence in some states for reduced Schedule III opioids following the legalization.

Who's Buying What and How Much? Correlates of Purchase Behaviors From Medical Marijuana Dispensaries in Los Angeles, California.

Venue-based distribution of marijuana has become the normative model in the United States to obtain marijuana. This study examines one-time purchase behaviors at medical marijuana dispensaries (MMDs) to identify potential venue- and individual-level targets for prevention. We used a two-stage, venue-based sampling approach to randomly select patrons exiting 16 MMDs in Los Angeles, California during the spring of 2013. Patrons (N = 595) reported their discrete purchase behaviors during their most recent visit to the sampled MMD. We used hierarchical linear modeling to examine the amount spent on marijuana products, regressed on characteristics of the sampled dispensaries and their patrons. We used hierarchical generalized linear modeling to examine the likelihood of purchasing specific types of marijuana products and total grams of loose-leaf buds purchased. Patrons spent US$41.73 on average, with a range of $0-$330. We observed significant variation in purchase behaviors across MMDs and associations between venues located within high median income census tracts and a higher total amount spent and lower odds of purchasing only loose-leaf buds. The networked distance between a patron's home and the sampled MMD was positively associated with the total amount spent and total quantity of buds purchased. We also found significant relationships between medical conditions reported for use in three models: total amount spent, purchase of pre-rolled joints, and total grams of buds purchased. Policy makers may want to explore regulating the availability of specialty items that may be attractive to naïve users, such as pre-rolled joints or edibles, or high-concentration products that may be sought out by regular, heavy users.

Systematic Review of the Costs and Benefits of Prescribed Cannabis-Based Medicines for the Management of Chronic Illness: Lessons from Multiple Sclerosis.

INTRODUCTION: Cannabis-based medicines (CBMs) may offer relief from symptoms of disease; however, their additional cost needs to be considered alongside their effectiveness. We sought to review the economic costs and benefits of prescribed CBMs in any chronic illness, and the frameworks used for their economic evaluation. METHODS: A systematic review of eight medical and economic databases, from inception to mid-December 2016, was undertaken. MeSH headings and text words relating to economic costs and benefits, and CBMs were combined. Study quality was assessed using relevant checklists and results were synthesised in narrative form. RESULTS: Of 2514 identified records, ten studies met the eligibility criteria, all for the management of multiple sclerosis (MS). Six contained economic evaluations, four studies reported utility-based quality of life, and one was a willingness-to-pay study. Four of five industry-sponsored cost-utility analyses for MS spasticity reported nabiximols as being cost-effective from a European health system perspective. Incremental cost-effectiveness ratios per quality-adjusted life-year (QALY) gained for these five studies were £49,257 (UK); £10,891 (Wales); €11,214 (Germany); €4968 (Italy); and dominant (Spain). Nabiximols for the management of MS spasticity was not associated with statistically significant improvements in EQ-5D scores compared with standard care. Study quality was moderate overall, with limited inclusion of both relevant societal costs and discussions of potential bias. CONCLUSIONS: Prescribed CBMs are a potentially cost-effective add-on treatment for MS spasticity; however, this evidence is uncertain. Further investment in randomised trials with in-built economic evaluations is warranted for a wider range of clinical indications. SYSTEMATIC REVIEW REGISTRATION: PROSPERO Registration Number: CRD42014006370.

Are dispensaries indispensable? Patient experiences of access to cannabis from medical cannabis dispensaries in Canada.

BACKGROUND: In 2001, Canada established a federal program for cannabis for therapeutic purposes (CTP). Medical cannabis dispensaries (dispensaries) are widely accessed as a source of CTP despite storefront sales of cannabis being illegal. The discrepancy between legal status and social practice has fuelled active debate regarding the role of dispensaries. The present study aims to inform this debate by analysing CTP user experiences with different CTP sources, and comparing dispensary users to those accessing CTP from other sources. METHODS: We compared sociodemographic characteristics, health related factors and patterns of cannabis use of 445 respondents, 215 who accessed CTP from dispensaries with 230 who accessed other sources. We compared patients' ratings of CTP sources (dispensaries, Health Canada's supplier, self-production, other producer, friend or acquaintance, street dealer) for quality and availability of product, safety and efficiency of access, cost, and feeling respected while accessing. RESULTS: Patients using dispensaries were older, more likely to have arthritis and HIV/AIDS, and less likely to have mental health conditions than those not using dispensaries. Those accessing dispensaries used larger quantities of cannabis, placed greater value on access to specific strains, and were more likely to have legal authorization for CTP. Dispensaries were rated equally to or more favourably than other sources of CTP for quality, safety, availability, efficiency and feeling respected, and less favourably than self-production and other producer for cost. CONCLUSION: Given the high endorsement of dispensaries by patients, future regulations should consider including dispensaries as a source of CTP and address known barriers to access such as cost and health care provider support. Further research should assess the impact of the addition of licensed producers on the role and perceived value of dispensaries within the Canadian medical cannabis system.

Mapping medical marijuana: state laws regulating patients, product safety, supply chains and dispensaries, 2017.

AIMS: (1) To describe open source legal data sets, created for research use, that capture the key provisions of US state medical marijuana laws. The data document how state lawmakers have regulated a medicine that remains, under federal law, a Schedule I illegal drug with no legitimate medical use. (2) To demonstrate the variability that exists across states in rules governing patient access, product safety and dispensary practice. METHODS: Two legal researchers collected and coded state laws governing marijuana patients, product safety and dispensaries in effect on 1 February 2017, creating three empirical legal data sets. We used summary tables to identify the variation in specific statutory provisions specified in each state's medical marijuana law as it existed on 1 February 2017. We compared aspects of these laws to the traditional Federal approach to regulating medicine. Full data sets, codebooks and protocols are available through the Prescription Drug Abuse Policy System (http://www.pdaps.org/; Archived at http://www.webcitation.org/6qv5CZNaZ on 2 June 2017). RESULTS: Twenty-eight states (including the District of Columbia) have authorized medical marijuana. Twenty-seven specify qualifying diseases, which differ across states. All states protect patient privacy; only 14 protect patients against discrimination. Eighteen states have mandatory product safety testing before any sale. While the majority have package/label regulations, states have a wide range of specific requirements. Most regulate dispensaries (25 states), with considerable variation in specific provisions such as permitted product supply sources number of dispensaries per state and restricting proximity to various types of location. CONCLUSIONS: The federal ban in the United States on marijuana has resulted in a patchwork of regulatory strategies that are not uniformly consistent with the approach usually taken by the Federal government and whose effectiveness remains unknown.