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Perceptions of cannabis as a stigmatized medicine: a qualitative descriptive study Bottorff, Joan L; Bissell, Laura J; Balneaves, Lynda G; Oliffe, John L; Capler, N R; Buxton, Jane Feb 16, 2013

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RESEARCH Open AccessPerceptions of cannabis as a stigmatizedmedicine: a qualitative descriptive studyJoan L Bottorff1,6*, Laura JL Bissell2, Lynda G Balneaves3, John L Oliffe3, N Rielle Capler4 and Jane Buxton5AbstractBackground: Despite its increasing prevalence and acceptance among the general public, cannabis use continuesto be viewed as an aberrant activity in many contexts. However, little is known about how stigma associated withcannabis use affects individuals who use cannabis for therapeutic purposes (CTP) and what strategies theseindividuals employ to manage associated stigma. The aim of this Canadian study was to describe users’ perceptionsof and responses to the stigma attached to using CTP.Methods: Twenty-three individuals who were using CTP for a range of health problems took part in semi-structured interviews. Transcribed data were analyzed using an inductive approach and comparative strategies toexplore participants’ perceptions of CTP and identify themes.Results: Participant experiences of stigma were related to negative views of cannabis as a recreational drug, thecurrent criminal sanctions associated with cannabis use, and using cannabis in the context of stigmatizingvulnerability (related to existing illness and disability). Strategies for managing the resulting stigma of using CTPincluded: keeping CTP ‘undercover’; educating those who did not approve of or understand CTP use; and usingcannabis responsibly.Conclusions: Understanding how individuals perceive and respond to stigma can inform the development ofstrategies aimed at reducing stigma associated with the use of CTP and thereby address barriers faced by thoseusing this medicine.Keywords: Cannabis, Medical marijuana, Stigma, Cannabis, Legal consequences, Social consequencesConcurrent with its increasing use as an illegal recre-ational drug, a growing number of studies have high-lighted the medical benefits of cannabis for diversehealth conditions [1,2]. In 2001, the Canadian govern-ment officially created a medical cannabis programme toauthorize the possession, production and distribution ofcannabis for therapeutic purposes (CTP) for individualsmeeting specific criteria. Nevertheless, researchers reportthat cannabis use continues to be viewed as aberrantand CTP users experience stigma related to their use ofcannabis [3]. The goal of this study was to describeusers’ perceptions of and responses to the stigma theyexperience related to CTP in order to provide a founda-tion for developing strategies for reducing the stigmaand supporting CTP users in their use of this medicine.BackgroundNotwithstanding its current illegal status in Canada, can-nabis has become the most widely used illicit drug andits use is on the rise among most population groups [4].In British Columbia, Canada, the setting of the currentresearch, over 50% of the population 15 years and olderhave consumed cannabis at least once in their lives [5].As a result, consuming cannabis has transitioned from aonce underground activity to one more openly accep-ted by many. Public opinion continues to shift towardsthe elimination or reduction of criminal penalties forcannabis-related activities. However, those who conti-nue to believe these activities should be penalized areincreasingly more likely to hold favourable attitudes* Correspondence: joan.bottorff@ubc.ca1School of Nursing, Faculty of Health and Social Development, University ofBritish Columbia’s Okanagan campus, Kelowna, BC V1V 1V7, Canada6Institute for Healthy Living and Chronic Disease Prevention, University ofBritish Columbia’s Okanagan campus, 3333 University Way, Kelowna, BC V11V7, CanadaFull list of author information is available at the end of the article© 2013 Bottorff et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Bottorff et al. Harm Reduction Journal 2013, 10:2http://www.harmreductionjournal.com/content/10/1/2toward cannabis when it is used for strictly therapeuticbenefits [6,7]. Despite these changes in public attitudestowards cannabis, users continue to experience a certainlevel of stigma and risk in their use of CTP, particularlyfrom authorities such as employers, landlords, and lawenforcement [3,8]. Specific civic norms and etiquetteare often employed by users in public spaces to avoiddrawing attention to their cannabis use. Even withthe establishment of Health Canada’s Canada MedicalMarihuana Access Regulations (MMAR) in 2001 stigmaagainst CTP users remains an issue [9]. Little is knownabout how the stigmatization of cannabis use influencestherapeutic users’ patterns of use and their personallives, and in-depth explorations of the strategies theyemploy to manage these experiences are limited.Stigma, health and CTPGoffman’s (1963) ground breaking work on stigmaunderpins our understanding of health-related stigma[10]. In this work, he defines stigma as: “The pheno-menon whereby an individual with an attribute which isdeeply discredited by his/her society is rejected as a re-sult of the attribute” (p.21) and argues that stigma is aninteractional process that “spoils identity.” As such,people who are perceived by others to deviate physicallyand behaviourally from social norms and values are sub-ject to disapproval, and marginalization, and often ex-perience discrimination and loss of status. These socialinteractions can result in enacted stigma (i.e., externalstigma) when others’ judgements about difference aretranslated into rejection, distancing and other discrim-inatory practices; as well as perceived stigma (i.e.,internal stigma) wherein individuals’ assumptions orfears of discrimination lead to self-perceptions of shameand guilt, and protective action such as self-imposedisolation.Efforts to use and refine the concept of stigma forpublic health have been prompted by observations of theprofound negative health effects of the social disqualifi-cation of individuals and groups who are identified withparticular diseases or disorders [11,12]. For example,disease-related stigma in the context of mental healthproblems highlight the significant deleterious effect ofstigma on health and well-being when individuals avoidhealth care or seeking other forms of support because offeelings of shame or embarrassment.As chronically ill individuals and illicit drug users,CTP users are at a high risk of experiencing multiplesources of stigma from various fronts [13]. A diagnosisof chronic illness that is either visible (e.g., multiplesclerosis, and epilepsy) or relatively invisible (e.g., HIV/AIDS, fibromyalgia, and mental illness) often results instigma and social isolation [14-17]. Although substanceuse is associated with varying degrees of stigma, illicitdrug users are among the most stigmatized groups[18,19]. Beyond the stigma of being labelled a drug user,the additional stigma of being formally charged as acriminal can also have lasting negative effects. Socialdisqualifications targeting other features of a person'sidentity (e.g., poverty, gender, sexual orientation) cancompound these experiences of stigma [20,21]. Anunderstanding of the experiences of stigma among CTPusers is, therefore, important and relevant to the healthservices provided to these individuals.Social and legal consequences of using CTPWhile studies that investigate the experiences andconcerns of recreational cannabis users are common,CTP remains poorly understood. A Canadian study ofcurrent HIV/AIDS CTP users reported many CTP userswere met with “laughter, scepticism, or with negativereactions” (p. 41) from non-users for their CTP use [22].They felt stigmatized for their choice of therapy both bytheir “healthy” peers and the medical system in general.Becoming licensed users through the MMAD HealthCanada program helped alleviate some of the relatedstress and perceived stigma of CTP use and empoweredthem to improve their overall health. Other authors havereported that social and legal concerns motivated someindividuals to conceal their CTP use and avoid disclos-ure beyond immediate family members [23]. When CTPusers met with disapproval from family members, theyreported it was often based on concern over the legalimplications of CTP use and the potential of negativehealth effects and addiction.The negative social implications of using CTP have alsobeen observed elsewhere. A California-based study ofpregnant women suffering from Hyperemesis Gravidarum(a highly debilitating pre-partum illness characterized bysevere nausea, vomiting, malnutrition and weight loss)found that for participants, cannabis was their best optionwhen traditional treatments were ineffective and, at times,traumatic [24]. Being pregnant and using cannabis, how-ever, put participants at high risk for stigmatization. Theywere often belittled and declared deviant by their peersand the medical community for their decision to use CTP.Additionally, while these women were open and successfulin using cannabis to treat extreme symptoms, they con-tinued to experience strong feelings of anxiety, guilt andfear over CTP use. As Canadian CTP regulations are nowover a decade old, it is timely that research be conductedexamining the social context of CTP use and the influenceof stigma on CTP users’ lives. The specific researchquestions guiding this study were: 1) What are CTP users’experiences of stigma? and 2) What strategies do CTPusers employ to negotiate their experiences of stigma? Byunderstanding how individuals perceive the potential so-cial implications of CTP use, new approaches can beBottorff et al. Harm Reduction Journal 2013, 10:2 Page 2 of 10http://www.harmreductionjournal.com/content/10/1/2developed to reduce the stigma associated with CTP andsupport individuals using CTP cope with stigma.MethodsThis research employed a qualitative descriptive design[25] and drew on the tenets of naturalistic inquiry [26] –a method recognised as particularly useful when investi-gating vulnerable persons with health disparities [27].Using qualitative methods, inductive analysis and pur-posive sampling, we developed an in-depth account ofthe experiences of CTP users.Study settingThis study was conducted in Canada, where the use ofCTP is directly shaped by the federal laws governing whatis considered to be a controlled substance. Cannabis pro-duction, distribution and possession remain illegal inCanada, with the exception of Health Canada’s licensingprogram for therapeutic users, the Medical MarihuanaAccess Program (MMAP). Since the MMAP’s formationin 2001, those persons wishing to legally possess and ob-tain CTP must apply for a license directly to HealthCanada, which acts as the governing body that overseesthe implementation of the Medical Marihuana AccessRegulations (MMAR). Paradoxically, Health Canada con-tinues to state that “marihuana [sic] is not an approvedtherapeutic product” [28]. Ostensibly mixed messages,such as this policy statement, along with public healthstrategies directed towards reducing cannabis use (e.g., theNational Anti-drug Strategy), has complicated the contextwithin which individuals use CTP. Although the establish-ment of the MMAP has been seen as a step forward bysome groups [29-31], others have expressed reservationsabout the program [9,32,33] pointing to access issues, thecomplexity of the application forms and the length of timerequired to process applications [9]. Apprehension aboutthe quality, potency, and lack of quality control and strainselection of MMAD-supplied cannabis also continuesto be a source of controversy for many CTP users [9].Concerns about access have resulted in a recent court de-cision in Canada that has found the MMAR to be “consti-tutionally invalid and of no force and effect” [34], forcingHealth Canada to engage in a community consultationprocess to discuss potential changes to the regulations andprogramme.The need for safe and informed access to cannabis hasbeen central to the development of community-baseddispensaries (i.e., compassion clubs) in Canada. The dis-pensaries provide illegal, high quality cannabis to theirmembers (who must have medical documentation of anapproved medical condition) as well as informationregarding CTP to assist with making decisions aboutcannabis use. The dispensaries reduce the risk of legalrepercussions associated with accessing illegal cannabisby providing a safe environment for members to pur-chase CTP and by acting as members’ social and legaladvocates [35]. Although access to CTP through dis-pensaries is a form of civil disobedience, many law en-forcement officers and courts recognize identificationcards from these dispensaries as adequate proof of legit-imate CTP use, giving discharges to verified membersand to dispensary operators who manage their clubs in atransparent and responsible manner [35].Recruitment and samplingFollowing university ethical approval, purposive sam-pling was used to recruit current CTP users throughfour British Columbia community-based cannabis dis-pensaries as well as through a Canadian online forum ofCTP users in 2007–2008. Eligibility criteria requiredparticipants to: a) report using CTP in the last 30 daysand for over 6 consecutive months, b) be at least 19 yearsof age, and c) speak English. In accordance with ethicalrequirements and to protect individual identities, allparticipants reviewed the consent form and were askedto give their consent verbally on tape at the start of theinterview. No record of participants’ names or identify-ing characteristics was kept and all participants receiveda C$25 honorarium for their time.The sample comprised 23 participants (13 women, 10men). Two transgendered (male to female) participantswere included in the women’s subgroup. Participantsranged in age from 25 to 66 years (mean = 45 years) andhad an average annual income of $21,000, slightly belowCanada’s 2008 low income cut-off for individuals livingin a large urban area ([36], p.25). Approximately 78%were either single or divorced/separated and over twothirds had completed at least some university or college.Most participants were engaged in paid work (52%) orcaring for a family member (39%). HIV/AIDS was themost commonly reported disorder for which CTP wasused (6 participants), followed by fibromyalgia (n = 5),arthritis (n = 4), mood/anxiety disorders (n = 3), cancer(n = 2), neurological disorders (n = 2), gender dysphoria(n = 2) and other disorders (n = 4). Some individualswere living with multiple diagnoses. Participantsdescribed their CTP use as long-term (mean = 8.3 years,range = 2 to 16 years). All participants smoked CTP; 15indicated they also ingested it and nine used a vaporizer.Other methods used by participants included tinctures(n = 5), sprays (n = 2), cannabis mixed with tobacco (n =1) and use of a poultice (cannabis mixed with alcoholand applied topically) (n = 1). When asked about theirpurchase locations, only five of the eleven participantsthat currently held a Health Canada license indicatedthey purchased their cannabis from Health Canada andmost (n = 20) purchased it from a community-based dis-pensary. Participants also indicated they accessed CTPBottorff et al. Harm Reduction Journal 2013, 10:2 Page 3 of 10http://www.harmreductionjournal.com/content/10/1/2directly through licensed growers (n = 10) and non-licensed growers (n = 10).Data collectionData were collected using semi-structured, individualface-to-face or telephone interviews. Participants wereinvited to discuss their beliefs about and experiences ofusing CTP and their experiences of stigma. At a timeand location convenient to the participant, interviewswere conducted by trained research assistants and lastedapproximately 1–3 hours. A short questionnaire wasadministered to gather demographic data, history of can-nabis use, and information about health issues influen-cing use of CTP.Data analysisUsing an inductive thematic approach to data analysis,interview transcripts were read and re-read by theauthors and sections of the data that reflected emergentideas and themes were highlighted. In investigative teammeetings, independent reviews of the data weresummated and shared to reach consensus about categor-ies for coding the data. The qualitative data managementsoftware program, NVivo™, was used to organize thedata for retrieval and in-depth analysis. Comparativestrategies were used to explore participants’ perceptionsof CTP.ResultsParticipants’ narratives included a predominant discourseof stigma associated with CTP use. Experiences of stigmaarose in interactions with family members and closefriends, as well as from others in society. The multipledimensions of stigma associated with using CTP use iden-tified in the data afforded a view of participants’ ex-periences whereby most contributed to more than onedimension. In order to achieve the benefits of cannabisuse, participants had to negotiate social censorship, disap-proval, threats, and isolation. Ways participants copedwith and minimized their experiences of stigma associatedwith CTP use are also described.Dimensions of stigma associated with CTPThree dimensions of stigma were identified that relatedto negative views of cannabis as a recreational drug, il-legal activity surrounding cannabis use, and layered vul-nerabilities related to poverty and particular illnessesand disabilities. Each dimension is described in thefollowing sections.Medicine in a jointUnlike other medications the participants used, CTP wasmore difficult to conceal particularly when consumedthrough smoking. The distinctive and often times strongsmell, appearance, and behaviours associated with smok-ing a joint invoke negative images for some, such as the“pothead,” and have been reinforced by the media andpublic opinion. We use the word “joint” deliberately tohighlight the stigma participants’ experienced. Dominantviews of cannabis, as a recreational drug used for pleasure,to just “get high” and to escape the realities of life wereperceived to make it difficult for the medicinal value ofcannabis to be recognized and defended in an objectiveway. As a consequence, participants reported being la-belled as “potheads” by their families, healthcare providersand society at large. Some were falsely accused of usingCTP not for medicinal purposes but “just to have somefun” (woman, aged 45, digestive disorder). These labelspositioned CTP users as irresponsible, non-contributing,and on the margins of society, unbecoming attributionsparticipants refuted. One man (aged 45, fibromyalgia)resented “being perceived as something less than accept-able” and felt that he was unfairly judged by others specif-ically because of his use of CTP:Nobody turns around and says you’re a junkie if youhave terminal cancer and are on heroin. But it doesn’tmatter why you’re on marijuana, [if] you’re onmarijuana, “You’re a pothead and get the hell awayfrom me.”In this example, the man reveals a comparison pointwhereby harder drugs such as heroin can be packaged astherapeutic and legitimate in the context of bufferingthe symptoms that accompany advanced disease whenthere is little hope of survival. Yet, cannabis is notunderstood as affording the same relief – rather, its usebrings into question both the legitimacy of the illnessand the role of smoked cannabis as a medicine.Constructions of cannabis as an addictive substancewere also perceived to contribute to condemnations ofits use as a medicinal drug of choice, and therebystigmatized users. Users of CTP reported being labelled“drug addicts” and that others, including physicians,continually reminded users that cannabis was a “badmedicine” that could lead to addiction. Even whenparticipants were prescribed other potentially addictivemedications (e.g., oxycotin, sleeping pills), it was theiruse of cannabis that was scrutinized and criticized.Healthcare providers went as far as to offer participantscounselling to “get help” with their assumed marijuanaaddiction.External stigma was also reflected in the lack of trustexpressed by family members as well as healthprofessionals as a result of participants’ use of CTP.Participants reported not being believed by others whenthey described the medical benefits they experiencedfrom cannabis and their requests for cannabis led to aBottorff et al. Harm Reduction Journal 2013, 10:2 Page 4 of 10http://www.harmreductionjournal.com/content/10/1/2questioning of the severity of their reported symptoms.Participants recounted that others thought they were“making things up,” “faking things” or “manipulatingsymptoms” to get safe access to cannabis. There was anunderlying sense that participants were viewed as beingunreliable, dangerous, unsavoury, and “abusing the sys-tem” when in fact, they believed they were attempting toresolve the health problems they experienced in a re-sponsible way.Perceptions that cannabis use “changed” people andinterfered with their ability to think clearly and act re-sponsibly also contributed to the stigmatization thatCTP users experienced. Participants reported to be re-luctant to tell their employers or coworkers of their CTPuse, fearing that they would lose their professional sta-tus, and they and their work performance would benegatively judged.In summary, there was consensus that the stigmaassociated with cannabis use negatively impactedparticipants’ social, professional and family ties as well astheir relationships with healthcare providers. Thesereactions forced participants to self-regulate and with-draw from some of their social networks and resulted insocial isolation, estrangement from family and friends,and for some, relocation to another city. The reactionsalso acted as a barrier to receiving the health care manyparticipants needed.Medicine on the wrong side of the lawCannabis as a stigmatized medicine was also confoundedwith the fact that it is an illegal substance. Users of CTP,therefore, explained they were faced with not only beinglabelled as “potheads” but also criminals. They reportedbeing viewed with suspicion and marginalized for theirillegal activities associated with using CTP. One woman(aged 45, digestive disorder) indicated that she was ini-tially hesitant to begin using CTP because of the stigmaassociated with cannabis as an illegal substance:When I first came to the compassion club it was anemotional thing for me, I cried when l left. I was like,“Oh my God, this is where my life has thrown me?I’ve lost my career. I’m in the ditch vomiting. Nowthis is what I have come to”. I was like, “It’s illegal! It’sillegal!” I want to be an upstanding citizen; I don’twant to be a criminal. But then, as I was realizing alittle clearer what was really going on, I realized it wasthe biggest gift and my complete ally and then mywhole concept just shifted.Having a federal license or community-based dispens-ary membership card provided recognition of their needfor medical cannabis and thus distinguished users ofCTP from illegal recreational users. However, for someholding a license or membership card did not negate thestigma they experienced as CTP users because they felt“branded” as being involved in an apparently illegal ac-tivity, and described additional scrutiny and differentialtreatment that negatively impacted their lives. For ex-ample, a 55-year-old woman thought her fears would berelieved upon receiving her license from Health Canada,but instead felt much regret over the process andbelieved she was in a worse situation:I thought I’d feel different but I don’t. . . I don’t feel assafe now because I’ve identified myself as a potsmoker where before I was anonymous and I think Iwas in a better position. . . If I had to do it over againI wouldn’t even tell my doctor, it wasn’t worth it.Similarly, a 27-year-old man with cancer believed thatsince receiving his Health Canada licence, he was“discriminated upon constantly” by police who wouldoften detain him until they verified the legitimacy of hislicense:It’s all fun and games the first 10 times you do it butafter, you know, you get pretty annoyed. I mean if Ijust had to flip them a card and walk away then thatwould be a little different but they’ve got to run yourname. They’ve never heard of the program, they wantto have it explained to them or if they have heard [ofthe MMAD], you know, I’ve literally had cops makeme wait while they bring a couple of other cops overto look at the licence.The inclination that those producing their own CTPmight be dealers was also a site for stigma. Despitebeing “legal,” those that cultivated their own cannabiswith licences were often harassed by local police,landlords and subsidised housing investigators. Severalhad been subjected to what they believed were unwar-ranted raids on their property and would often lose theircannabis plants in the process either due to confiscationby the police or by their own hand to conceal theirgardens. One 36-year-old woman living with AIDS wasrepeatedly harassed by the police who were supposed tobe checking the security of her residence. They wantedto see her garden and questioned the validity of her fed-eral licence. Legal producers also had difficulty findingand keeping their housing due to landlords’ concernsabout the legitimacy and impact on other tenants oftheir cultivation of cannabis. One participant, a man liv-ing with AIDS in a subsidised housing residence,complained that he was constantly investigated by thehousing officials. He often dismantled his garden toavoid confrontation and to keep his lease despite theloss of his home-grown medicine.Bottorff et al. Harm Reduction Journal 2013, 10:2 Page 5 of 10http://www.harmreductionjournal.com/content/10/1/2Because of the current criminal sanctions associatedwith cannabis, participants believed their CTP use alsoraised suspicions and judgements about their ability toparent. Several participants feared losing custody of, oraccess to, their children as a result of being caught withCTP. One user of CTP (aged 34, AIDS) resented this,stating people “shouldn’t have to fear [their] kid beingtaken away because of [their] choice in medicine.” Beinga parent, therefore, led participants to take steps to con-ceal their use of CTP.Using cannabis in the context of layered vulnerabilitiesFor many participants, the stigmatization they expe-rienced in using cannabis was entangled with otherstigmatized vulnerabilities, such as living with a mar-ginalized disorder (e.g., HIV/AIDS, fibromyalgia, mentalillness, history of drug addiction), transitioning gen-der identity, being homosexual, or living in poverty. A34-year-old man who held a federal licence, talked aboutthe multiple stigmas he lived with which made his can-nabis use less acceptable than that of others who did nothave AIDS or a history of drug addiction:It doesn’t matter how many federal licences [I have]. . .I’ve got the stigma of AIDS, I’ve got the stigma of anex-junkie, okay, so I’ve got a lot of dirt in my closet thatcan be thrown up, right. But if one of [my brother’s]friends who don’t have this dirt, if one of those friendssuddenly started smoking cannabis and he got a federallicence like me, I think it would be a little moreaccepted.In this example, the man’s history of addiction prevailsand the remnants of his past drug use (i.e., HIV/AIDS)locate CTP as little more than a new addiction. Thesevulnerabilities created challenges in accessing CTP.Requests for CTP were often questioned or not takenseriously on the basis of already suspect diagnosis andpractices, and frequently resulted in long delays inaccessing CTP. Other individuals who had struggled foryears to get diagnosed or be referred to specialists haddifficulty generating enough energy to lobby or negotiateaccess to CTP when healthcare providers had already la-belled them “problem” patients or held judgementalattitudes about their illnesses.Coping with stigma associated with CTP useChoosing to continue their use of CTP because of thesignificant benefits experienced in relation to managingtheir health problems, participants engaged in a varietyof coping strategies to respond to the stigma associatedwith CTP use. Strategies identified in this data were:keeping use of CTP undercover, convincing others ofthe benefits of CTP, being responsible in their use ofCTP and actively defending their right to choose theirown medication.Covert use: keeping CTP use undercoverSome participants believed that with the overwhelmingcondemnation attributed to cannabis and the currentcriminal sanctions associated with cannabis in Canada,there was little they could do except be covert in theirCTP use. As such, they guarded and hid their use ofcannabis from others. When one 55-year-old womanwas asked if she had any advice for other CTP users, shestated: “Keep your mouth shut, grow it, use it, don’t tellanybody, don’t even tell your family, don’t tell yourfriends, keep it to yourself and save your own life.”Individuals went to great length to cover up their CTPuse, including lighting incense to mask the smell, smok-ing away from their home, changing their clothes aftersmoking cannabis, and being vigilant about who wasaround when they smoked.By using CTP covertly, participants also protectedthemselves through self-imposed social isolation. Someisolated themselves in order to avoid criticism andfeeling “guilty” about their use. Others smoked in privateto avoid children seeing them smoke cannabis. Onewoman who isolated herself from her family explained:I have a very difficult time convincing my family whyI have to use it and it’s just got to the point where Idon’t even bother talking to my family because of thefact that they just keep dissing me because I use it....They’re old school, a drug’s a drug, that’s theirmentality.Expert use: convincing others of the benefits of CTP useSeveral participants believed that the harsh judgementalattitudes they had experienced were the result of “misin-formation” from the media and a general lack of know-ledge of CTP. As such, several participants believed thatthe only way to address this was to educate and discussthe therapeutic properties of cannabis “to open otherpeople’s eyes.” One man (aged 42, daily user, AIDS)argued that if the perception of cannabis was to changeto being a therapeutic agent rather than a recreationaldrug, much would be improved:It’s that stigma attached to pot, that lovely word pothas such a bad condemnation to it. Meanwhile peoplecan pop sleeping pills left, right and center andnobody thinks anything of it. So it’s a perception.When we can change that perception of what this isand what the approach is [cannabis as therapy], thebattle is half won. [It would help for] people to talkabout the issue, get proper information out there, andif you can stack the seats with informed people andBottorff et al. Harm Reduction Journal 2013, 10:2 Page 6 of 10http://www.harmreductionjournal.com/content/10/1/2reach out to a community where you need to reachout to, then you can start the process.The work of informing friends and family was often along (but important) process of education on the part ofparticipants. A 36-year-old woman’s experience with hermother typified this experience:She [participant’s mother] goes, “I think you have aproblem, I think you have an addiction.” Now Ilooked at her and said “I’m not taking really any painkillers at all, okay, nothing, I’ve taken myself offprednisone, taken myself off the [mesalamine], nottaking [acetaminophen/codeine], and you’re tellingme, Mother, I’m possibly addicted to cannabis?” Wehad a slight fight about it [laughing] and then, ofcourse, she changed her mind because I had toeducate her, as well as many others, and now shedoesn’t like to admit to that little story because nowshe is a full on cannabis granny, raging granny. Imean she is so supportive. Now she looks at me andshe is very, very proud. She doesn’t feel I have anaddiction problem in any way.Responsible use: doing everything “right”In an effort to reinforce the differences between recre-ational and therapeutic uses of cannabis, some participantscast aspersions on recreational users while exulting them-selves as being a responsible user and “clean on otherfronts” (aged 43, daily user, Fibromyalgia). For example,when asked how her therapeutic use compared to recre-ational users, one woman (aged 36, licensed user, HIV-AIDS) asserted, “They act stupid some of them. . .becausethey flaunt it, they’ll smoke it anywhere.” In contrast andas a “responsible” CTP user, she took precautions and al-ways smoked with discretion: “I don’t flaunt it, like sit therewith my arm out the window.” She identified recreationalusers as “pimps, pushers and, people in the criminal world”and stated they were “different” from her. A 36-year-oldman (daily user, chronic back pain) believed therapeuticuse was fundamentally different because “recreationalpeople are the people who use it and giggle and laugh andjoke around and then that’s it.” Participants perceived theiruse of CTP as “necessary” while recreational use was oftenstrictly “social” in nature. A third participant (aged 36, dailyuser, HIV/AIDS) who indicated she never used cannabisrecreationally stated: “I think the recreational is more forrelaxation not for pain, what it’s supposed to be for, it’smore for them to party with. For us, it’s more of a lifething.” As a result of the necessity of their use of CTP,participants were very particular in how they procuredtheir cannabis, how much they used, and when so as notto be confused with recreational drug addicts.Leading by example was what one participant (aged42, daily user, HIV/AIDS) believed he could do tochange society’s perceptions of him and his CTP use.And while he was fully aware that he would not be ableto change opinions overnight, he remained hopeful andbelieved that once others saw him as a responsible user,their attitudes towards him and CTP would start tochange:I can only do what I can do for myself and presentmyself and approach my life in the way that showsthat I am not a drug addict. I am not a detriment tosociety. I’m actually trying to be a part of society but Iam kind of running into a lot of roadblocks. I knowhow the world works. It happens slowly, very slowlyand usually it’s one or two or three people who startand take it somewhere and then other people build onit. That’s all you can do.Participants also attempted to control the stigmasurrounding their use of CTP by being open and honestabout their use. Applying for a federally-issued licencefor CTP use and production, and notifying law enforce-ment of their CTP production were ways someparticipants attempted to manage their image as a re-sponsible cannabis user.Activist use: CTP as a human rights issueNotwithstanding the stigma experienced for using an il-legal substance therapeutically, participants continued tostaunchly defend their right to choose their own medica-tion. And despite “swimming [in a] pool with sharks”and illegally accessing CTP, many participants werecommitted to using CTP and helping others gain accessregardless of the potential risks, including arrest and/orimprisonment. Several participants became activists intheir own right and argued that neither the governmentnor the medical community had the right to deny themaccess to their “medication”, or to persecute them forusing it. Doing what he felt was “logically and ethicallycorrect in [his] heart”, one 34-year-old man living withAIDS dared the government to take away his CTP:Screw them, I’m a free man, you know? Furthermore,I’m [now] like a 60 or 70 year old man. I’m living outmy final years. Do you really think I’m going to listento some federal regulation for Christ’s sake? I meanthis is insane.Similarly, other participants believed it was the dutyand “moral ethical obligation” of Health Canada to ex-plore the therapeutic uses of cannabis and to “open upaccess in order to maximize the benefits of medical can-nabis in society as a whole”. Some were hopeful thatBottorff et al. Harm Reduction Journal 2013, 10:2 Page 7 of 10http://www.harmreductionjournal.com/content/10/1/2through their activism, the laws surrounding CTP wouldeventually change and they would be able to use theirmedication freely and openly without fear of prosecution(woman aged 36, daily user, AIDS):I will get the message across, because I know it’scoming. Yeah, freedom is a right. I hope this all goesthrough finally [and] that we shouldn’t have to go tojail for what we believe in, for helping sick people. Idon’t believe it’s a crime and I believe it’s a waste oftaxpayer’s money, and the government should stay outof it. This should be a medical, a medical thing andthat’s it.DiscussionStigmatization as a form of social control which func-tions to discourage and penalize deviant behaviour,characteristics or identities was reflected in the findings.The findings suggest there are complex and overlappingfactors that produce both the stigmatization experiencedby CTP users that related to the ambiguous status ofcannabis, lack of acknowledge about medical cannabis,and stigma associated with particular health disorders.While public acceptance of cannabis continues to grow,it appears that CTP users remain highly vulnerable tostigma at both interpersonal and institutional levels.Participant experiences of stigma related to CTP usestemmed from external sources, including their friends,family, healthcare providers, and law enforcement, andfrom their own internalized guilt and discomfort relatedto using a medication that is also often used recreation-ally and illegally. In addition, victim blaming discoursewas evident, whereby the illness for which CTP was usedattracted harsh judgements about the person’s previoushealth practices (e.g., HIV/AIDS in homosexual and IVdrug users, smokers who get cancer) and the validity oftheir treatment requests. Suspicion about previous riskybehaviours was prompted by CTP use and interpreted asemerging from irresponsible acts and disregard for self-health. In addition, illnesses for which others adjust oradequately cope with using conventional medical treat-ments, rendered suspect the use of CTP as a legitimatecourse of treatment.Stigmatization related to cannabis as a substance andits illegal status are clearly intertwined. Historically, can-nabis was made illegal not because of problems asso-ciated with its use, but rather, as a result of propagandathat encouraged the public to view cannabis as risky anduntoward in order to reify its criminal classification [37].Engaging in illegal activities, more generally, is stig-matized in society. Criminalizing activities render themdeviant, and it is generally assumed within society thatthere is a good reason for this status. Even though devi-ance and criminality were not central to the majority ofparticipants’ self concepts, “disidentifiers” [10] were com-monly used to distance themselves from these labels. Forthese individuals who were already living with a chronic,often life-limiting illness and on the margins of society,this additional form of stigmatization increased the phys-ical and emotional distress they experienced.Even more problematic from a human rights perspec-tive is the potential for discrimination in the healthcaresystem, where individuals fail to receive appropriate as-sessment and treatment for a health condition becauseof being labeled as drug dependent or a pothead. In thiscontext, patient-provider consultations become focusedon extraneous issues, such as addiction and one’s moralfiber, rather than the larger concerns of symptom man-agement and the underlying pathology of illness. Amidthis preoccupation resides an uneasiness and lingeringdoubt that CTP use is contrived and manipulative,whereby cannabis is masking, and in many cases addingto, the individual’s and societal problems. This discoursethreatens the trust essential for a caring patient-providerrelationship and may disrupt future care-seeking behav-iour by patients as well as the delivery of efficacioustreatments by healthcare providers. Physicians, in par-ticular, have the obligation and duty to provide safe,competent, and ethical care to all individuals in accord-ance with current and accepted standards of prac-tice [38]. Although CTP remains in the hinterland ofaccepted standards of practice within North America,the growing body of evidence supporting its use as amedical treatment and its availability through anestablished federal health program is forcing the hand ofphysicians and other healthcare providers to considerthe potential value of cannabis as a therapeutic agent.To not do so could be potentially viewed as a breach incare and a discriminatory action.The Supreme Court of Canada recognized that it isconstitutionally problematic to put people in a positionto have to choose between their liberty and their health,and this led to the establishment of the federal medicalcannabis programme [39,40]. And while there continueto be advancements in the rights of CTP users at the ju-dicial level, they are often on a case by case basis, andincidents of discrimination continue to be documentedand arrests are common [41,42]. All participants in thisstudy were either MMAD licence holders or medicalcannabis dispensary members, meaning that their use ofCTP was legitimate (i.e., it was for a documented med-ical condition). However, only those with MMADlicences who procured CTP from Canada’s contractedproducer were using CTP legally. For some, choosingthe legal government route was a way to quell their in-ternal concerns about acting lawfully. However, it wasapparent from our interviews that this did not necessar-ily relieve external stigma. Outing themselves as CTPBottorff et al. Harm Reduction Journal 2013, 10:2 Page 8 of 10http://www.harmreductionjournal.com/content/10/1/2users made them feel more vulnerable, and some actu-ally found themselves facing more external stigma thanif they had been hiding their use. It appears that due tothe overarching illegal status of cannabis outside of thenarrow exception for therapeutic use, the legal routedoes not necessarily alleviate stigma for CTP users.Although the use of CTP appeared to be a marker of in-dividual expression or identity, not unlike some recre-ational users experiencing stigma, fear of shame and loss ofstatus necessitated efforts to manage stigma. Managementof personal information and others’ knowledge of CTP useappear to be of critical importance to CTP users, withmany choosing between hiding their use from others inorder to pass as normal to avoid sanctions (i.e., socialavoidance) or being open about it (selective or indiscrimin-ate disclosure) in an attempt to inform others about CTPand assist with redefining users as “normal” law-abidingcitizens [43]. These reactions are common in the stigma lit-erature and both serve as an attempt to protect oneselffrom further stigma [44,45]. Study participants’ efforts tobe responsible and discrete in their CTP use to avoiddrawing attention (particularly from law enforcement) aresimilar to those observed among both therapeutic and rec-reational cannabis users [3,23,46]. The fact that someparticipants chose to be open about their CTP use may re-flect established coping strategies developed in response tolong-standing stigmatizing illnesses.While many study participants took it upon them-selves to educate others about the value of cannabis as amedicine, it is unrealistic that the work of stigma reduc-tion rest solely on individuals compromised by healthproblems. Instead, formal education programs and policyreform is required that targets healthcare providers, lawenforcement personnel, government authorities, as wellas members of general society. Interventions that ad-dress the history of cannabis criminalization, as well asthe legitimacy of CTP use and the options for legal CTPuse, would go a long way to ensuring CTP users experi-ence the full spirit of their constitutional right to healthwithout fearing legal repercussions or experiencing thestigma of being associated with an illegal activity. Suchprograms could be modelled after other successfulstigma reduction interventions that have been developedfor other marginalized groups, including HIV/AIDS andmental illness [47-49].Several limitations to this research are recognized.Participants were from British Columbia, a Canadianprovince known for its illegal cannabis production and tol-erance of recreational use. The contradictions experiencedby the CTP users in this study cannot be understood apartfrom the social and structural conditions that influencedhow users viewed themselves and how they are viewed byothers. Experiences of and reactions to using CTP mayhave differed if participants had been recruited from moreconservative regions. As most of the participants indicatedthey were long-term users and had made the decision touse CTP several years before, their experiences of stigmamay not be the same as those who have just begun to useCTP. Furthermore, the participants were self-selected (i.e.,they were willing to speak openly about CTP). As a result,it could be that those who had experienced more negativestigma while using CTP, those who no longer used CTPfor fear of its social and legal ramifications or who did notwant to be a magnet for their friends’ or families’ discon-tent were thus likely underrepresented in this study.Further research is required to examine how experiencesof stigma evolve over the course of CTP treatmentand among different populations in different legal/socialclimates.ConclusionExperiences of stigma among those with illness and therole stigma plays in seeking treatment are not new inthe literature. However, in this literature it is not neces-sarily the treatment that is stigmatized, but the illnessfor which the treatment is used. CTP stands as one ofthe few treatments where users are directly stigmatizedfor their use of it regardless of their particular illness.The findings of this study shed light on how individualsusing CTP experience stigma, and the effect on theirphysical and emotional wellbeing as well as the impacton healthcare interactions. The stigmatization of CTPusers is related to the ambiguous status of cannabis (anillegal substance and a legal therapeutic agent at thesame time), and to the lack of acknowledge about med-ical cannabis among the public, physicians, and law en-forcement personnel. The findings reinforce the urgentneed for finding better solutions and strategies to reducestigmatization associated with use of CTP.Competing interestsThere are no competing interests to report.Authors’ contributionsJLB and LGB were the principal study investigators, contributed to theconceptualization, design, conduct and analyses of the study, interpretation,and writing of this manuscript. LJLB, JLO, NRC, JB contributed to theconceptualization, design, analysis and interpretation of the data, and writingof the manuscript. All authors read and approved the final manuscript.AcknowledgementsThis research was supported by a grant from the Social Science andHumanities Research Council of Canada (SSHRC) and by Canadian Instituteof Health Research (CIHR) Investigator awards to Drs. Oliffe and Balneaves, aswell as a Michael Smith Foundation for Health Research (MSFHR) Scholaraward to Dr. Oliffe. We also acknowledge the involvement of Dr. BonitaLong in the development of this research, Bindy Kang and Terry Howardwith data collection, and the support of community stakeholder groups andthe individuals who participated in this project.Author details1School of Nursing, Faculty of Health and Social Development, University ofBritish Columbia’s Okanagan campus, Kelowna, BC V1V 1V7, Canada. 2Facultyof Health and Social Development, University of British Columbia’s OkanaganBottorff et al. Harm Reduction Journal 2013, 10:2 Page 9 of 10http://www.harmreductionjournal.com/content/10/1/2campus, Kelowna, BC V1V 1V7, Canada. 3School of Nursing, University ofBritish Columbia, T201 2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada.4Interdisciplinary Graduate Studies Program, University of British Columbia,T201 2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada. 5School ofPopulation and Public Health, University of British Columbia, 171 - 2206 EastMall, Vancouver V6T 1Z3, Canada. 6Institute for Healthy Living and ChronicDisease Prevention, University of British Columbia’s Okanagan campus, 3333University Way, Kelowna, BC V1 1V7, Canada.Received: 23 May 2012 Accepted: 11 February 2013Published: 16 February 2013References1. Tramer MR, Carroll D, Campbell F, Reynolds DJM, Moore A, McQuay H:Cannabinoids for control of chemotherapy induced nausea andvomiting: Quantitative systematic review. BMJ 2001, 323(16):1–8.2. 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