Arts and Social Sciences, Irving K. Barber Faculty of (Okanagan)
Psychology, Department of (Okanagan)
DSpace
UBCO
Cates, Jordyn Mackenzie
Master of Arts - MA
University of British Columbia
Since the legalization of adult recreational cannabis use in Canada, Indigenous leaders have made numerous calls on the provincial and federal governments for adequate and appropriate consultation regarding the Cannabis Act. These calls parallel the narrative surrounding research with Indigenous communities, which have historically enacted Western methods, often leading to non-collaborative approaches or exclusionary dynamics. This study brings together Indigenous researchers, substance use experts, and representatives from Indigenous communities and organizations to provide a platform for Indigenous perspectives on cannabis. Guided by Two-Eyed Seeing, in conjunction with Wilson’s (2008) circular research paradigm, this mixed-methods study explores what Indigenous Peoples think about cannabis use, what motivates them to use it, how it is used as a substitute for other substances, the modes and patterns of use, the access of cannabis, barriers to health care, and the impacts of legalization. Our findings show that the majority of respondents consider cannabis to be a medicine. Cannabis was used for an array of reasons both within and between respondents, with most reporting both cannabis for therapeutic purposes (CTP) and cannabis for recreational purposes (CRP). Cannabis was used as a substitute for a variety of substances including, alcohol, stimulants, opioids, cigarettes, and benzodiazepines. It was predominately disliked due to the associated stigma. Similarly, almost half of the respondents reported experiencing discrimination from their doctor because of cannabis use. Overall, we heard that cannabis use was perceived as an approach to enhance overall well-being and was not generally considered problematic.
“IT’S A PLANT AND THAT’S WHY I THINK IT’S A MEDICINE”: INDIGENOUS PERSPECTIVES OF CANNABIS USE ON TURTLE ISLAND by Jordyn Mackenzie Cates B.Sc., University of British Columbia, 2021 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE COLLEGE OF GRADUATE STUDIES (Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) August 2024 © Jordyn Mackenzie Cates, 2024 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis entitled: “IT’S A PLANT AND THAT’S WHY I THINK IT’S A MEDICINE”: CANNABIS USE ON TURTLE ISLAND: INDIGENOUS PERSPECTIVES submitted by Jordyn Mackenzie Cates in partial fulfillment of the requirements for the degree of Master of Arts Examining Committee: Dr. Zachary Walsh, Psychology, Irving K. Barber Faculty of Arts and Social Sciences Supervisor Dr. Lindsay Farrell, Psychology, Irving K. Barber Faculty of Arts and Social Sciences Supervisory Committee Member Dr. Jessica Lougheed, Psychology, Irving K. Barber Faculty of Arts and Social Sciences Supervisory Committee Member Dr. Alanaise Ferguson, Community, Culture and Global Studies, Irving K. Barber Faculty of Arts and Social Sciences University Examiner iii Abstract Since the legalization of adult recreational cannabis use in Canada, Indigenous leaders have made numerous calls on the provincial and federal governments for adequate and appropriate consultation regarding the Cannabis Act. These calls parallel the narrative surrounding research with Indigenous communities, which have historically enacted Western methods, often leading to non-collaborative approaches or exclusionary dynamics. This study brings together Indigenous researchers, substance use experts, and representatives from Indigenous communities and organizations to provide a platform for Indigenous perspectives on cannabis. Guided by Two-Eyed Seeing, in conjunction with Wilson’s (2008) circular research paradigm, this mixed-methods study explores what Indigenous Peoples think about cannabis use, what motivates them to use it, how it is used as a substitute for other substances, the modes and patterns of use, the access of cannabis, barriers to health care, and the impacts of legalization. Our findings show that the majority of respondents consider cannabis to be a medicine. Cannabis was used for an array of reasons both within and between respondents, with most reporting both cannabis for therapeutic purposes (CTP) and cannabis for recreational purposes (CRP). Cannabis was used as a substitute for a variety of substances including, alcohol, stimulants, opioids, cigarettes, and benzodiazepines. It was predominately disliked due to the associated stigma. Similarly, almost half of the respondents reported experiencing discrimination from their doctor because of cannabis use. Overall, we heard that cannabis use was perceived as an approach to enhance overall well-being and was not generally considered problematic. iv Lay Summary Indigenous Peoples have historically been excluded from participating in research and policy development that affects them. This is an Indigenous-led study that explores Indigenous perspectives of cannabis use. Through the lens of Two-Eyed Seeing, we explore the motivation behind cannabis use, how it is used as a medicine, and the barriers Indigenous Peoples face when accessing cannabis as a medicine. To our knowledge, this is the first Indigenous-led study that explores these aspects of cannabis use among Indigenous Peoples in Canada. Our findings reveal that Indigenous Peoples use cannabis for an array of reasons. The majority use cannabis as a medicine and for pleasure. Respondents disliked the social stigma associated with cannabis and experienced discrimination from health care professionals when talking about cannabis use. Overall, Indigenous Peoples did not consider their cannabis use to be problematic; instead, they spoke about how cannabis is used to enhance their overall well-being. v Preface The Behavioural Research Ethics Board of the University of British Columbia’s Okanagan Campus granted ethics approval for this study (H21-00370). The research included in this thesis has not been published. The design of the study was co-created for Phase-One by Dr. Zach Walsh, Dr. Lindsay Farrell, Chief of Woodland Cree First Nation Isaac Laboucan-Avirom, the previous Director of Health Woodland Cree First Nation Kimberly Carifelle, Senior Vice President of Indigenous Bloom Cooperation Michael Lane, Dr. Michael Evans, and Dr. Michael J. Milloy. Tatiana Sanchez coordinated the scheduling of interviews and Jennifer Lavalley, Rachael Babcock, and I conducted the interviews. The design of the study was adjusted for Phase-Two by the Governance manager of Zagimē Anishinabēk, Ken Acoose, Zagimē Anishinabēk Liaison Karen Debroni, and it was approved by Chief Lynn Acoose and Council of Zagimē Anishinabēk. I was responsible for conducting Phase-Two interviews, analyses, interpretation, and writing of this thesis with the supervision of Dr. Zach Walsh and guidance from committee members Dr. Lindsay Farrell and Dr. Jessica Lougheed. Generative AI tools were used solely to enhance readability and grammar. Figure 1 is a copyrighted image; it has been properly credited in accordance with copyright regulations. vi Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface .............................................................................................................................................v Table of Contents ......................................................................................................................... vi List of Tables .............................................................................................................................. viii List of Figures ............................................................................................................................... ix Acknowledgements ........................................................................................................................x Dedication ..................................................................................................................................... xi Chapter 1: Introduction ................................................................................................................1 1.1 Positioning of Self........................................................................................................... 1 1.2 Approach: Two-Eyed Seeing .......................................................................................... 3 1.3 Literature Review............................................................................................................ 7 1.3.1 Cannabis .................................................................................................................. 7 1.3.2 Research and Indigenous Peoples ........................................................................... 9 1.3.3 The Cannabis Act .................................................................................................. 13 1.3.4 Cannabis Use Motivations .................................................................................... 13 1.3.5 Barriers to Health Care ......................................................................................... 16 1.3.6 Current Therapeutic Applications ......................................................................... 17 1.3.7 Cannabis as a Substitute........................................................................................ 18 Chapter 2: The Current Study ...................................................................................................21 2.1 Research Aims .............................................................................................................. 21 Chapter 3: Methodologies ...........................................................................................................22 3.1 Phase-One ..................................................................................................................... 22 3.1.1 Participant Recruitment ........................................................................................ 22 3.1.2 Data Collection ..................................................................................................... 23 3.2 Phase-Two..................................................................................................................... 23 3.2.1 Participant Recruitment ........................................................................................ 23 3.2.2 Data Collection ..................................................................................................... 24 3.3 Collaborative Instrument Development ........................................................................ 24 3.3.1 Demographics ....................................................................................................... 25 3.3.2 Qualitative Demographics Introduction ................................................................ 25 3.3.3 Qualitative Cannabis Use History and Perceptions .............................................. 25 3.3.4 Current Cannabis Use Details ............................................................................... 25 3.3.5 Law Enforcement Related to Cannabis................................................................. 25 3.3.6 Medication, Substance Use, and Substitution ....................................................... 26 3.3.7 Access to Medical Cannabis ................................................................................. 26 3.3.8 Social Norms ......................................................................................................... 26 3.3.9 Legalization........................................................................................................... 27 vii 3.3.10 Brief Composite Cannabis Assessment Tool (BCCAT) ....................................... 27 3.3.11 The Cannabis Use Disorder Identification Test-Revised (CUDIT-R (Adamson et al., 2010)). ............................................................................................................................. 27 3.4 Data Analysis ................................................................................................................ 27 Chapter 4: Results........................................................................................................................29 4.1 Positioning The Project ................................................................................................. 29 4.2 Participants .................................................................................................................... 32 4.3 Cannabis Use Perceptions ............................................................................................. 35 4.4 Motivations ................................................................................................................... 50 4.5 Substitution ................................................................................................................... 54 4.6 Modes and Patterns of Use ........................................................................................... 63 4.7 Cannabis Access ........................................................................................................... 66 4.8 Stigma and Barriers to Health Care .............................................................................. 74 Chapter 5: Discussion ..................................................................................................................78 5.1 Strengths and Limitations ............................................................................................. 88 5.2 Implications and Future Directions ............................................................................... 90 5.3 Conclusion .................................................................................................................... 92 References .....................................................................................................................................95 Appendices ..................................................................................................................................112 Appendix A - Interview Script ................................................................................................ 112 Appendix B - Data Sharing Agreement .................................................................................. 132 Appendix C - Phase-One Preliminary Results ........................................................................ 139 viii List of Tables Table 1 Participant Demographics .............................................................................................. 34 Table 2 Cannabis Use Motivations .............................................................................................. 51 Table 3 Reasons for Preferred Source ......................................................................................... 70 Table 4 Descriptive Social Norms ............................................................................................... 77 ix List of Figures Figure 1 Two-Eyed Seeing ............................................................................................................. 4 Figure 2 Alcohol Substitution....................................................................................................... 56 Figure 3 Opioid Substitution ........................................................................................................ 58 Figure 4 Stimulant Substitution .................................................................................................... 60 Figure 5 Tobacco Substitution ..................................................................................................... 62 Figure 7 Modes of Cannabis Use in the L6M .............................................................................. 64 Figure 7 Patterns of Cannabis Use in the L6M ............................................................................ 64 Figure 8 Source of Cannabis........................................................................................................ 69 Figure 9 Injunctive Social Norms ................................................................................................ 77 x Acknowledgements I would not be writing this acknowledgment if it weren’t for several people. Although, my words here will never be enough to express the gratitude I have for all of you. First, I would like to thank Rachel Andreychuk for accepting me into the Indigenous Mentorship Program, connecting me with Dr. Zach Walsh, and introducing me to AISES. Without you believing in me, several years ago, I don’t know where I would be. Zach, you are an incredible supervisor who has stood in my corner every step of the way. You have taught me so much about drugs, therapy, and most importantly life. I would also like to thank Dr. Jessica Lougheed and Dr. Lindsay Farrell as members of my committee. Your time, patience, and perspectives were greatly appreciated. Lindsay, you are such an inspiration. Thank you for your support and guidance before, and during, graduate school. I would like to say thank you to the members of my lab. Specifically, Tatiana Sanchez, Michelle St. Pierre, Tashia Petker, Joey Rootman, and Chris Nelson. I am so lucky to share space with such rad people. Similarly, I would like to express my gratitude to my cohort members, Toria Violo and Sage Wiebe. I cannot imagine these last two years without you two. I must express my appreciation for everyone at IPS. I’d specifically like to thank Joel Liman. You are much more than our chapter advisor; you are a mentor and a friend. I am so thankful for your unwavering support, your wise words, and your kind heart. I’d also like to express my appreciation for all those within the UBCO AISES chapter. Most importantly, I’d like to thank Christopher Paul, my co-founder and partner. You have been a constant support, an inspiration, and without you, OAISES would not exist. Finally, my family. I cannot thank you enough for your unconditional love and support as I navigated this part of my journey. xi Dedication This project is dedicated to the respondents who shared their stories, the community partners, and the next seven generations. Most profoundly, this work is dedicated to the woman who has shown me love when I could not find it for myself, who taught me resiliency through the display of her own, and who made sacrifices so I would not have to. Mom, this is for you. 1 Chapter 1: Introduction 1.1 Positioning of Self After decades of prohibition, the Cannabis Act was passed on October 17, 2018, making non-medical cannabis legal in Canada. Since legalization, Indigenous leaders have made numerous calls on the provincial and federal governments for adequate and appropriate consultation regarding the cannabis act. (First Nations Leadership Council [FNLC], 2023; Standing Senate Committee on Indigenous Peoples, 2023). These calls parallel the narrative surrounding research with Indigenous communities, which have historically enacted Western methods, often leading to non-collaborative approaches or exclusionary dynamics. As we act on the Truth and Reconciliation Commission of Canada’s 94 Calls, researchers, institutions, and governments are becoming increasingly aware of their roles and responsibilities when considering research partnerships with Indigenous Peoples and communities. There is still a lot of work to be done, especially when considering the topics of substance use, health, and well-being. An important step when working towards equitable partnerships is to understand the context within which such collaborations take place. Wilson (2008) explains: Indigenous [Peoples] in Canada recognize that it is important for storytellers to impart their own life and experience into the telling. They also recognize that listeners will filter the story being told through their own experience and thus adapt the information to make it relevant and specific to their life. When listeners know where the storyteller is coming from and how the story fits into the storyteller’s life, it makes the absorption of the knowledge that much easier. (p. 32). As such, I’d like to introduce myself and my involvement in this project before jumping into the literature review. I am Jordyn Cates, my mother is Sam Clark, my grandmother is Terri Jones, 2 and my father is of settler descent. My grandmother, my mother, and I are members of Okanagan Indian band. I have lived in the Okanagan for all my life. I began working with Dr. Zach Walsh in the third year of my undergraduate degree through the Indigenous Research Mentorship Program (IRMP). I participated in the IRMP for two years and, subsequent to that, completed a directed studies project with Dr. Walsh. During that time, I focused on exploring the literature on Indigenous cannabis use within Canada. Once graduated, I was brought on to the first of its kind, Indigenous-led, research project titled: Cannabis Use Among Indigenous Peoples of Turtle Island: Motives for Use, Substitution and Impacts of Legalization (CUTI Project). Phase-One of the CUTI Project was initiated and co-developed with Woodland Cree First Nation and Indigenous Bloom dispensaries. The research team and I completed The Fundamentals of OCAP online course and carried the principles of ownership, control, access, and possession forward to inform this research (First Nations Information Governance Centre [FNIGC], 2023). Interviews for Phase-One were conducted by three Indigenous research assistants, one of whom was a member of Woodland Cree. In line with the principles of OCAP®, Phase-One preliminary results were shared with all participants who consented to receive them. Given my interest in the topic of Indigenous cannabis use and my early involvement in the CUTI project, the decision to make it the focal point of my thesis was an obvious choice. An important note, our team did not seek out multiple phases of this project. Rather, the second Phase was born out of the initiation by a secondary (not in importance, but in chronological sequence) community partner, Zagimē Anishinabēk. The present study brings together Indigenous researchers, substance use experts, and representatives from Indigenous communities and organizations to provide a platform for Indigenous perspectives on cannabis to be heard. Knowledge from our study pertains not only to 3 the disseminated results but also to the sharing of our methods and processes. As such, we will describe our methods of conducting a mixed-methods research study of cannabis among Indigenous Peoples living on Turtle Island. Following, we will qualitatively describe perceptions of cannabis, through the presentation of themes and respondent quotes. Subsequently, descriptive quantitative results of cannabis use motivations, substitution practices, modes and patterns of cannabis use, impacts of cannabis regulation, and experiences with discrimination and barriers to health care will be supported with qualitative findings. To further contextualize this project, I will first describe the approach that guided this exploration. Following this, literature on cannabis, prior research and Indigenous Peoples, the Cannabis Act, motivations for cannabis use, current therapeutic applications of cannabis, and substitution behaviours will be reviewed. 1.2 Approach: Two-Eyed Seeing Etuaptmumk is the Mi'kmaw word for “Two-Eyed Seeing”, and was first described in 2004 by Mi’kmaq Elders, Albert and Muerdena Marshall (Institute for Integrative Science & Health [IISH], n.d.-b; Bartlett et al., 2012; Wright et al., 2019a, Wight et al., 2019b). Elder Albert Marshall shares that “Two-Eyed Seeing is the gift of multiple perspectives” (IISH, n.d.-b, para. 4) by: Learning to see from one eye with the strengths of Indigenous Knowledges and ways of knowing, and from the other eye with the strengths of Western knowledges and ways of knowing, and learning to use both eyes together, for the benefit of all. (IISH, n.d.-b, paras. 3). An additional explanation of Two-Eyed Seeing by Elder Albert Marshall is: Two-Eyed Seeing is hard to convey to academics as it does not fit into any particular subject area or discipline. Rather, it is about life: what you do, what kind of 4 responsibilities you have, how you should live while on Earth … i.e., a guiding principle that covers all aspects of our lives: social, economic, environmental, etc. The advantage of Two-Eyed Seeing is that you are always fine tuning your mind into different places at once, you are always looking for another perspective and better way of doing things. (IISH, n.d.-b, paras. 14). A visual representation of Two-Eyed Seeing can be seen in Figure 1. IISH (n.d.-b) explains that the two eyes lay behind two connected puzzle pieces which act as a reminder that “no one person ever has more than one small piece of the knowledge” (para. 20), “the distinct and whole nature of Indigenous knowledge and ways of knowing” (para. 21), “the distinct nature of Western knowledge and ways of knowing” (para. 21), “Two-Eyed Seeing asks that these two eyes work together” (para. 21), and that “Two-Eyed Seeing can require a ‘weaving back and forth’ between knowledges… [drawing] upon abilities to meaningfully and respectfully engage in an informed manner in collaborative settings” (para. 22). Figure 1 Two-Eyed Seeing Note: From Two-Eyed Seeing, by IISH, n.d. (http://www.integrativescience.ca/Principles/TwoEyedSeeing/). Copyright n.d. by Basma Kavanagh. IISH (n.d.-a) share four “philosophical questions” (para. 6) that speak to ontology, epistemology, methodology, and goals. The first speaks to ontology, “What do we believe the 5 natural world to be?” (para. 7). The second relates to epistemology, “What do we value as ‘ways of coming to know’ the natural?” (para. 9). Third is methodology, “What can remind us of the complexity within our ways of knowing?” (para. 11). The last question speaks to goals, “What overall goals do we have for our ways of knowing?” (para. 13). Within Western knowledge and ways of knowing, these four components may be thought of separately but as Wilson (2008) proposes, [Try] to think of them in a circle… The entire circle is an Indigenous research paradigm. Its entities are inseparable and blend from one into the next… Just as the components of the paradigm are related, the components themselves all have to do with relationships. The ontology and epistemology are based upon a process of relationships that form a mutual reality. The axiology and methodology are based upon maintaining accountability to these relationships. (pp. 70-71). I will acknowledge that the IISH (n.d.-a) and Wilson (2008) differ in their four components of a research paradigm. IISH (n.d.-a) queries goals, whereas Wilson (2008) examines axiology. The remaining components are fundamentally aligned. Wilson (2008) describes ontology with the question, “What is real?” (p. 33), epistemology with “How do I know what is real?” (p. 33), methodology with “How do I find out more about this reality?” (p. 34), and axiology with “What part of this reality is worth finding more about?” and “What is it ethical to do in order to gain this knowledge, and what will this knowledge be used for?” (p. 34). Overarchingly, I would argue that both IISH (n.d.) and Wilson (2008) reach the same paradigm premise with their questions. Notably, IISH (n.d.) incrementally adds to our understanding of a research paradigm by asking these questions for both Indigenous and Western worldviews. 6 Admittedly, but perhaps unsurprisingly, I found it quite challenging to fit each of these components, and the way I understand them in relation to this project, into a dominant Western paradigm. I explored intersectionality as a critical theory, social constructivism, feminist epistemologies, and specific Indigenous epistemologies (Else-Quest & Hyde, 2016; Quinn, 2022). I found that the selection of one felt disingenuous and would disservice the mosaic of perspectives provided by the study team. Two-Eyed Seeing, in conjunction with Wilson’s (2008) circular thinking of each component, fully encompasses my approach to the study as an Indigenous researcher within a colonial institution. I should note that the term colonial institution is purposeful, but not accusatory. There is no debate as to whether UBC is an uninvited guest on the lands of those it inhabits. There is no debate as to whether post-secondary attainment enfranchised First Nations Peoples (Crey, 2009). Thus, it is not an accusation or a critique, but a conscious reiteration of the historical, and ongoing, environment within which academics exist. This historical, and ongoing, environment may be best described by the term colonialism. The term colonialism is intentionally used as colonization, more so, refers to the past tense action of settling and establishing control over Indigenous Peoples (Oxford English Dictionary, 2023). The In Plain Sight Report (2020) defines colonialism as: Colonialism occurs when groups of people come to a place or country, steal the land and resources from Indigenous peoples, and develop a set of laws and public processes that are designed to violate the human rights of the Indigenous peoples, violently suppress their governance, legal, social, and cultural structures, and force them to conform with the colonial state. (p. 8) This definition goes beyond the historical actions and centers the current and ongoing injustices faced by Indigenous Peoples. Steps towards reconciliation taken by universities, for example, are 7 also an acknowledgment of the past, and current, effects of colonialism. As one need not reconcile if dissension has not, or does not, exist. My consideration of dominant Western paradigms aims not to critique them or justify my choice of Two-Eyed Seeing. Rather, my aim here is to be transparent about my thought processes, in an effort to aid others who embark on similar journeys. How does one carry out research within the Two-Eyed Seeing paradigm? Wright et al. (2019a) conducted an integrative review of the current interpretation and application of Two-Eyed Seeing within the literature. Six components emerged from how Two-Eyed Seeing has been defined and characterized by researchers including 1) authentic relationships between researchers and the Indigenous community, 2) researchers and participants benefit from the research process, 3) the research team is responsible for the well-being of those involved in the research, 4) the Indigenous community is involved in the research process, 5) recognition of, and prior guidance from, local Indigenous customs, and 6) Western researchers take the role of follower, listener, and learner. The discussion, section 6, is where I will share how each of these components come alive within this project. For now, I wanted to plant the seed of my approach and allow the reader their own experience of viewing the project through the lens of Two-Eyed Seeing. 1.3 Literature Review 1.3.1 Cannabis The taxonomy and classification of the green leafy plant, cannabis, continue to be debated as new technology and knowledge come to fruition. Several classification models exist, some based on morphology, geography, chemistry, or a combination of these features. The prevailing model, the monotypic model, states that the Cannabis genus (Cannabaceae Family) contains one 8 species (i.e., Cannabis sativa) with two or three subspecies (i.e., Cannabis sativa, Cannabis indica, and Cannabis ruderalis) (Lapierre et al., 2023; Simiyu et al., 2022). Little remains undebated in the field of cannabis research, and the historical use by Indigenous Peoples in North America is no exception. Evidence exists to support that Indigenous Peoples of Turtle Island used cannabis and hemp prior to colonialism (National Indigenous Medical Cannabis Association [NIMCA], 2017; Spicer, 2002). Despite this, uncertainty remains within the broader Western scientific community (Koutouki & Lofts, 2019). Many terms are used when referring to cannabis such as, “weed,” “pot,” or “marijuana”. For our purposes, the term cannabis will be used when referring to plants or products that contain a concentration of THC >0.3% or that are used for medical or recreational consumption (Lapierre et al., 2023). Whereas the term hemp is used when describing plants with <0.3% concentration of THC and is typically used for the production of fibre (Lapierre et al., 2023; Simiyu et al., 2022). Delta-9-tetrahydrocannabinol (THC), the primary psychoactive component of cannabis, and cannabidiol (CBD) are two cannabinoids that have gathered much attention in terms of policy, legislation, and therapeutic applications. However, at least 120 cannabinoids have been identified (Hurgobin et al., 2021; Lapierre et al., 2023). Cannabinoids are not the only phytochemicals of importance. Terpenes, which are mainly responsible for the aroma and flavour of the Cannabis plants, have been found to have independent and dependent bioactivity (Chacon et al., 2022). Dependent bioactivity refers to one component’s ability to impact the activity or effects of another component. Dependent bioactivity here relates to another debated feature of cannabis, the entourage effect. It is often the case that phytochemicals in mixtures (e.g., using flower or full-spectrum cannabis oil) can have different, or more effective results, compared to those in isolation (Chacon et al., 2022; Russo, 9 2011). While the entourage effect has been reported between cannabinoids (e.g., THC and CBD), where cannabis products containing more than one cannabinoid produce differing effects compared to single cannabinoid products (Arkell et al., 2020, Bansal et al., 2023, Zamarripa et al., 2023). The question of synergy between phytochemicals (e.g., cannabinoids and terpenes) remains debated (Chacon et al., 2022). However, recent research suggests that the co-administration of THC and the D-limonene terpene can reduce THC-induced anxiety, demonstrating validity for the entourage effect between phytochemicals (Spindle et al., 2024). Although the squabbles within the scientific community can cast a blanket of uncertainty over cannabis, Indigenous Peoples have been using sacred Plant Medicines since Time Immemorial. If the pursuit of knowledge for the betterment of humankind is the goal within research, then perhaps limiting the accepted knowledge to that gained by Western methodologies may perpetuate a sense of ambiguity. Unfortunately, this has largely been the case in research involving Indigenous Peoples, where methods and interpretations have centered on Western ideologies leading to a dearth of literature by Indigenous Peoples for Indigenous Peoples. 1.3.2 Research and Indigenous Peoples As stated in the Tri-Council Policy Statement Ethical Conduct for Research Involving Humans (TCPS-2) (2022), “Research involving Indigenous Peoples in Canada has been defined and carried out primarily by non-Indigenous researchers. The approaches used have not generally reflected Indigenous world views, and the research has not necessarily benefited Indigenous Peoples or communities” (p. 146). This is true at a federal level, where the Canadian Community Health Survey (CCHS), the Indigenous Peoples Survey (IPS) (i.e., formerly known as Aboriginal Peoples Survey (APS)), and the National Cannabis Survey are three examples of national surveys that exclude First Nations people who live on-reserve (Statistics Canada, n.d., 10 2018, 2023). The IPS also excludes some First Nations groups in the Yukon and the Northwest Territories (Statistics Canada, 2018). However, in 1997, the First Nations Regional Health Survey was developed to address the exclusion of First Nations living on-reserve from some of the national surveys mentioned above (FNIGC, 2018). The statement made by TCPS-2 also applies to the field of cannabis research and, more broadly, substance use research. Historically, cannabis use research among Indigenous Peoples has predominately focused on frequency, prevalence, or rate (referred to as frequency hereafter) of cannabis use and is often then compared to the cannabis use of other racial groups (Diem et al., 1994; Elton-Marshall et al., 2011; Gfellner, 1994; Hop Wo et al., 2020). At least two factors have limited the knowledge of Indigenous cannabis use. The first issue lies within the comparison of Indigenous participants to non-Indigenous participants, that is, the use of deficit-based research methods (Diem et al., 1994; Elton-Marshall et al., 2011; Gfellner, 1994; Hop Wo et al., 2020). Although deficit-based research can identify existing issues, without the appropriate contextual information and involvement of the partnered Indigenous community/group/organization, it runs the risk of perpetuating harmful stereotypes or a population-level deficit discourse (Hyett et al., 2018 & 2019). Gorringe (2015) defines deficit discourse as “a mode of thinking that frames and represents [Indigenous] identity in a narrative of negativity, deficiency and disempowerment” (para. 2). Pruden (2021) further explains the issue with this comparison method using an analogy of comparing apples to oranges. Although both are round and grow on trees, they have differences. An orange will never be an apple and an Indigenous person will never be a non-Indigenous person (and vice versa). A deficit discourse surrounding Indigenous identity is often created as a result of this comparison. This is specifically true within substance use research where there is a risk of multiple discrimination, 11 and subsequently, cumulative disadvantage. Whereby, an Indigenous person simultaneously experiences discrimination related to their Indigenous identity and their substance use. On the other hand, the comparison group, which is typically White people, gains a more positive narrative. Pruden (2021) argues that this can create a site of perpetuating the norm of the system of White Supremacy which can be mitigated by the intra-comparison of Indigenous Peoples within research. Related to the concepts of deficit-discourse and multiple discrimination is, intersectionality. Kimberlé Crenshaw first coined intersectionality in 1989 where she argued that the analysis of race or gender in isolation excludes women of colour, simultaneously however, the experiences of women of colour can be understood (Else-Quest & Hyde, 2016). Multiple definitions of intersectionality exist within the literature. Among the differing interpretations, Else-Quest & Hyde (2016) have identified three assumptions: 1) multiple, interconnected factors such as gender, sex, ethnicity, class, ability, and sexuality exist within individuals 2) inequality or power is ingrained within each factor, and 3) not only do these factors make up an individual’s identity but also the larger social context within which individuals exist; as such their impact may be fluid and dynamic depending on the context. Taken together, the comparison of Indigenous peoples to non-Indigenous peoples within the literature doesn't account for intersectionality and multiple discrimination. Furthermore, the repeated identification of known health-related issues can increase the barriers Indigenous Peoples face when accessing health care, which is a topic that will be discussed in section 1.4.5. Hence, intersectional approaches to research that consider the multiple factors that make up an individual’s social experience, examine how power and inequity are engendered by multiple social memberships. Further, they 12 recognize the fluidity of an individual’s social categories within the broader social context may help to mitigate the shortcomings presently seen (Watson-Singleton et al., 2023). The second issue is the predominant focus on frequency of use data where increased cannabis use is typically interpreted as a symptom of dependence (Asbridge et al., 2014; Sznitman & Room, 2018). Hakkarainen et al. (2019) state that frequency data alone provides minimal insight into the pre-existing blurred boundaries when distinguishing between recreational, therapeutic, and problematic motivations for cannabis use. The lack of research exploring motivations for cannabis use among Indigenous Peoples is an issue which will be discussed in section 1.3.4. Temple et al. (2011) echo the limitations of current cannabis user classification systems based on frequency of use. The authors explain that the lack of agreed-upon definitions for the classification of cannabis users (e.g., light user, infrequent user, regular user, daily user, heavy user, dependent user, etc.) impacts the validity of such classifications, especially when acknowledging the heterogeneity that exists within cannabis users. The authors expand by questioning the equivalence of two people who are considered daily users. Is person A, who shares a low-THC joint with several people for most days of the week, really the same as person B, who smokes five high-THC joints to themselves, the same? Further, the authors argue that studies conducting such comparisons typically focus on the identification of risk factors related to cannabis use, within which there is an assumption that all cannabis use will become problematic. As research is a powerful modality for policy innovation, the inclusion of Indigenous perspectives, through co-developed projects, should be at the forefront of the minds of those who are committed to fostering Nation-to-Nation partnerships. 13 1.3.3 The Cannabis Act Five years after the legalization of cannabis (referred to as cannabis regulation hereafter), Indigenous Peoples are still calling on provincial, territorial, and federal governments for appropriate legislative and fiscal frameworks for cannabis (FNLC, 2023). Crosby (2019) provides a throughout summary of deliberations between Indigenous Peoples, the governments, and the Standing Senate Committee on Indigenous Peoples regarding cannabis legalization and jurisdictional authority. The work of Koutouki and Lofts (2019) reviews the Cannabis Act in terms of the potential benefits and risks to Indigenous Peoples and communities. Furthermore, the authors demonstrate a lack of consultation before the implementation of the Cannabis Act and shortcomings of the legislation, with respect to Indigenous Peoples and communities. An important aspect of ensuring that Indigenous Peoples are able to maximize benefits and minimize potential harms related to changes in cannabis regulations is conducting appropriate and relevant research. By centering the voices of Indigenous Peoples, it is our hope that our work will aid in the construction of a new foundation in academic literature and ultimately policy. Aspects of cannabis use among Indigenous Peoples that require further research include motivations for use, health care autonomy, and therapeutic capabilities of cannabis. 1.3.4 Cannabis Use Motivations Substance use is a multifaceted behaviour, a mosaic of internal and external factors, also referred to as set and setting, which impact the ways one uses a substance (Hartogsohn, 2017). Set describes internal aspects of a person such as their mood, energy levels, previous experience, or motivations. Setting refers to elements that are external to the person including, where they are, who they are with, and the society they live in (Hartogsohn, 2017). These factors coalesce, forming the motivations for one’s substance use. Motivations, like people, are not stagnant and 14 change depending on the factors at play. For our purposes, motivations will be categorized into therapeutic and recreational which have yet to be explored among Indigenous Peoples who use cannabis. Prior literature exploring cannabis use motivations has employed varying methodologies, leading to a heterogenous conceptualization of medical (i.e., therapeutic), recreational, and problematic use. For example, Lin et al. (2016) differentiated medical from recreational motivations by asking if cannabis had been recommended by a doctor. Whereas Espinosa et al. (2023) classified cannabis use motivations into approach motives (e.g., expansion) and avoidance motives (e.g., coping) by using the five-factor Marijuana Motives Measure (MMM) developed by Simons et al. (1998). In contrast to the previously mentioned studies, Lake et al. (2020) took a different approach to differentiating what motivates people to use cannabis. Participants selected their reason(s) for cannabis use from a pre-set list, with an “other” option if their motivations were missing, which included: to relieve pain, to help with sleep, to help with HIV medications and AIDS symptoms, to treat nausea or loss of appetite, to substitute for other substances, to relieve stress, to treat a mental health concern other than addiction, for spiritual purposes, for creativity, to get high/recreation/socialize, to come down off of other drugs, or to treat withdrawal, or other. Participants were then categorized into non-therapeutic and therapeutic classes (i.e., Class 1: Recreational, Class 2: Non-Pain Therapeutic, Class 3: Pain, and Class 4: Pain +) based on their self-reported motivations. This article is notable for several reasons. First, it was conducted from the harm reduction philosophy with a greater focus on exploring therapeutic motivations for cannabis use in comparison to studies that focus on identifying risk factors. Second, daily cannabis use was found to be positively associated with therapeutic cannabis use (classes 2-4) and negatively associated with non-therapeutic cannabis 15 use (class 1). Although daily cannabis use has commonly been associated with problematic use, the increase of studies reporting more frequent use among therapeutic cannabis users may reveal a lag in the ways in which problematic cannabis use is evaluated and further calls into question the benefit of research that has examined Indigenous cannabis users using frequency metrics alone (Asbridge et al., 2014; Sznitman & Room, 2018; Turna et al., 2020). Lastly, the use of latent class analysis (LCA) demonstrated that the majority of participants (n = 496, 76.0%) who completed more than one interview (i.e., a baseline interview and at least one follow-up interview) moved between the four classes, speaking to the fluidity of motivations within an individual over time. Questionnaires have been developed to assess an individual’s motivations for cannabis use. As previously mentioned, Simons et al. (1998) developed the five-factor MMM. Lee et al. (2009) built off the MMM to create the 12-factor Comprehensive Marijuana Motives Questionnaire (CMMQ). While the MMM contains the five motivations of Enhancement, Coping, Social, Conformity, and Expansion, the CMMQ classifies motivations into 12 categories; Enjoyment, Conformity, Coping, Experimentation, Boredom, Alcohol, Celebration, Altered Perception, Social Anxiety, Relative Low Risk, Sleep/Rest, and Availability (Simons et al., 1998 & Lee et al., 2009). While these measures provide a more detailed understanding of cannabis use, as opposed to defining medical use based on who has been authorized, studies employing these measures often focus on predicting future impairment or identifying risk factors (Blevins et al., 2016 & Schultz et al., 2019). To my knowledge, there are no published studies that have provided a thorough review and exploration of Indigenous cannabis use motivations within Canada. However, one study by Davis et al. (2020) explored motivations for cannabis use among American Indian and White 16 youth (i.e., grade 7). The authors presented 13 motivations to each participant, the same motivation items as those found in the Monitoring the Future survey. Participants responded dichotomously, indicating whether that motivation applied to them. Item response theory was conducted on the 13 motivations, resulting in the removal of five items based on a less than 5% response rate, high difficulty, or poor discrimination. Exploratory factor analysis was conducted on the eight remaining items resulting in a two-factor model. Factor 1 measured coping motivations, while factor 2 measured recreational and expansion motivations. American Indian youth were more likely to endorse coping motivations and three of the four items functioned differently between the two groups. White youth were more likely to endorse recreational and expansion motivations and all four items functioned differently. The prevalence of coping motives could suggest that American Indian youth are using cannabis therapeutically. A greater understanding of cannabis use motivations among Indigenous Peoples is especially important when considering the significant barriers Indigenous Peoples face in various systems with systemic Indigenous-specific racism, like the health care system (In Plain Sight, 2020). 1.3.5 Barriers to Health Care There is no shortage of literature identifying the overrepresentation of Indigenous Peoples in the criminal justice system (Owusu-Bempah & Luscombe, 2021), who are without basic human rights like a home (Uppal, 2022), who experience fatal and non-fatal drug poisonings (i.e., overdose) (Lavalley et al., 2018), in foster care (Government of Canada, 2020), or with chronic health conditions (In Plain Sight, 2020, p. 66). While this discourse provides tangible evidence of the ongoing inequities experienced by Indigenous Peoples as a direct result of colonialism, if reconciliation truly is the goal, the systems that maintain these injustices should be the focus of attention. The In Plain Sight Report (2020) aimed to do just that by examining 17 the experiences of Indigenous Peoples within the B.C. health care system. The report highlighted that stereotyping and discrimination of Indigenous Peoples reaches every corner of the health care system. 84% of Indigenous respondents endorsed experiencing discrimination, related to at least one of the following, when accessing health care: ancestry or origins, income level, education, sexual orientation, substance use, skin colour, appearance, and residence. This, compounded with the deep roots of colonial policies, makes health care less accessible for Indigenous Peoples. The policies and legislation that have laid the foundation for the disparities Indigenous Peoples experience include, but are not limited to, the Indian Act, Indian Hospitals, High Arctic Relocation, Indian Residential School System, Indian Day Schools, the 60’s Scoop, and currently, the Millennial Scoop. Moreover, Indigenous Peoples and other racialized and marginalized communities, do not need to be ‘worse off’ to be recognized. Our pain does not need to be deemed ‘greater’ for it to be worth consideration. The marginalization of Indigenous Peoples within the current health care system may have parallels with how Indigenous Peoples engage with the medical cannabis system. Given the longstanding Traditional use of Plant Medicines by Indigenous Peoples and the recent legalization of cannabis, there may be an emerging acceptance of cannabis as a therapeutic tool. In addition, the legalization of cannabis may then provide an opportunity for increased health care sovereignty, self-determination, and autonomy among Indigenous Peoples. 1.3.6 Current Therapeutic Applications Cannabis has been used to alleviate and treat a variety of symptoms and conditions. Leung et al. (2022) examined self-reported reasons for therapeutic cannabis use in Canada and the USA. Pain management and anxiety were the most common reasons, endorsed by over half of 18 respondents. Nearly half reported using cannabis for sleeping problems and depression, about one-third for headaches or migraines, and approximately one-fifth for a lack of appetite, nausea, post-traumatic stress disorder, and trauma. A small percentage endorsed the use of cannabis for muscle spasms, seizures, cancer, management of drug or alcohol use, psychosis, and schizophrenia. Recent guidelines from Bell et al. (2024) support the use of cannabis-based medicines (CBM) for the management of chronic pain and a variety of co-occurring conditions. The recommended use of CBM (i.e., monotherapy, replacement, or adjunct treatment), the formulation (e.g., THC dominant, CBD dominant, THC/CBD mixture, moderate [THC] vs. low [THC], or synthetic vs. plant-based), and the route of administration (e.g., herbal combustion, herbal vaporization, oral capsule, oral oil, edible, or oromucosal spray) varies depending on the condition. In addition to CBM for chronic pain, the examined co-occurring conditions include HIV, multiple sclerosis, arthritic conditions, fibromyalgia, chronic headache and migraine, nausea, sleeping problems, appetite loss, PTSD, anxiety, depression, unsatisfactory analgesia from opioid treatment, and the reduction of opioids as treatment for chronic pain. Investigating how, or if, the therapeutic applications of cannabis differ among Indigenous Peoples can provide valuable insights into the optimization of cannabis-based treatments for various symptoms and conditions. 1.3.7 Cannabis as a Substitute The therapeutic capabilities of cannabis can be useful for a number of conditions. In fact, cannabis has a role to play in the use of other substances, like opioids. What may first come to mind is the “gateway” theory, coined in the 1970s by Denise Kandel. That is, the use of cannabis precedes the use of illicit drugs. This theory has been discredited by findings that indicate no 19 increase in cannabis use disorder, alcohol use, or the consumption of illegal substances post-legalization of recreational cannabis (Zellers et al., 2023). Developed within the field of behavioural economics, the substitution effect explains that the use of products can be influenced by the overall expense of other products (Lucas, 2017). Within the context of substance use, the term “overall expense” goes beyond the price tag and encompasses health and legal implications that may occur upon using a substance (Williams et al., 2006). Moreover, harm reduction is a broad term that can be used to describe programs, policies, and practices that aim to reduce the negative effects or harms of behaviours without the prerequisite of behavioural cessation (Hawk et al., 2017; Vearrier, 2019). Recent literature has shown that cannabis has been used as a substitute for other substances like prescription opioids, illicit opioids (e.g., raw fentanyl, down, heroin), illicit stimulants (e.g., cocaine, crack cocaine, methamphetamine), and alcohol (Lucas et al., 2021; Lucas et al., 2016). Beaugard et al. (2024) interviewed 14 people who used cannabis as a substitute for opioids, methamphetamine, and crack. Cannabis substitution was found to be employed in three ways: 1) to decrease/cope with cravings, 2) to mimic the effects of another drug, and 3) to mimic the rituals of other drug use. Reddon et al. (2021) found a statistically significant association between daily cannabis use and the frequency of illegal opioid injection use, where people who use cannabis at least daily had a significantly lower frequency of injection opioid use when compared to people who use cannabis less than daily. Taken together, the use of cannabis as a substitute for other substances is indeed a therapeutic motivation, driven by the philosophy of harm reduction, and supported by behavioural economics. In sum, substantial gaps exist in research and literature on cannabis use among Indigenous Peoples. In particular, there have been no Indigenous-led studies that have approached the 20 understanding of cannabis use behaviours among Indigenous Peoples from a person-centred, Indigenous and OCAP®-informed perspective. Guided by Two-Eyed Seeing, this study aims to explore motivations for cannabis use, modes and patterns of cannabis use, the role of cannabis in reducing barriers to health care access, impacts of cannabis regulation, and the utilization of cannabis as a medicine, with a specific focus on substitution behaviours for other substances and medications. 21 Chapter 2: The Current Study 2.1 Research Aims The focus of this mixed-methods, exploratory, study is to increase the understanding of, and provide a platform for, Indigenous perspectives of cannabis use. The aims of this research are: 1. Share our methods and process of conducting a collaborative, mixed-method research study of cannabis use among Indigenous Peoples living on Turtle Island. While the methodology section will outline our process, we aim to delve deeper by discussing the hurdles we faced and how we overcame them. 2. Qualitatively describe cannabis use perceptions among respondents through the presentation of themes and respondent quotes. Present descriptive quantitative results regarding cannabis use motivations, substitution practices, modes and patterns of cannabis use, impacts of cannabis regulation, and experiences with discrimination and barriers to health care to support qualitative findings. 22 Chapter 3: Methodologies The interviews used in the present study were collected as a part of the CUTI Project. The CUTI Project was co-directed by Dr. Walsh and Dr. Lindsay Farrell, in partnership with Woodland Cree First Nation and Indigenous Bloom Corporation. Phase-Two of the CUTI project was initiated by Zagimē Anishinabēk. 3.1 Phase-One The CUTI Project was initiated and conducted in partnership with Woodland Cree First Nations and Indigenous Bloom Corporation. The study team included: substance use and Indigenous health experts, Woodland Cree First Nation Chief Isaac Laboucan-Avirom, Woodland Cree First Nation’s Director of Health, Senior Vice President of Indigenous Bloom, two Indigenous graduate researcher assistants (RA), one non-Indigenous graduate RA, and myself as an Indigenous undergraduate RA. At this time, I had recently graduated with a Bachelor of Science. The principles of OCAP provided a framework for these partnerships. 3.1.1 Participant Recruitment In total, 61 respondents were interviewed. 58 respondents were recruited through Indigenous Bloom cannabis dispensaries and 3 respondents were recruited through Woodland Cree. Snowball recruitment was encouraged (Forbes et al., 2020). Individuals were able to participate if they self-identified as Indigenous (i.e., First Nations (Non-Status or Status), Métis, or Inuit) and were over the age of 18. Eligible participants were sent a consent form and were invited to participate in a semi-structured interview. Interviews were conducted over Zoom, from December 2021 to August 2022. A $50 compensation was given to participants in the form of an e-transfer or a mailed MasterCard gift card. 23 3.1.2 Data Collection Interviews were recorded and began with a review of the consent form. Verbal consent was required for respondents to participate in an interview. Two graduate Indigenous RAs and I conducted the interviews. The interview script was transformed into a Qualtrics survey to facilitate RAs in conducting the interviews. RAs recorded respondents’ responses in Qualtrics. All interviews were recorded over Zoom, and the audio file and the transcript file were saved. Participants were contacted via email following their interview to provide preliminary findings, if requested, and offered an opportunity to connect with an interviewer to provide feedback or ask any questions. 3.2 Phase-Two The second Phase of the CUTI Project was initiated by and conducted in partnership with Zagimē Anishinabēk. The study team included: substance use and Indigenous health experts, the Governance Manager of Zagimē Anishinabēk, a Zagimē Anishinabēk liaison, and myself as an Indigenous graduate research assistant. A data-sharing agreement was created with the representatives of Zagimē Anishinabēk and was approved by Chief and Council. 3.2.1 Participant Recruitment Eight respondents were recruited through the Zagimē Anishinabēk community Facebook page and word of mouth, as snowball recruitment was encouraged (Forbes et al., 2020). Individuals were able to participate if they were registered members of Zagimē Anishinabēk and were over the age of 18. Eligible participants were sent a consent form and were invited to participate in a semi-structured interview. Interviews were conducted over Zoom from October 2023 to January 2024. A $50 compensation was given to participants in the form of an e-transfer or a mailed MasterCard gift card. 24 3.2.2 Data Collection Interviews were recorded and began with a review of the consent form. Verbal consent was required for respondents to participate in an interview. I conducted the interviews and recorded responses in a Qualtrics survey. All interviews were recorded over Zoom, and the audio file and the transcript file were saved. Dissemination of the findings with participants and community members will be decided upon with representatives of Zagimē Anishinabēk. 3.3 Collaborative Instrument Development The interview scripts, the data sharing agreement, and the Phase-One preliminary findings can be seen in the appendix section. Appendix 1 corresponds to the interview script used for Phase-One interviews. Slight changes were made to the interview script to suit the goals of our community partner, Zagimē Anishinabēk. The Phase-Two interview script differs only in the exclusion of COVID-19 related questions. Appendix 2 contains the Phase-Two data-sharing agreement that was created in collaboration with Zagimē Anishinabēk. The Phase-One preliminary findings can be seen in Appendix 3. These were shared with participants who consented to receiving project updates, following their interview. Our Phase-One team created a semi-structured interview based on the work of Walsh et al. (2013). The interview began with open-ended questions, followed by more structured questions. There are 10 sections of the interview which include: a demographics questionnaire, a qualitative demographic section, a qualitative section on cannabis use history and perceptions, current cannabis use details, law enforcement related to cannabis, other medication and substance use behaviours, access to medical cannabis, social norms, legalization, and lastly, two standardized assessments, the Brief Composite Cannabis Assessment Tool (BCCAT) and the Cannabis Use 25 Disorder Identification Test-Revised (CUDIT-R). Each of the interview sections can be seen, in detail, below. 3.3.1 Demographics Respondents were asked to provide their age, marital status, gender, sexual orientation, spoken languages, area of residence, education level, yearly household income, and perceived level of food security. 3.3.2 Qualitative Demographics Introduction Respondents were asked 8 open-ended questions to expand on the initial demographic questions. Questions pertained to Indigenous identity, current living conditions, current life supports, occupation, and health status. 3.3.3 Qualitative Cannabis Use History and Perceptions Respondents were asked 12 open-ended questions if they endorsed being a regular cannabis user. Questions pertained to motivations for current cannabis use, previous and current opinions on the medicinal properties of cannabis, stigmatization of cannabis, characteristics of medical cannabis, and likes and dislikes of cannabis. All respondents were asked one question about the impacts of cannabis regulation. 3.3.4 Current Cannabis Use Details Respondents who endorsed regular cannabis use were asked about their modes and patterns of cannabis use, average amount of cannabis consumed, source of cannabis in the last 6 months, and motivations for cannabis use. Respondents were asked about the pattern, helpfulness, and affordability of cannabis for their main motivation if was medicinal. 3.3.5 Law Enforcement Related to Cannabis All respondents were asked about interactions with law enforcement regarding cannabis. 26 3.3.6 Medication, Substance Use, and Substitution Respondents were asked about their medication use in the last year. For each medication reported, respondents were asked about their use of cannabis as a substitute. Respondents were asked about their unregulated drug and alcohol use in the past year. Respondents were asked about their use of cannabis as a substitute for alcohol, opioids, stimulants, tobacco, nicotine vapes, and other drugs. 3.3.7 Access to Medical Cannabis Respondents were asked six questions about the authorization of medical cannabis by a health professional and discrimination felt by discussing cannabis. If a respondent had not discussed the use of cannabis with their doctor, they were presented with an additional question. 3.3.8 Social Norms Descriptive social norms were measured using five questions that asked respondents to estimate, from 0% to 100%, the extent to which community members, family members, close friends, people similar to them, and people they admire use cannabis. Injunctive social norms were measured using five questions that asked respondents to rate each item on a 5-point scale from “Strongly Disapprove” to “Strongly Approve”. Respondents were asked to rate the perceived approval of their own cannabis use among the following five groups: community members, family members, close friends, people similar to them, and people they admire. If respondents endorsed having a romantic partner and using cannabis with their partner, they were asked 6 questions about their partner’s cannabis use and the impact of cannabis use on their relationship. 27 3.3.9 Legalization Respondents were asked three to five questions, depending on their responses, regarding the impact of cannabis regulation on their attitudes, behaviours, and perceived risks of cannabis. 3.3.10 Brief Composite Cannabis Assessment Tool (BCCAT) Respondents were asked to rate 12 questions on a 5-point scale, from “Almost Never / Disagree” to “Almost Always / Agree”, relating to their cannabis use over the past six months. 3.3.11 The Cannabis Use Disorder Identification Test-Revised (CUDIT-R (Adamson et al., 2010)). The CUDIT-R is an 8-item measure to identify problematic cannabis use in the last six months. Of the 8-items, five are rated on a 4-point scale from, “0-Never” to “4-Daily or almost daily”, one item is rated on a 4-point scale from “0-Never” to “4-Four or more times a week”, one item is rated on a 4-point scale from “0-Less than 1” to “4-Seven or more”, and one item is rated on a 3-point scale from “0-Never” to “4-Yes, during the past 6 months”. The CUDIT-R has been shown to be internally consistent, reliable, and valid. 3.4 Data Analysis The aims of this mixed-methods study were exploratory in nature. Our approach to data analysis was guided by the approach described in section 1.2 and the current gaps within the literature. The qualitative analysis was narrowed to select questions from the interview script, specifically “In general, would you say your health is: excellent, very good, good, fair, or poor?” and all questions within section 3.3.3. We recognize that anonymizing and reducing sections of interviews into themes is a Western approach which diminishes the context within which the story is told (Simonds & Christopher, 2013). In an effort to maintain the context within which the interviews took place, data complementarity was used. Initially, data triangulation was 28 considered. However, triangulation is typically used to increase the validity of results by utilizing the mixing of methods (Alele & Malau-Aduli, 2023). In contrast, data complementarity “seeks to elaborate and enhance results from one method with results from another method… [permitting] attention to multiple facets of the same question” (Watson-Singleton et al., 2023, p. 4). When appropriate, quantitative and qualitative results are jointly presented in the results and discussion sections. The rationale for this was that a qualitative analysis of cannabis use perceptions, for example, in combination with quantitative data on cannabis motivations, would provide a more comprehensive understanding of cannabis use among respondents. Additionally, data complementarity aligned more with our approaches to the study than the presentation of qualitative or quantitative results in isolation. Key themes that emerged from the qualitative sections were identified via thematic analysis. For the quantitative analyses, derivative statistics were reported in frequencies and percentages. 29 Chapter 4: Results 4.1 Positioning The Project The first aim of this project was to share the methods and process, including the obstacles faced and how we overcame them. While the methodology section delineates our study teams, participant recruitment, data collection, and the interview script used within each phase, partially fulfilling the first aim, it fails to encompass the whole picture of our process. This project is not without hurdles. As such, within this section I intend to fulfil the remainder of Aim 1 by sharing the encountered obstacles and how we chose to overcome them. My rationale for including this section within the results is twofold. First, the obstacles were unexpectedly encountered, making it feel more appropriate to include them as a result of the research. Second, the obstacles arose temporally after the determined methodology but before the results were examined. Within Phase-One, the encountered obstacles included clarification of methodologies with the UBCO Behavioural Research Ethics Board (BREB), staff changeover within the Woodland Cree First Nation band, and attempted interference from representatives of the settler cannabis industry. The obstacle in Phase-Two surrounded difficulties in recruitment resulting from Indigenous Identity Fraud, or what might be referred to as the “Pretendian problem” (Kolopenuk, 2023; Narine et al., 2023). With regards to the BREB process, we were surprised by the BREB’s unexpected level of concern about our team’s ethical competency in upholding OCAP principles, which delayed the onset of the project. By articulating this as an obstacle, we do not diminish the importance of a thorough BREB review of research with Indigenous Peoples and communities. We recognize and echo the importance of ensuring ethical and equitable partnerships. Nevertheless, the apparent caution from an authority within a colonial institution (i.e., the UBCO BREB), without 30 Indigenous representation, regarding the capacity of an Indigenous-led research team that included community leaders to ethically conduct research with Indigenous Peoples highlights the complexity of conducting research in this area (UBC, n.d., “Indigenous Representation on the BREBs” section). As suggested by Grenz (2023), “We need institutional research-ethics review processes designed specifically for Indigenous scholars conducting research alongside Indigenous communities. Anything else is colonialism masquerading as inclusion” (para. 5). Factors related to infrastructure, which may be familiar to those who engage in research with rural communities, presented another obstacle. Specifically, we had planned to allocate a space within the Health Centre for Woodland Cree respondents to participate in the interviews. This included the provision of tablets for the Health Centre to facilitate the participation of those who may not have access to a laptop or tablet, the internet, or a safe space to participate in the interview. Tablets were mailed two times to establish a space for respondents. Despite these efforts, the tablets were incidentally returned and changes in staff positions at the Health Centre resulted in a delay of recruitment and a decreased number of respondents recruited from Woodland Cree First Nation. Perhaps the most unexpected and unwelcome obstacle involved threats of state-sanctioned aggression in the form of criminalization and penalization. These threats emerged from representatives of the non-Indigenous cannabis industry, who attempted to delegitimatize the Indigenous cannabis industry. These threats were particularly salient in light of the historic and ongoing criminalization of Indigenous Peoples by the Canadian government, through the war on drugs (Lavalley et al., 2018; Owusu-Bempah & Luscombe, 2021; Wiese et al., 2023). Representatives from the Okanagan Cannabis Collective (OCC) contacted Dr. Walsh and said that we were “supporting a criminal organization” (i.e., Indigenous Bloom Cooperation). Gibson 31 (2021) reported in an online news article that the OCC emailed the provincial government stating, “We immediately demand that you terminate your agreements with this illegal cannabis company and that any research/findings derived from the illegally procured cannabis not be used in your final analysis” and “With respect to your research funding, we have cc’d all BC MLA’s on this email and are asking them to evaluate the appropriateness of such funding considering the UBC’s disregard for cannabis laws.” We found it ironic that this did not come from the government but from the deeply ingrained colonial attitudes of a cannabis dispensary collective. Phase-Two presented an obstacle that has gained familiarity within the academic community: Indigenous Identity Fraud. Pejoratively referred to as the Pretendian problem, Indigenous Identity Fraud is typically encountered when non-Indigenous people intentionally make fraudulent claims of Indigenous Identity to be awarded career advancement, grants, or other opportunities designated for Indigenous Peoples (Kolopenuk, 2023; Leroux, 2019; Narine et al., 2023; National Indigenous Identity Forum, 2022). However, in our experience, which is perhaps a more novel manifestation of this issue, Indigenous Identity Fraud arose in the form of respondents. We learned from Phase-One that recruitment through Indigenous Bloom dispensaries was successful. We carried this knowledge forward into Phase-Two and considered recruitment through two dispensaries operated by Zagimē Anishinabēk. The location of the dispensaries became the limiting factor and our team opted to recruit respondents using the Zagimē Anishinabēk community Facebook page. We received immense interest in the study, motivated by the financial incentive to falsely claim Indigenous Identity. Approximately 25 of the inquiries and the first four interviews were of non-Zagimē Anishinabēk members. We originally screened prospective respondents by asking them four questions: 1) Do you use cannabis (or have used cannabis in the past), 2) Do you self-identify as Indigenous (First 32 Nations, Métis, or Inuit), 3) Are you a member of Zagimē Anishinabēk, and 4) Are over 18 years of age. After discussion with representatives of Zagimē Anishinabēk, we included a screening question which asked for the first and last three digits of the respondent’s status number to ensure band membership. Members of Zagimē Anishinabēk did not mention discomfort with sharing the digits of their status number. In contrast, non-member inquiries presented drawn out difficulties. For example, non-members often questioned my request for the digits of their status number. In addition, two of the four non-members who were interviewed attempted to deposit their honorarium with an email address that differed from the one the e-transfer was sent to. I will acknowledge the irony in using a colonial system to ensure band membership. However, the lack of discussion surrounding this particular manifestation of Indigenous Identity Fraud resulted in minimal guidance with how to navigate it. In sum, the process of conducting this research highlighted several barriers that were distinct to the context of Indigenous research including, institutional communication, community resistance and threats, infrastructure factors related to remote locations and finally, Indigenous Identity Fraud from respondents falsely claiming Indigenous Identity. Despite the difficulties that these obstacles presented, there exists a gift within each of them. A gift of knowledge and resilience that can be carried forward by others who find themselves in the complex intersection of bridging Indigenous ways with those of Western institutions. 4.2 Participants Sixty-nine people participated in the CUTI Project, 61 from Phase-One and eight from Phase-Two – see Table 1 for respondent demographics. Most respondents identified as status-holding members of First Nations communities (n = 52, 75%), with the remaining respondents identifying as non-status First Nations (n = 5, 7%), Métis (n = 11, 16%), and Inuit (n = 1, 1%). A 33 number of respondents reported speaking an Indigenous language at home (n = 18, 26%), including Cree, Wet’suwet’en, Squamish, Nlaka’pamuxcheen, Gitxsanimaax, Hul'q'umi'num', Mic Maw, Saulteaux, and Ojibwe. 34 Table 1 Participant Demographics n % Age 18 – 29 21 30 30 – 39 19 27 40 – 49 11 16 50 + 18 26 Gender a Female 46 67 Male 19 28 Two-Spirit/Other 8 10 Residence Rural or Remote 16 23 Suburban 6 9 Urban 47 68 Living In/Outside of Community In community 12 17 Outside of community 57 83 Education High School 14 20 Post-Secondary (Non-University) 15 21 University (Undergraduate) 7 10 University (Graduate) 4 6 Other 29 41 Household Income $60,000 + 17 125 $30,000 – $60,000 24 35 Less than $30,000 28 41 Note: The gender categories of “Two-Spirit” and “Other” have been collapsed into a single category. a Four respondents selected two gender categories: One selected “Female” and “Other”, one selected “Female” and “Two-Spirit”, one selected “Male” and “Other”, and one selected “Male” and “Two-Spirit”. 35 4.3 Cannabis Use Perceptions The majority of respondents (n = 64, 93%) indicated that they were regular cannabis users (RCU). For the results specific to RCU, the corresponding percentages are calculated based on this group total (n = 64). For results that pertain to the entire sample, non-RCU and RCU, the percentages are calculated based on the whole sample (n = 69). Only RCU were presented the prompts 4.3.1 – 4.3.6. The themes that emerged from the responses of respondents are presented below the corresponding six prompts. Quotes were selected to balance the important themes. Some quotes are quite long because I opted to keep quotes intact to preserve the respondent’s knowledge. 4.3.1 Prompt: “Do you think cannabis can be a medicine? Why or why not?” Every RCU respondent, but one, thought that cannabis could be a medicine (n = 63, 98%). Several themes emerged throughout responses including, personal experience of benefits, natural properties, versatility and lack of side effects, and research evidence. Personal Experience of Benefits The majority of respondents (n = 47, 73%) described their own benefits, or the observed benefits of others, as the justification for why cannabis can be a medicine. I think it is a medicine, I would love to call it a medicine. My brother was an alcoholic and we didn't see him often. When I found out about the medicinal uses of cannabis, I told him and he ended up doing it, it wasn't getting him to quit but it did show him there is help out there. Once he used cannabis we have our brother back, we've had him back since 2017. Most importantly we have him back and we don’t need to worry about where he is. When he was drinking, he would be under a trampoline, passed out in a church. Now with cannabis he is looking at what things are triggers. I think without cannabis you don't have that opportunity to step back from your emotions and make a decision that is healthy for you (Participant 075, Indigenous Bloom, Female, Under 40). Yes, I totally think so, there are so many properties within weed. CBD and THC can really help pain, it can slow down anxiety for me, it doesn't eliminate it. It gets me out of those little rumination, helps prevents the spiraling (Participant 023, Indigenous Bloom, Female, Under 40). 36 It helps with most kinds of pain, I used to have trouble sleeping and I never liked using Tylenol and Advil because it can impact my liver and I used to be a drinker, so I don't want to add more. People say it’s the gateway, but I think alcohol does more (Participant 046, Indigenous Bloom, Female, Under 40). Plant Medicine Some respondents (n = 11, 17%) justified the ability for cannabis to be a medicine because it is a plant or because it was given to us by the Creator. Most definitely, it is a medicine, because it’s a plant. It comes to us from the Creator you know? So every plant does something good, you know, even stinging nettle makes tea that heals us (Participant 015, Indigenous Bloom, Female, Over 40). I absolutely think it’s a medicine. It’s an internal sage. It helps with cancer, mental illness, physical pain (Participant 021, Indigenous Bloom, Female, Under 40). I do yeah because it is a plant, here on the earth, the Creator gave it to us, but it’s here to be used as a medicine (Participant 001, Indigenous Bloom, Female, Over 40). Versatility and Lack of Side Effects Some respondents (n = 11, 17%) based their medicinal views of cannabis on the versatility or lack of side effects, in comparison to pharmaceuticals. Yes, mostly because of the different ways you can use it and the variety of different ways you can administer it. Many people can use it in different ways (Participant 044, Indigenous Bloom, Female, Under 40). I prefer it to taking medication to relax, like pills. It's natural medicine. I don’t really feel like there’s long-term side effects, like you might get when you take pills. I would see these commercials that tell you to try this new medication and it say ‘might cause heart attack, death, seizures, and all these things. So I feel like it's safer, you can't really overdose on it like you could from taking too many pills (Participant 014, Indigenous Bloom, Female, Over 40). Research Evidence Some respondents (n = 4, 6%) supported their medicinal views of cannabis with research findings. Absolutely… I’ve done a good amount of research and how it can help Parkinson’s, like CBD… it changes people's lives (Participant 018, Indigenous Bloom, Male, Under 40). 37 Definitely cannabis is a medicine, and why? My god, look at all the studies, there are children with cancer, and they take THC pills, and they are feeling better and eating (Participant 079, Indigenous Bloom, Female, Over 40). 4.3.2 Prompt: “Have you always felt this way about cannabis?” Most respondents expressed that their views on the therapeutic capabilities of cannabis have been consistent throughout their lives. In contrast, others shared that their perspectives had shifted over time. The corresponding quotes can be seen below. Always Felt This Way More than half of the respondents (n = 38, 60%) indicated a consistent position regarding cannabis as a medicine. The consistency of respondent views of cannabis as a medicine was anchored in the natural aspect of cannabis and familial and traditional medicinal cannabis use. Absolutely… I’ve always lived my life more natural so finding something that helps rather than taking pills, or whatever is definitely something I like to do better (Participant 054, Indigenous Bloom, Female, Over 40). I kind of think so bc it’s a medicine that has grown on the land. When I talk to certain people as long as you don’t abuse it, everything is medicine I believe, it’s a plant and that’s why I think its medicine. It’s like tobacco, sage, sweetgrass, and I think cannabis is another medicine to help us (Participant 008, Zagimē Anishinabēk, Two-Spirit, Over 40). I had family members who had systematic cancer and they were one of the first people to get access to medical marijuana and I saw how that helped them and in my four-year-old brain I was like ‘oh it helps people’ (Participant 061, Indigenous Bloom, Two-Spirit, Under 40). Yes, for as long as I've known, I saw my uncles using it when I was young and when I became of age, I started to use it. With my dialysis I can’t drink so I use cannabis (Participant 017, Zagimē Anishinabēk, Male, Under 40). I’ve grown up with a lot of family members with cancer and they always turn to cannabis. I’ve never disagreed with it. Well, I’ve disagreed with it being outlawed (Participant 008, Indigenous Bloom, Female, Under 40). Well, I followed my roots and it’s literally in my blood. We’re the dope growers. It’s in my blood, it’s in the soils. You are what you stand, walk, and eat on, right… Where my people originate from, they grew dope, they are the smoke walkers. This is what my history is telling me (Participant 002, Indigenous Bloom, Butch, Over 40). 38 Changed Perspective Almost half of the respondents (n = 26, 41%) expressed that their views on cannabis as a medicine had changed over time. No definitely not. I’m Indigenous, when it was illegal it’s like yea no, not a chance man. When weed was illegal, being brown and smoking weed in the city doesn’t go well (Participant 029, Indigenous Bloom, Male, Under 40). No, it’s something that I've read up on as I’ve gotten older. It used to be experimental. So try it out and then yea just seeing it didn’t give me a hangover that alcohol would, and I would still be in control whether I smoked 6 or 20 doobies (Participant 036, Indigenous Bloom, Male, Over 40). when I first started it was just for fun, I didn’t think about medicinal purpose, it was during the pandemic that I started using alone and more medicinally (Participant 068, Indigenous Bloom, Two-Spirit, Under 40). No, not in my teenage years, even in my younger 20s. I wasn't against it, but I never really prompted it until I started utilizing it as a medicine. I actually now harvest cannabis and because we have a lot of traditional medicine in our cultures and one of the treatments is cottonwood bud that grows within our territory. My elders have taught me how to make a traditional salve, like an ointment. I’ve also started experimenting, now that I know how to extract the medicinal properties from cottonwood bud, I started exploring with cannabis… I’m trying to help share the knowledge of medicinal properties of cannabis through the salve because a lot of our elders, that’s the kind of medicine they grew up with… They never put nothing in their mouth, so I’m trying to educate our new elders that never got to grow up in our culture because of residential school. I’m trying to teach them about our cottonwood bud but then also trying to introduce CBD… In my home community a lot of our elders and a lot of our people that went to residential school they don’t like taking any kind of cough syrup or any kind of pills because when they were growing up in the residential school system, that’s like one of their triggers, they were given like spoonfuls of stuff and weird pills… So I’m really trying to encourage them. Back in the day, we would suck on roots for nutrients… and utilized the whole plant and nowadays we just strain the medicinal properties from the plant (Participant 075, Indigenous Bloom, Female, Under 40). 4.3.3 Prompt: “Have you had any past experiences which changed your mind about cannabis?” Respondents shared a variety of past experiences that changed their perspectives on cannabis. Themes that emerged included past personal experiences, observed benefits in others, 39 the legalization of cannabis, and experience with pharmaceuticals. Corresponding quotes can be seen below. Personal Experience of Benefits Over a quarter of respondents (n = 18, 28%) expressed that personal experiences while using cannabis, caused a shift in their thinking. I went through a divorce, a new phase in my life that just focused on my mental health and becoming more self-aware. I am reusing cannabis in a different perspective because I didn’t realize how much night terrors affected my life. I started dabbling back into it, using CBD with my grandmother and I started realizing how much sleep I was missing out on, and I struggled with drinking a lot after my divorce, so cannabis helped to keep me sober a lot too (Participant 008, Indigenous Bloom, Female, Under 40). Well, when I was pregnant, maybe that changed my mind, I stopped smoking it. Then I started smoking it again after [my son] was maybe four months. I think it was helping with my postpartum, I was getting really bad postpartum symptoms (Participant 021, Indigenous Bloom, Female, Under 40). I think when I met my partner, he noticed that I had a little bit of anxiety. I didn’t even know I had anxiety, and my changing was when he asked me to take CBD for a month to see my steps. Basically, he noticed when we were going to work, my attitude changed and it was like short, cut off. After CBD, that same spot where I would kind of shift my gears to like short and cut off changed. It was no amping up my anxiety and so realizing that within myself was definitely more of an eye-opener for me (Participant 054, Indigenous Bloom, Female, Over 40). I think when I started taking CBD all the time… I was just like wow like not I kind of understand what everyone’s been talking about. Like the difference is kind of night and day with just like falling asleep and quality of sleep. You know, like not being in physical pain and not having headaches all the time (Participant 065, Indigenous Bloom, Male + Transgender, Under 40). I think being able to understand the use of cannabis and using the correct one that I need at that time in my life. Just seeing how cannabis has helped me through overcoming the challenges and the embarrassment and everything that comes with being a sexual abuse survivor and then losing our mom and then being a recovered alcoholic. Through that and how the cannabis flower can help with my ADHD… We always have a strain to help with my ADHD…So really being able to know what the flower is used for and being able to utilize the correct flower to help with which Phase I’m in at the time… I do feel that’s what helped me a lot. Without the cannabis, I wouldn’t be as strong as I am today (Participant 075, Indigenous Bloom, Female, Under 40). 40 I had a shift in my thinking about 4/5 years ago. when I started picking medicine out on the land and learning the properties of it. Cannabis was also put on earth for us to use. In the past it was about getting high, now it’s about needing it, it has more of a purpose now, and that’s why I think its medicine for me. 5 years ago is when I really thought about it, and I have started defending my use. It is harm reduction, like I have no cravings for cocaine (Participant 008, Zagimē Anishinabēk, Two-Spirit, Over 40). Observed Benefits A quarter of respondents (n = 16, 25%) described the observed benefits of others as a past experience that changed their minds. Yeah, my mom started smoking it and her whole everything did like a 180. She went from being really uptight, just kind of cold, to like, she just kind of opened up a lot (Participant 005, Indigenous Bloom, Female, Under 40). I guess through my work, I’ve learned a lot and I’ve seen a lot of women use it that are trying to get clean, or you know might be having a stressful day and they use cannabis to help them cope through the day, other than using harder drugs or taking pills (Participant 014, Indigenous Bloom, Female, Over 40). Kind of a shift within myself, I supposed, because I started seeing more people around me using it. I was like okay, well I know these people don’t have like addiction problems and they don’t use heavier stuff. I’m really judgmental when it comes to drugs in general, so hopping off of the judgment weed train was kind of a big moment (Participant 024, Indigenous Bloom, Gender, Over 40). Legalization A small minority of respondents (n = 6, 9%) expressed that legalization changed their minds about cannabis, both positively and negatively. I wish it was in the old day when they used to sell black market cannabis. Now, it’s all in stores, I don’t like that because the dispensary weed is not as good as some weed could be (Participant 010, Indigenous Bloom, Female, Under 40). What's going on right now [referring to government control of cannabis]. My view on it is, I’m very let down and it should be better than what it is. They treat your pot, that you pay so much for, like shit. You get small buds when you should be getting fucking high-quality bud. You know, you're paying high quality prices, they’re not giving you the right percentage, they are giving you next to fucking shake... so they are giving you 14/15% pot when it says it’s 25%. They are lying to you and not only that, they are lying to you on the weight. You don’t think with growing 600 plants, you don’t think I know what an ounce looks like or a quarter or a gram? So that upsets me when I feel like I’m getting ripped off and they give you this fancy fucking gadget and you can’t even see what 41 you're buying. At least when you went to your fucking drug dealer you could see what the fuck you were buying, and they treated you with respect and not lie to your face and name all these stupid fancy names [referring to the strains] meanwhile it’s the same fucking shitty weed. Same name, different name, it’s the same plant, nobody knows the difference because it’s so premature, you can’t even tell what fucking strain it is (Participant 012, Indigenous Bloom, Male, Over 40). Other than the price, no (Participant 073, Indigenous Bloom, Female, Over 40). Pharmaceuticals A small minority of respondents (n = 3, 5%) mentioned an experience with pharmaceuticals that changed their mind about cannabis. Well I mean, negatively you’re always going to have a stigma about it because the way people used to look at it. On the positive side, it’s hard to describe, I just can’t imagine my day without it, I really can't. the amount of just plain grief I would go through. So, I mean it’s just very positive in my life. There are days when I wish, maybe, I didn’t consume so much but I remember what it was like when I had cancer. I was strung out on fentanyl, on my hands and knees, puking into a garbage can. Went for my next patch because I wasn’t allowed to have another patch for 12 more hours, and I have such a high metabolism that I would use up all my medicine, like those patches are good for 72 hours, and I would start detoxing in like 60 – 65 hours. I would run out of medicine, and I would sit there and have violent withdrawal symptoms for you know anywhere from 5, 7, to 12 hours every third day. They did that to me for 5 months. So it’s non-comparable, which one I would rather be using (Participant 003, Indigenous Bloom, Male, Over 40). What the doctors were trying to give me. All the drugs they wanted to give me, and I did. I brought home all the prescriptions because as soon as they see your status card, they want to just hand out…and everything I researched was highly addictive and I thought, I don’t want to do that, you know? I’d rather make changes to my diet, I’d rather eat healthy, and see what I can do to medicate it with something different. So you know, at the marijuana store, they had this great big thing up on the wall, with all the different strains and which ones helped with this and which ones helped with that. So I kind of went through it all and… then tried to pick some that would be appropriate for my symptoms and the stuff works… So I thought well why wouldn’t I try this as opposed to taking these pills that I know are addictive, that I know are going to damage some of my organs. You know if you have to take something with food, it’s not good for your stomach. It [referring to cannabis] was the most logical choice (Participant 015, Indigenous Bloom, Female, Over 40). I used to be really against marijuana or any kind of substance… And then when it was prescribed to me, then my mind sort of opened up. I see it as a good thing… When I was 30, I was taking oxycontin and it was prescribed to me, and I think I got addicted to it. It was a long time ago and I just don’t have opioids now (Participant 045, Indigenous Bloom, Female, Over 40). 42 4.3.4 Prompt: “Can cannabis be both a medicine and used for pleasure? Why or why not?” The majority of respondents (n = 61, 95%) indicated that cannabis can be used as a medicine and used for pleasure. Only one respondent expressed that cannabis should only be used recreationally. I use it for pain to get through the day and recreational is just you now when I’m hanging out with friends or if I’m just by myself and just want to relax and watch a movie or just going to do my cleaning, I just find that it helps to get me in the mood for whatever I’m going to do. Just kind of put me in a more upbeat mood (Participant 022, Indigenous Bloom, Female, Under 40). Yes, because there are different types of strains, some would make you more relaxed and relieve your anxiety. Whereas some would make everything more enjoyable, where you can sit down and watch a movie and laugh (Participant 036, Indigenous Bloom, Male, Over 40). I think you can enjoy a joint after work or you can use it medicinally, like if you're anxious or having trouble sleeping. Yeah, it can definitely be used more both (Participant 054, Indigenous Bloom, Female, Over 40). Yes, I think it can be used for both of those things. Medicinally if I’m taking something from the ground, and I have harvested it the way my ancestors taught my grandparents or my father and mother, or if I’m taking something over the counter or if I’m smoking something like marijuana, of course I’m going to feel good after I take it. So I definitely feel, and I guess I also need to air on that side of caution too. I’m aware that I have limitations, that if a smoke more than what is allowed for my body, what’s good for my body, then I go into a state of anxiety and I start to sweat and my breathing irregulates, so there’s a certain amount for medical and pleasure (Participant 057, Indigenous Bloom, Female, Over 40). Absolutely… I have really severe stomach issues and so I struggled to drink alcohol, because it would hurt my stomach. But I’m also on a bunch of meds and now I can’t drink on my medication… so it was just really nice that I finally have something to kind of have a buzz on, have fun, be social, and not have like the pain and the potential medical harms. It’s also nice that I don’t really get a hangover so I feel like I can have fun and not like risk my health (Participant 068, Indigenous Bloom, Two-Spirit, Under 40). I feel it can be both, because that’s something I utilize in my capacity. I utilize the medicinal part to get me through the tough phases of my life and just to help me on a daily basis… then I also use recreationally. For example, we have THC gummies… those I use on Friday nights by the pool or when we’re going out to the lake and we’re going camping out there (Participant 075, Indigenous Bloom, Female, Under 40). 43 4.3.5 Prompt: “What do you like about using cannabis?“ The majority of respondents mentioned multiple reasons why they like cannabis. Thus, multiple themes may be present within a respondent’s quote. Themes that emerged from responses included the calming properties, pain relief, ability to help with a mental health concern, ability to help with sleep, the feeling of being high, pleasure, ability to decrease nausea or stimulate appetite, increased motivation, being present, and that cannabis can make life easier. Other positive features of cannabis use that respondents mentioned included its use as a harm reduction tool and for substitution (n = 6, 9%), aids with concentration and focus (n = 4, 6%), and increased creativity (n = 2, 3%). Calming, Relaxing, and Stress Relief Half of the respondents (n = 32, 50%) mentioned they liked the calming and relaxing effects of cannabis. I think just the mellow properties of it, like the relaxation. I’m more of an indica person, I like mellowing (Participant 069, Indigenous Bloom, Female, Under 40). The fact that it is able to relax me, and I feel relaxed while using it (Participant 014, Zagimē Anishinabēk, Female, Under 40). Pain Relief About a third of respondents (n = 22, 34%) expressed their gratitude for the pain-relieving properties of cannabis. Honestly, I use it [referring to cannabis] every day. It’s become like, I don’t like Tylenol for pain, I want to use it [referring to Tylenol] if I absolutely need to because cannabis isn’t working. So I do like that it [referring to cannabis] works for me. I honestly do, it works for my aches and pains (Participant 034, Indigenous Bloom, Female, Over 40). Being a little stoned ahah, pain relief, it helps me sleep. I am a novelist, and it helps me create, because I don't have pain, so I can do more (Participant 045, Indigenous Bloom, Female, Over 40). 44 Mental Health About a third of respondents (n = 22, 34%) noted they liked cannabis for helping with a mental health concern (i.e., depression, anxiety, or trauma). Maybe it jumpstarts my brain, I don’t know. I have done it so long that I don’t even know why I do it. Well, I do because of PTSD (Participant 002, Indigenous Bloom, Butch, Over 40). I know a lot of people that are on antidepressants and stuff. I just never wanted to go on them and my doctor was heavily against them but it [referring to cannabis] did help a lot with that [referring to depression] (Participant 005, Indigenous Bloom, Female, Under 40). Sleep Just over a quarter of respondents (n = 17, 27%) reported sleep-related benefits from using cannabis. My favourite part is, I am not bleeding on my family… I feel right now that I have to be really, really strong and through that [referring to the use of cannabis] I don’t feel that. So with the use of it, I am really grateful for like stress relief, it helps me unwind and actually go to sleep. I know that I need sleep to allow my body to heal… without sleep I won’t be able to heal. My whole community, we are all really hurt, and I feel through this part, especially with the use of cannabis, I can be that strong person that people need be to be and not have to fake it when I actually go home (Participant 075, Indigenous Bloom, Female, Under 40). I like how it makes me feel and I like the fact that I can sleep easy without like I don’t know, I used to get a lot of nightmares as a kid and I still do now, but like nowhere near as often. So like I can sleep a lot easier, and I can actually do things in public without being an absolute wreck [referring to anxiety] (Participant 018, Indigenous Bloom, Male, Under 40). The Feeling of Being High Almost one-fifth of respondents (n = 12, 19%) spoke positively about the feeling of being high. I like the way it makes me feel, the way it makes me think… a different mindset too (Participant 010, Indigenous Bloom, Female, Under 40). 45 I like that it makes me eat. I feel like it does give me a bit of pleasure. It does [relieve pain] if my stomach is hurting because I do have that problem often. But yeah, I do believe that it helps with all of that. I like the cloudiness [referring to the feeling of being high], it feels like I’m floating and it’s like I’m in another dimension or something (Participant 021, Indigenous Bloom, Female, Under 40). Pleasure Almost one-fifth of respondents (n = 12, 19%) mentioned they liked using cannabis for the pleasure it gives them. I like the euphoric effect when I’m feeling down, it lifts me up, makes me feel happy. Sometimes it just makes things a lot funnier, you’re watching a video and it just seems 10 times funnier (Participant 060, Indigenous Bloom, Female, Under 40). Nausea and Appetite Almost one-fifth of respondents (n = 11, 17%) appreciated the decrease of nausea or the increased appetite effects of cannabis. I'd probably say appetite, like it’s a big thing. I used to have an eating disorder, so it feels like that’s really beneficial for me and I especially like being able to fall asleep. I feel like there’s just so many benefits like I can’t really see my life without it (Participant 048, Indigenous Bloom, Female, Under 40). I like that I get to sleep at night, that I’m not up with indigestion all night, I like that for sure. I get heartburn and indigestion as soon as I lay down, and I like that I’m not bloated anymore, you know my stomach is down to a normal size. I like that food tastes that much better (Participant 015, Indigenous Bloom, Female, Over 40). Motivation A little over one-tenth of respondents (n = 8, 13%) spoke about the increased motivation they receive from using cannabis. It motivates me to complete tasks (Participant 013, Zagimē Anishinabēk, Female, Under 40). It helps me get through my day and makes it easier for me to cope, it makes it easier to want to get stuff done like go outside into the world and stuff like that (Participant 030, Indigenous Bloom, Female, Under 40). 46 Being Present Roughly one-tenth of respondents (n = 7, 11%) spoke positively about the ability of cannabis to help them feel connected and present. The main thing that I like about it is that it makes my body feel like me. I feel normal. Most people probably think ‘oh get high’, that doesn’t happen to me. It probably shows, maybe my eyeballs are showing I’m high, but I don’t feel high. There’s no out of control “hahaha” or anything like that (Participant 019, Indigenous Bloom, Female + Free-Spirit, Over 40). I feel like it works like an anti-anxiety for me and that it allows for more focus. Like on a walk, I could be thinking about a lot of the things I have to do, which I probably will later. But it's a meditative practice as well as a medicinal practice for me. Meditative can be fun and adventurous, and all the things that make it pleasurable and fun, but it's meditative yes and medicinal. It allows me to kind of reflect a bit more, slow down, kind of be in touch with my own body a bit more, relax. I think that’s why it’s always medicinal for me, like it allows me to check in with my body more which I think I often ignore (Participant 050, Indigenous Bloom, Female, Under 40). I like the process of it, I feel more connected to the herbs when I’m smoking it. I’m just an old-school smoker. Just the whole process is great to me. It calms me down, it makes me more patient… I don’t think about the small thing… I have really bad social anxiety so… I don’t panic before I go in somewhere and wonder how many people are there and if they are looking at me… I don’t think about that anymore, I just go about my business because of the CBD (Participant 054, Indigenous Bloom, Female, Over 40). Make Life Easier Roughly one-tenth of respondents (n = 7, 11%) liked cannabis because it made their day-to-day lives easier and acted as a mood elevator. Medically speaking, it makes some of my worst days more tolerable and makes life easier to deal with. Chronic illness is chronic and sometimes you just need a moment of relief (Participant 061, Indigenous Bloom, Two-Spirit, Under 40). it’s just helpful with my moods, I feel less irritated and angry (Participant 015, Zagimē Anishinabēk, Female Under 40). 4.3.6 Prompt: “What do you not like about using cannabis?“ Most respondents mentioned multiple things they do not like about cannabis. Thus, multiple themes may be present within a respondent’s quote. Themes that emerged from 47 responses included stigma and smell, anxiety, paranoia, and getting too high, quality, cost, and lack of access, dependency and increased tolerance, modes of use, the munchies, and burning out. Stigma and Smell Roughly one-third of respondents (n = 21, 33%) disliked the stigma they felt from others by using cannabis. This dislike was typically mentioned in conjunction with the reaction the smell of cannabis creates in others. The smell is probably why I don’t smoke grass because of how pungent it is. I enjoy it but it really gives me the ‘everybody look at me, I’m smoking weed (Participant 036, Indigenous Bloom, Male, Over 40). That its stigmatized, and I think this research is cutting edge. I compliment all of you for having the maturity to ask the questions you’ve been asking me because… there isn’t a place for us to talk about this. There isn’t a place for us to talk about healthy usage of anything you know? I am not opposed to… but someone I love so much is microdosing mushrooms and I don’t personally have a need for that. Personally, I just like some marijuana and sometimes I’ll have a cider from time to time, and that’s okay, but we don’t have a place to have these conversations (Participant 057, Indigenous Bloom, Female, Over 40). The stigma and I don’t like lying. I feel that if you withhold information and you’re not sharing it with me, I feel that to be a lie. In my head, I feel like I’m not withholding or lying to people, but I wish I could be a little more open and honest with individuals, especially in the older generation… I wish I could be open with how I healed and how I became who I am. This isn’t something I can share with my 94-year-old uncle or my 89-year-old auntie, that I’m a regular cannabis user… so I think that’s the hardest part for me… I don’t just go out in the community and say I’m using [cannabis] for this because I know how I’ll get treated after (Participant 075, Indigenous Bloom, Female, Under 40). Anxiety, Paranoia, and Getting too High Just over a quarter of respondents (n = 17, 27%) spoke about the anxiety or paranoia that arises from getting too high. Sometimes it makes me paranoid. Now that I’m not doing it for like high-dose cancer treatment stuff, I’ve become really sensitive to it (Participant 001, Indigenous Bloom, Female, Over 40). 48 Very seldom, if I take too much, like if I take gummies… it might affect me differently so then I can have strange thoughts or dreams… it can kind of give you a bit of anxiety, but that doesn’t really happen anymore now that I’ve been using it for so long… I’m just careful that if I do try a different kind that I don’t use too much at once (Participant 014, Indigenous Bloom, Female, Over 40). I guess like inconsistency. Sometimes I just get like way too high. When I want to have a chill day, like downtown with my roommate and then be absolutely, so stupid in public. Yeah, I guess just inconsistencies in how high I can get (Participant 023, Indigenous Bloom, Female, Under 40). Quality, Cost, and Lack of Access Just under a quarter of respondents (n =13, 20%) disliked the quality of cannabis given the current price point at dispensaries. Others noted wishing they could receive medical coverage to aid in the high cost. Maybe access to the medical marijuana… is hard because my doctor will not prescribe it. I’ve even asked for the marijuana pills, and she’s like nope we don’t do that here, like wow that’s just crazy you know? Those who have less medical condition than I do, have a marijuana card, and they can go to the dispensary and get it for free, whereas I have to buy it which is totally not fair (Participant 047, Indigenous Bloom, Female Over 40). I wish that it could be covered under like my prescription plan… I buy the drops now, but I’d prefer to just take the capsules but they’re obviously more expensive (Participant 065, Indigenous Bloom, Male + Transgender, Under 40). The regulated stores… are hit and miss, you spend 100 bucks, and you want to go home, kick back and feel relaxed but then your throat is burnt because this stuff is totally radiated. If you’re going to stick stickers on stores and label them and make them, go to your standards, then make sure that your standards are, you know, where they should be (Participant 012, Zagimē Anishinabēk, Female, Under 40). Dependency and Increased Tolerance A little over one-tenth of respondents (n = 8, 13%) shared their dissatisfaction with an increased tolerance or a feeling of dependency on cannabis. No, I’ve always enjoyed it and everything that comes with it. Maybe having a higher tolerance makes me buy more (Participant 048, Indigenous Bloom, Female, Under 40). I feel like the problem I have is how much I smoke and what I smoke for… I don’t want to smoke for my mental health, I want to smoke more for fun, like the way normal people do (Participant 027, Indigenous Bloom, Female, Under 40). 49 Modes of use A little over one-tenth of respondents (n = 8, 13%) spoke about their dislike of the effects of smoking cannabis. Flower doesn’t always feel good when you are choking on it because you took too big of a bit (Participant 024, Indigenous Bloom, Gender, Over 40). I personally love the sensation of smoking, but I know it’s not good. I really struggle with that (Participant 068, Indigenous Bloom, Two-Spirit, Under 40). I do smoke it once in a while. I’ve worked in fibreglass glass for a lot of years and when I do smoke it congests my lungs a bit. I try to stay away from smoking it. I do eat it a lot but if I need fast pain relief, I do go out and have 2 or 3 puffs of it (Participant 072, Indigenous Bloom, Gender, Over 40). Munchies A minority of respondents (n = 5, 8%) expressed their dislike of the increased appetite that cannabis gives them. With edibles, I get the munchies like insatiably hungry, which is great, girl I’m Greek I love to eat, and I don’t mind a little badonkadonk. It’s just the insatiable hunger that I don’t like too much (Participant 028, Indigenous Bloom, Female + Two-Spirit, Under 40). The munchies. I do like munching, but I don’t know, some nights I’ll put grapes beside my bed because if I’m going to have some munchies it should be something healthy. A lot of the time it’s not and I feel guilty (Participant 073, Indigenous Bloom, Female, Over 40). I don’t like that sometimes it makes me eat more (Participant 077, Indigenous Bloom, Male, Under 40). Burn out A minority of respondents (n = 5, 8%) disliked feeling tired or burning out. I don’t like smoking during the day, just like the whole tired part during the day. Maybe it’s the strain too but yeah just being burnt out (Participant 069, Indigenous Bloom, Female, Under 40). I don’t like getting tired and having the munchies (Participant 039, Indigenous Bloom, Male, Under 40). 50 4.4 Motivations Most RCU indicated that they used cannabis for both therapeutic and recreational reasons (n = 53, 83%), while a minority endorsed solely therapeutic (n = 6, 9%) or recreational motivations (n = 5, 8%). When asked about cannabis use motivations, respondents were asked to select all the reasons they had been using cannabis in the last 6 months (L6M) and to pick one main motivation – See Table 2. On average, respondents selected 8.1 (SD = 2.1) motivations for cannabis use in the L6M. If a therapeutic motivation (i.e., any motivation other than, to get high, to have fun, or peer pressure) was selected as the main motivation, respondents were asked further about their main motivation. Of those respondents (n = 60, 94%), the majority (n = 47, 78%) reported using cannabis “daily” or “multiple times a day” for their main motivation. The majority of respondents (n = 55, 92%) considered cannabis to be “very helpful” or “extremely helpful” for their main motivation. 65% (n = 39) of respondents reported 80% – 100% relief from using cannabis, for their main motivation. While only 53% (n = 32) of respondents reported that they could “always” afford to buy enough cannabis to relieve their symptoms for their main motivation. 51 Table 2 Cannabis Use Motivations Main Motivation L6M n % n % To help with sleep 15 23 53 83 To relieve pain including, MS, arthritis, etc. 13 20 54 84 To relieve stress 6 9 59 92 To help with anxiety 5 8 55 86 To cope with trauma 5 8 50 78 To reduce or stop the use of other substances including, opioids, coke, meth, or alcohol 5 8 33 52 To get high a 4 6 49 77 To help with depression 1 2 46 72 To treat a mental health concern other than anxiety 4 6 25 39 To have fun a 0 0 50 78 To treat nausea or loss of appetite 1 2 31 49 Peer pressure a 0 0 1 2 Other specified 5 8 12 19 To socialize 1 2 1 2 Digestion problems 1 2 1 2 Relax 1 2 2 3 To elevate mood, to focus 1 2 1 2 Slow down brain (ADHD) 1 2 1 2 ADHD 0 0 2 3 Loneliness 0 0 1 2 Night terrors 0 0 1 2 To get energy (motivation) 0 0 1 2 To treat bipolar 0 0 1 2 a Non-therapeutic motivations. 52 4.4.1 Prompt: “Why do you use cannabis? Is it mostly for medical reasons, recreational, or pleasure reasons? Or both?” The respondent’s quotes can be seen below and provide further insight into the multi-motivational use of cannabis. Only RCUs were presented with prompt 4.4.1. Because I deal with depression, anxiety, insomnia, and night terrors, cannabis gives that peaceful sleep…If I have a really bad nightmare, I can be up for a couple hours, I can be up for days like that’s how much it can affect my mental health… It’s both, it goes in between. During the weekday it’s just at night and on the weekends, smoking helps creativity (Participant 008, Indigenous Bloom, Female, Under 40). I find I use it to try and get more sleep and I also have bad back pain from being in an accident… recreationally, I have friends that will come over and they’ll light it up and whatever… better than drinking alcohol (Participant 064, Indigenous Bloom, Male, Under 40). If I was quantifying my use now, I would say for recreational pleasures and very necessary medical, what I would consider safer medical uses. For sleep, for muscle pain… and migraines… all these are kind of connected to sleep because if you’re in pain and you're hurt then it just cycles. On weekends, we like to experiment with buying different things, like something fun and then go for a hike and it gets us out in nature (Participant 050, Indigenous Bloom, Female, Under 40). Regarding respondent’s main motivation for cannabis use, to help with sleep was the most endorsed motivation. To relieve pain was the second most endorsed main motivation followed by relieving stress. To cope with trauma, to help with anxiety, and to reduce or stop the use of other substances tied for the fourth most selected main motivations. However, within the L6M, the majority of respondents endorsed using cannabis to relieve stress. Among those who identified as “Male”, the most endorsed main motivations were to get high (n = 3, 5%), to cope with trauma (n = 3, 5%), and to help with sleep (n = 3, 5%). Among those who identified as “Female”, the most endorsed main motivations were to help with sleep (n = 11, 17%) and to relieve pain (n = 10, 16%). Among those who identified as “2S/Other”, the most endorsed main motivation was to help with sleep (n = 3, 5%). When considering all motivations within the L6M, the most endorsed motivation was to relieve stress among those who identified as “Male” (n = 17, 11%) 53 and “Female” (n = 40, 12%). Among those who identified as “2S/Other” the most endorsed motivations within the L6M were to cope with trauma (n = 7, 11%), to help with sleep (n = 7, 11%), and to help with depression (n = 7, 11%). The endorsed motivations, found in Table 2, provided the scaffolding for the categorization of themes. Given the frequent multi-motivational cannabis use among RCU, few respondents spoke to a single reason for their use. As such, only one quote was presented under each of the 5 themes. Quotes related to substitution are presented in section 4.5. Sleep Nearly a quarter of respondents endorsed using cannabis to help with sleep as their main motivation. The vast majority of respondents endorsed using cannabis to help with sleep in the L6M. I use cannabis because I really enjoy the feeling of it and I’d rather fall asleep right away than toss and turn all fucking night… so if I smoke a joint before I go to bed, I cave into my pillow and I fall asleep right away. Sometimes if I don’t fucking smoke, I’m tossing and turning (Participant 012, Indigenous Bloom, Male, Over 40). Pain relief A fifth of respondents endorsed using cannabis to relieve pain as their main motivation. Most respondents endorsed using cannabis to relieve pain in the L6M. It helps with my pain, I suffer from chronic pain… it doesn’t really take the pain away, but it distracts my mind from thinking about it 24/7 (Participant 072, Indigenous Bloom, Gender, Over 40). Stress relief A small minority of respondents endorsed using cannabis to help relieve stress as their main motivation. The substantial majority of respondents endorsed using cannabis to relieve stress in the L6M. It’s been really stressful and challenging like going to work and working a lot of overtime. There isn’t enough staff and like a lot of stress involved in that, especially 54 where I work. A lot of women, where I work, have a lot of mental health wellness issues and drug use. So you’re like always on edge worrying about the next overdose and stuff like that. I have to Narcan people a lot…so just trying to wind down sometimes after work or on the weekend (Participant 014, Indigenous Bloom, Female, Over 40). Trauma A small minority of respondents endorsed using cannabis to cope with trauma as their main motivation. Over three-quarters of respondents endorsed using cannabis to cope with trauma in the L6M. I use it to relax or to help me sleep when I’m stressed out or if I’m not feeling well… I feel like since I retired, I’ve had a calmness in my life, harmony, love, and kindness. I’m not witnessing all of those abuses and I’m not having to… I breathed in a lot of deaths. When you Narcan people, they’re dead, they’re dying, and you’re trying to breathe life back into them. I think that was a big part of what was happening to me. All the death I was breathing in… I am stable now, I feel emotionally stable… I feel spiritually connected again. You know, I don’t want to be medicating my whole entire life, I want to be out there living my life (Participant 015, Indigenous Bloom, Female, Over 40). Anxiety A small minority of respondents endorsed using cannabis to help with anxiety as their main motivation. Most respondents endorsed using cannabis to help with anxiety in the L6M. I have high anxiety sometimes, I get really bad anxiety actually. So it helps with calming and being chill. With anxiety comes, I don’t eat, because my anxiety is through the roof. So when I smoke my anxiety comes down and I have more of an appetite (Participant 029, Indigenous Bloom, Male, Under 40). 4.5 Substitution All respondents (n = 69, 100%) responded to the substitution questions. 41% (n = 27) of respondents reported that they have used cannabis to help reduce cravings for other drugs. Cannabis was most commonly reported as a substitute for alcohol (n = 8, 30%) followed by, cocaine (n = 7, 26%), opiates/opioids (n = 6, 22%), crack (n = 6, 22%), methamphetamine (n = 5, 19%), cigarettes (n = 4, 15%), benzodiazepines (n = 3, 11%), MDMA (n = 3, 11%), methadone/suboxone (n = 2, 7%), sleeping medication (n = 1, 4%), and non-illicit stimulants (n 55 = 1, 4%). Respondent’s quotes, arising from prompt 4.4.1, provide further insight into respondent’s substitution behaviours. 4.4.1 Prompt: “Why do you use cannabis? Is it mostly for medical reasons, recreational, or pleasure reasons? Or both?” I’m tapering off of methadone. I was injured, for like a few years pretty heavily. I’m like consistently kind of withdrawing so it kind of just helps ease the muscle cramps and stuff during the day so I can work (Participant 005, Indigenous Bloom, Female, Under 40). I quit drinking about 5 – 6 months ago and I’ve chosen this way to basically keep me sane. It’s my “mom wine” now (Participant 021, Indigenous Bloom, Female, Under 40). for sure a mood control, it allows me to focus. Otherwise, I have too many things coming at me at once. I feel I can really focus, I feel like I can do a great job. I also smoke it so I can taper the alcohol, and it's been really working (Participant 028, Indigenous Bloom, Female + Two-Spirit, Under 40). When I was a crack addict, and I was in my past, when I was drinking was when I wanted to go buy crack. When I smoked a joint, I didn’t want to go buy crack (Participant 079, Indigenous Bloom, Female, Over 40). Alcohol Substitution Most respondents (n = 45, 68%) reported that they previously or currently regularly consume alcohol. Of those respondents, 84% (n = 38) reported that they had used alcohol and cannabis together. Most respondents agreed that they don’t need to use as much alcohol when they use cannabis and that cannabis has more tolerable side effects than alcohol. Most respondents disagreed that they use more alcohol when they use cannabis, that cannabis has no effect on their alcohol use, that they don’t use alcohol when they use cannabis, and that cannabis negatively interferes with alcohol. Responses were split when asked if they would use cannabis in place of alcohol if it were more available. See Figure 1 for a visual representation of alcohol substitution perspectives. 56 Figure 2 Alcohol Substitution 024681012141618202224262830When I use cannabis, I don’t need to use as much alcoholWhen I use cannabis, Iuse more alcoholCannabis has moretolerable side effects thanalcoholCannabis has no effect onalcohol useWhen I use cannabis, I don’t use alcoholCannabis negativelyinterferes with alcoholIf cannabis were moreavailable, I would use itin place of alcoholNo. of ResponsesAlcohol Substitution QuestionsStrongly DisagreeDisagreeNeutralAgreeStrongly agree 57 Opioid Substitution Approximately one-fifth of respondents (n = 14, 21%) reported that they previously have or currently regularly consume opioids. Of those respondents, 71% (n = 10) reported that they had used opioids and cannabis together. Most respondents agreed that cannabis has more tolerable side effects than opioids and that they would use cannabis in place of opioids if it were more available. Most respondents disagreed that they use more opioids when they use cannabis, that cannabis has no effect on their opioid use, that they don’t use opioids when they use cannabis, and that cannabis negatively interferes with opioids. Responses were split when asked if they don’t need to use as much opioids when they use cannabis. See Figure 3 for a visual representation of opioid substitution perspectives. 58 Figure 3 Opioid Substitution 02468When I use cannabis, I don’t need to use as much opioidWhen I use cannabis, Iuse more opioidCannabis has moretolerable side effects thanopioidCannabis has no effecton opioid useWhen I use cannabis, I don’t use opioidCannabis negativelyinterferes with opioidIf cannabis were moreavailable, I would use itin place of opioidNo. of ResponsesOpioid Substitution QuestionsStrongly DisagreeDisagreeNeutralAgreeStrongly agree 59 Stimulant Substitution 39% (n = 26) of respondents reported that they previously have or currently regularly consume stimulants. Of those respondents, 58% (n = 15) reported that they had used stimulants and cannabis together. Most respondents agreed that cannabis has more tolerable side effects than stimulants. Most respondents disagreed they don’t need to use as much stimulants when they use cannabis, that they use more stimulants when they use cannabis, that cannabis has no effect on their stimulant use, that they don’t use stimulants when they use cannabis, and that cannabis negatively interferes with stimulants. Responses were split when asked if they would use cannabis in place of stimulants if it were more available. See Figure 4 for a visual representation of stimulant substitution perspectives. 60 Figure 4 Stimulant Substitution 02468101214When I use cannabis, I don’t need to use as much stimulantsWhen I use cannabis, Iuse more stimulantsCannabis has moretolerable side effects thanstimulantsCannabis has no effect onstimulants useWhen I use cannabis, I don’t use stimulantsCannabis negativelyinterferes with stimulantsIf cannabis were moreavailable, I would use itin place of stimulantsNo. of ResponsesStimulant Substitution QuestionsStrongly DisagreeDisagreeNeutralAgreeStrongly agree 61 Tobacco Substitution Until 1951, ceremonial tobacco use, among other ceremonial practices, was made illegal under the Indian Act of 1885 (Nez Henderson et al., 2021). To foster cultural safety, we delineated the difference between commercial and ceremonial tobacco by specifying that our question was referring to tobacco consumption “outside of ceremony”. Most respondents (n = 45, 68%) reported that they previously have, or currently, regularly consume tobacco outside of ceremony. Of those respondents, 87% (n = 39) reported that they had used tobacco and cannabis together. Most respondents agreed that cannabis has no effect on the use of tobacco. Most respondents disagreed they don’t need to use as much tobacco when they use cannabis, that they use more tobacco when using cannabis, that they don’t use tobacco when using cannabis, and they would use cannabis in place of tobacco if it were more available. See Figure 5 for a visual representation of tobacco substitution perspectives. 62 Figure 5 Tobacco Substitution 0246810121416182022When I use cannabis, I don’t need to use as much tobaccoWhen I use cannabis, I use moretobaccoCannabis has no effect on tobaccouseWhen I use cannabis, I don’t use tobaccoIf cannabis were more available, Iwould use it in place of tobaccoNo. of ResponsesTobacco Substitution QuestionsStrongly DisagreeDisagreeNeutralAgreeStrongly agree 63 Nicotine Substitution A small portion of respondents (18%, n = 12) reported that they previously have or currently regularly consume nicotine vapes. Of those respondents, 67% (n = 8) reported that they had used nicotine vapes and cannabis together. The views were mixed in terms of the impact of cannabis on nicotine use. Three-quarters of respondents (n = 6) who used nicotine vapes and cannabis together felt neutral or strongly disagreed that using cannabis reduces their nicotine use. Three-quarters of respondents (n = 6) disagreed or strongly disagreed that they use more nicotine while using cannabis. Some respondents felt that cannabis affects their nicotine use (n = 3) while others endorsed the opposite (n = 4). Most respondents indicated that they use nicotine while using cannabis (n = 6). A small number of respondents (n = 2) agreed they would use cannabis as a substitute for nicotine if it were more available. 4.6 Modes and Patterns of Use All RCU (n = 64, 100%) responded to questions about how they use cannabis. Smoking flower was the most commonly reported mode of cannabis consumption, followed by edibles, vaping, topicals, other oral preparations, and concentrates. See Figure 6 for a visual representation of the methods of cannabis consumption. Smoking flower was the most frequently used mode of consumption with more than half of respondents reporting at least daily use. Vaping cannabis was the second most frequently used mode of consumption. See Figure 7 for a visual representation of the patterns of cannabis use. 64 Figure 7 Modes of Cannabis Use in the L6M 92%53%31%77%36%41%0%10%20%30%40%50%60%70%80%90%100%Smokingbud/flowerVaping Concentrates Edibles Other oralpreparationsTopicals% of ResponsesModes of Consumption0%10%20%30%40%50%60%70%80%SmokingflowerEdibles Vaping Concentrates Other oralpreparationsTopicals% of ResponsesModes of ConsumptionNeverLess than 1x/month1-3x/month1-3x/weekDailyMultiple times per dayFigure 6 Patterns of Cannabis Use in the L6M 65 To better understand how the form of cannabis contributes to the medicinal feeling of cannabis, respondents were asked the open-ended question below. Only RCU responded to prompts 4.6.1. 4.6.1 Prompt: “Does the form cannabis comes in shape how you feel about cannabis as a medicine or not? (i.e. oil, dried, etc.)” The majority of respondents (n = 40, 63%) felt that the form in which cannabis is consumed does not impact their perception of its ability to be a medicine. In contrast, about one-third of respondents (n = 20, 31%) spoke about how the different forms of cannabis impact their perception of medicinal cannabis. Four respondents (6%) did not directly answer the question but shared their experience with different forms of cannabis. Here is what we heard: Different Forms Feel More Medical Yes, with straight grass, you gotta burn it… that’s just unhealthy so trying to pass that off as a medicine would be difficult. With edibles and stuff like that… there’s no carcinogens, nothing burns. Vaporizing too… that it is healthier than smoking. So I can see how people look at the grass as not medicine because you gotta burn it (Participant 036, Indigenous Bloom, Male, Over 40). When you ingest it, you don’t know when it’s going to take effect right? When you smoke it, you know it’s going to come at you right away… you get to experience the actual bud (Participant 064, Indigenous Bloom, Male, Under 40). Yeah, I’d say so. It’s all wrapped up like prescription medication. It’s all labeled… you know how many are in there… it kind of reminds me of getting pills at the pharmacy (Participant 065, Indigenous Bloom, Male + Transgender, Under 40). All Forms Feel Medical Honestly, I think they all benefit in a way, I do believe in a benefit because they still have THC in it (Participant 021, Indigenous Bloom, Female, Under 40). No, I think it is all the same. It's just up to the person's discretion as to how they want to use it (Participant 069, Indigenous Bloom, Female, Under 40). No, it is good to see all that it is available in all forms... The different forms are really beneficial (Participant 012, Zagimē Anishinabēk, Female, Under 40). 66 4.7 Cannabis Access All RCU (n = 64) responded to cannabis legalization questions. Almost half (n = 32, 46%) endorsed using cannabis before legalization and increased use following legalization. More than one-third of respondents (n = 26, 38%) endorsed cannabis use before legalization and no change in use following legalization. A minority (n = 8, 12%) endorsed cannabis use before legalization and decreased use following legalization. Even less (n = 3, 4%) did not use cannabis before legalization but had used it following legalization. Over half of respondents (n = 37, 54%) felt that the risks of cannabis have decreased since it was legalized, while some (n = 29, 42%) believed that the risks of cannabis were unchanged following legalization. A minority (n = 3, 4%) of respondents felt that cannabis was more risky following legalization. 4.7.1 Prompt: “Has legalization changed your cannabis use attitudes or habits?” Responses to prompt 4.7.1 revealed several themes including, variety of products, accessibility, safety, price, and acceptability. However, some participants felt that the legalization of cannabis did not change anything for them. RCUs and non-RCUs responded to prompt 4.7.1. Quotes are from RCUs unless otherwise specified Products Increased variety of cannabis products (e.g., edibles, oils, flavour profile, and potency level) was reported as a positive aspect following cannabis legalization. Yes, I use different products. It is totally weird actually. Legalizing it is actually how I found out why some weeds I’d smoke, I’d just get all weird and just didn’t enjoy my high and it was sativa. Oh, and there’s other stuff too like bath bombs, edibles, lotion things are the stuff I use (Participant 029, Indigenous Bloom, Male, Under 40). I feel like I’m more open to trying different products, like different types of edibles… now I’m on the dab carts, so I feel that’s a little bit more accessible (Participant 048, Indigenous Bloom, Female, Under 40). 67 All the different forms, I’ve tried extracts and flower. I’ve never tried the oils… you can vaporize it and there’s no smoke, which I really like. There’s no paper burning… So a vape is just perfect (Participant 041, Indigenous Bloom, Female, Under 40). Accessibility Increased accessibility of cannabis was reported as a benefit following cannabis legalization. However, some respondents reported no change in accessibility or decreased accessibility following legalization. I would say it made it easier to access for me (Participant 027, Indigenous Bloom, Female, Under 40). I’m going to say [legalization] has not affected the use of it for me. It has always been available (Participant 020, Indigenous Bloom, Male, Over 40). Oh yeah for sure. Well, I can’t grow it now. They ruined that so… I’m pissed that I can’t grow 600 plants (Participant 012, Indigenous Bloom, Male, Over 40). Safety and Quality Increased safety and quality of cannabis products were reported as a result of the ability to access cannabis from a cannabis store. I’m more confident in the quality and safety, especially around knowing that it’s just cannabis in there (Participant 055, Indigenous Bloom, Female, Over 40, Non-RCU). I think I was more open about it… I don’t know I just felt like if it’s legal, it’s okay… I think that it’s safe too (Participant 008, Zagimē Anishinabēk, Two-Spirit, Over 40). I think it’s helped, and I’ve gotten to try a lot more, and feel a bit safer trying that because like, you can trust a dealer but like can you ever really trust the dealer? (Participant 023, Indigenous Bloom, Female, Under 40). Price Increased price was reported as a negative feature of legalization by some participants. Well, I say, ‘yay Trudeau’, that’s what I said when that came out, even though I know they are making a lot of money. It’s a big money racket (Participant 019, Indigenous Bloom, Female + Free-Spirit, Over 40). 68 I use less because it’s more expensive. Otherwise, it’s just nice not to worry about someone busting down my door (Participant 061, Indigenous Bloom, Two-Spirit, Under 40). Acceptability Increased acceptability of cannabis use was reported as a result of legalization. It’s more open now because before everybody used to have to hide it (Participant 064, Indigenous Bloom, Male, Under 40). I don’t hide it as much. I’ll pull out a joint… like on the beach and stuff like that. Where before the only time I ever did that was 420… yeah smoking it in public, I’m not so worried (Participant 079, Indigenous Bloom, Female, Over 40). Other people that may have used it behind closed doors, you know… closet drinkers. It’s kind of you know, not feeling like they’re doing something illegal. I’m just happy I can just go get it from a dispensary (Participant 070, Indigenous Bloom, Female, Over 40). Somehow, it's helped a lot of the stigma, I would say around like older people like my parents which has kind of helped them, accept that like ‘oh no our daughter doesn't want to get drunk every weekend, she just wants to get high’ (Participant 023, Indigenous Bloom, Female, Under 40). All RCU (n = 64, 100%) reported where they sourced their cannabis in the last six months – See Figure 8. An Indigenous cannabis dispensary was the most commonly reported source of cannabis among respondents in the L6M, the source frequented most often, and the most preferred source. Respondents reported a variety of reasons that contributed to a certain source being most preferred. Price, quality, and location were reported as the most important reasons that made a source preferred (see Table 3). 69 Figure 8 Source of Cannabis 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%Indigenous Cannabis DispensaryNon-Indigenous Cannabis DispensaryLegal Retail StoreFriend, family member, etc.DealerPrivate GrowerOnline Legal CannabisIllegal online or mail-order% of ResponsesSourcePreferredMost OftenLast 6 Months 70 Table 3 Reasons for Preferred Source Most Important Reason L6M n % n % Price 22 34 47 73 Quality 11 17 53 83 Location 8 13 38 59 Indigenous owned 7 11 38 59 Safety 7 11 30 47 Loyalty/habit 1 2 33 52 Variety 1 2 43 67 Good service 0 0 46 72 To avoid police 0 0 10 16 Other specified 7 11 18 28 Carries pax pods 1 2 1 2 Convenient hours 0 0 1 2 Delivery service 0 0 2 3 Display of products, some places I can't see the information 0 0 1 2 Easier access 0 0 1 2 Get tax off/tax free products 1 2 3 5 Good friend, helps me when I have no money 1 2 1 2 Honourable harvest 1 2 1 2 I feel welcomed here 0 0 1 2 I’m from Zagimē and this is a dispensary that is run and owned by my community 1 2 1 2 Knowledge of product 1 2 2 3 Money back in Indigenous pockets 0 0 1 2 More discrete 1 2 1 2 They have pre-rolls so I don’t have to roll my own 0 0 1 2 71 Respondents were asked prompts 4.7.2 and 4.7.3 to gain a deeper understanding of how the source and quality of cannabis contribute to the medicinal feeling of cannabis. Only RCU (n = 64, 100%) responded to prompt 4.7.2 and 4.7.3. 4.7.2 Prompt: “Does availability or access of cannabis, such as where you buy it, shape how you feel about cannabis as a medicine or not?” Half of the respondents (n = 33, 52%) indicated that the source of cannabis does not have an impact on how they feel about it as a medicine. Whereas the other half (n = 28, 44%) indicated that the source of cannabis does have an impact on how they feel about it as a medicine. Three respondents (5%) were conflicted. Throughout all responses, several themes emerged including safety and regulation, trust of the source, cost and accessibility, and stigma. Safety and Regulation Absolutely not. [Cannabis] has been available for hundreds of years and these stores are just opening and they’re the ones that need to do the research (Participant 020, Indigenous Bloom, Male, Over 40). Oh yeah definitely, I used to buy from dealers forever and you don’t know anything about it. I love the science of it [referring to cannabis], I love the percentages, the terpenes, like where it comes from. That it’s safe like people can’t just sell weed and give it to you at these places, like you have to have some accountability there. You know, especially with fentanyl. I’ve never heard of anyone personally, like I haven’t seen anyone get hurt from fentanyl and weed, but I mean now you have to worry about that, you know, it’s not going to happen from a dispensary (Participant 030, Indigenous Bloom, Female, Under 40). I think if I were buying it from a dealer, I would still be really concerned about what was in it because it’s not regulated. I’ve bought from my dad who was growing, I’ve bought from an under the table medicinal grower, and I’ve also bought from dispensaries and just feeling more confident, especially in our drug crisis right now, feeling more confident about what’s in my weed have been better (Participant 068, Indigenous Bloom, Two-Spirit, Under 40). No really, I mean I get it from all sources, whether it be a dispensary or my friend who grows. So either way I’m looking at it in the same way (Participant 077, Indigenous Bloom, Male, Under 40). 72 Trust of the Source Maybe, I don’t go to the government weed stores. I have a relative, who has a relative, who has a relative, who grows it. So I know that it’s going right from the grower to me and that there’s no cross-contamination, there’s no pesticides or anything being used, it’s all being grown very naturally. And it goes from the plant to my house. I have gone into some of the weed stores out of curiosity. I don’t know, I think it’s overpriced. But it’s the same thing they’ve done with the alcohol, once they make it legal, you know. I don’t think we should pay tax on it and especially not here, in BC, where BC is famous and has been since the hippie days for marijuana growing. It’s like the government’s got a lot of nerve coming in here and taking over our businesses and profiteering from it and trying to create rules (Participant 015, Indigenous Bloom, Female, Over 40). It’s certainly nice to go to the dispensary. I don’t trust the government either, as far as I can throw them. But the sense that it’s really it, you know what you are getting, you can ask for certain things and it is safer. There’s nobody with a bunch of fentanyl next to your weed (Participant 041, Indigenous Bloom, Female, Under 40). Not really no, I would prefer to support a smaller grower or Indigenous Bloom over these government dispensaries. So I don’t go to government dispensaries at all (Participant 001, Indigenous Bloom, Female, Over 40). Cost and Accessibility Where you get it, yes, completely changes things but in two different ways: money and regulation… It feels like it’s unregulated if you're getting it from somebody who’s just growing it but it’s affordable, Or you go to the cannabis store here and it’s insanely expensive… and the fact that it’s not covered by health care so that brings in a political element… I wish it was an affordable thing to many people in the community who I know smoke it and buy it from the non-weed shop because it is more affordable and good, but I think it makes it feel like you can’t talk about it in public if you’re buying it from your neighbour’s son (Participant 050, Indigenous Bloom, Female, Under 40). I’m not sure how to answer that question. [The dispensary] is kind of far away and [my partner] doesn’t want to go to the cannabis store here because [the cannabis] is a bit dry, we like ours a bit more fresh (Participant 021, Indigenous Bloom, Female, Under 40). Variety of Products Yes, because where I get it not there’s more variety and instead of me just going to meet my buddy, now I can go into a store and they have weed, they have shatter, gummies, oils, they got bath bombs, everything you can imagine. You know I just see it as more a natural product. For people who react differently, like there are ones you can get with low THC or ones without THC or just CBD and stuff like that. I find that its going into more medical and recreational together (Participant 022, Indigenous Bloom, Female, Under 40). 73 Yeah, I think honestly having all the options really helps seeing it, that it could be a medicine, especially in a dispensary. If you get it from a friend, or a dealer, then typically you can get more and if you are using it consistently, and it’s probably more potent than standardized dispensary weed (Participant 023, Indigenous Bloom, Female, Under 40). The dealers usually don’t have the oils and all that. They’ll just have the flower. I still consider that a medicine but not for those who have bad lungs. You know, you could bake it into a brownie or something. So yeah, I believe it’s a medicine no matter where you get it (Participant 047, Indigenous Bloom, Female Over 40). Back when I was 13, there were no dispensaries. When you look at it that way… I would see that as pleasure, recreation, but going to a dispensary, for example, where you can choose your percentages of THC or CBD, different strains, and they have some of the effects with little descriptions, so I think that would be more medicinal than going to your neighbourhood guy (Participant 060, Indigenous Bloom, Female, Under 40). Stigma I don’t know actually, I never really thought about it too much. I used to get it from a dealer when it wasn’t legal, but I’ve been buying from dispensary ever since it’s been legal. I don’t really know… maybe I feel better about when I buy it legally. I feel like more ethically right, like I’m allowed to do that… I feel less judged maybe. It’s like packaged properly instead of being in a Ziplock bag. So much waste there [referring to the legal packaging], the idea is right, but the execution is wrong (Participant 027, Indigenous Bloom, Female, Under 40). No, I don’t believe so. I’d probably feel more comfortable buying it from a dispensary nowadays, maybe (Participant 048, Indigenous Bloom, Female, Under 40). 4.7.3 Prompt: “Does the quality of the cannabis accessed shape how you feel about cannabis as a medicine or not?” Most respondents (n = 43, 67%) expressed that the quality of cannabis impacts how they feel about it as a medicine. Just over a quarter of respondents (n = 18, 28%) indicated that the quality of cannabis does not have an impact on how they feel about it as a medicine. Three respondents (5%) were undecided. Two themes emerged amongst all responses, knowledge of product and potency/effectiveness. 74 Knowledge of Product I would say, yes. Knowing that it’s like lab tested, right? It is good quality and I know what I’m getting and how much, you know what’s in there. I would take that more like medicine (Participant 001, Indigenous Bloom, Female, Over 40). How I go about quality is just at the dispensary just go by the percentages that they show there. I usually go for the highest THC... but when it comes to going to a buddy’s house it is mostly just feeling the bag and eyeballing it, I guess (Participant 036, Indigenous Bloom, Male, Over 40). As the consumer, you need to know what is going into your medicine. If you’re smoking it and using it for medicine, I think knowing the background of it definitely helps (Participant 054, Indigenous Bloom, Female, Over 40). With how everything’s legalized, everything is so regulated, and you know exactly what you’re getting dosage wise, for like edibles and beverages and stuff like that. I haven’t had any surprises and I’m confident with how it’s being regulated and labeled. I know what to expect, just like I would with any other medication (Participant 065, Indigenous Bloom, Male + Transgender, Under 40). Potency and Effectiveness I can’t really grow strong enough marijuana for myself. This year what I did was I got half my stuff made into concentrates because it’s basically the only thing that is strong enough for me (Participant 003, Indigenous Bloom, Male, Over 40). As long as it’s got a high potency and as long as it’s grown properly, through all stages, it could be a great medicine (Participant 010, Indigenous Bloom, Female, Under 40). Kinda, like I don’t know, I have a high tolerance so I got to smoke higher percentages to like actually get the medicinal effect out of it but I guess that could vary from person to person (Participant 018, Indigenous Bloom, Male, Under 40). No, I don’t think the quality of it should be the determining factor of whether it’s a medicine or not. All cannabis can be a medicine if it’s used for medicinal purposes (Participant 050, Indigenous Bloom, Female, Under 40). 4.8 Stigma and Barriers to Health Care All respondents (100%, n = 69) responded to questions related to medical cannabis authorization. Over half of the respondents (n = 38, 55%) endorsed that they have discussed cannabis with a health professional. 39% (n = 27) of respondents endorsed that they have wanted to discuss CTP with their doctor, but have not done so. Of these respondents, 14 endorsed that 75 they did not feel comfortable talking with their doctor about cannabis and 12 expressed feelings of nervousness, uncertainty, and fears of, or previous experience with discrimination or judgment. Almost half of respondents (n = 32, 46%) reported experiencing discrimination by their doctor because of cannabis use or bringing up the topic of cannabis use. The vast majority of respondents (n = 59, 86%) endorsed that their doctor has never recommended that they try cannabis. The majority of respondents (n = 57, 83%) have never been authorized medical cannabis. Only 6 respondents (9%) had cannabis recommended to them by their doctor and 5 respondents (7%) were authorized medical cannabis by their doctor. Whereas almost a quarter of respondents (n = 16, 23%) were refused assistance with medical cannabis authorization. 4.8.1 Prompt: “Do you think cannabis is stigmatized as a potential medicine?” Only RCUs (n = 64, 100%) responded to the prompt. The majority of respondents (n = 44, 69%) felt that cannabis is stigmatized as a potential medicine. Almost one-fifth of respondents (n = 10, 16%) felt that the stigma around cannabis has decreased over time. A minority of respondents (n = 8, 13%) felt that cannabis was not stigmatized as a potential medicine. Notable quotes can be seen below. I think people just think pot smokers are brain dead… They don’t realize that they’re probably masking smoking or using it for some reason. It’s a gateway drug, that’s what they try and say, but it’s not. Trauma is the gateway. Everything else is just what people do to try and close the gate… They almost look at pot as different than just having a drink… Why is it acceptable but smoking isn’t (Participant 002, Indigenous Bloom, Butch, Over 40). Yeah for sure, I felt that my whole life… how do you explain to somebody, look if I don’t smoke this joint maybe I’ll be suicidal today… or depressed… just have a real shitty day, and you can’t explain that to people… but if you're sitting on a park bench and pull out your prescription medication and shove 3 of those down your mouth then you're an okay guy (Participant 003, Indigenous Bloom, Male, Over 40). I’ve had doctors laugh at me for saying I used it medically… but my physical response to the edibles shows that its beneficial for me (Participant 009, Indigenous Bloom, Female, Over 40). 76 It is looked down upon, especially with people I’ve met in recovery saying ‘oh, you're not clean… a drug is a drug’ like NA people… I’ve been to meetings where I’ve tried to justify my use, but they always say ‘no, no, no’ (Participant 008, Zagimē Anishinabēk, Two-Spirit, Over 40). All participants (n = 69, 100%) responded to questions related to descriptive social norms. All but one respondent (n = 68, 99%) responded to questions related to injunctive social norms. Outside of health care settings cannabis use, cannabis use was thought to be used by at least half of respondent’s community members, family members, friends, people like them, and people they would like to be like - See Table 4. Respondents felt that people they would like to be approved of their cannabis use the least. Greater approval of cannabis use was felt by the following groups, their community members, their family, other people like them, and their friends - See Figure 9. 77 Table 4 Descriptive Social Norms What % of each of the following groups do you think use cannabis? M (%) SD (%) People in your community 60 21 People in your family 50 33 People in your friends 70 29 People like youa 75 26 Others you would like to be like 50 30 a n = 68 responded to this question. Note: The clusters represent responses to the question: “How much do [group] approve of you using cannabis?” The group titles have been shortened for clarity. 0%10%20%30%40%50%60%70%80%People in yourcommunityPeople in yourfamilyClose friends People like you Others you wouldlike to be like% of ResponsesGroupsStrongly DisapproveDisapproveNeutralApproveStrongly ApproveFigure 9 Injunctive Social Norms 78 Chapter 5: Discussion The first aim of the study was to share our methods and process of conducting a collaborative, mixed-methods study of cannabis use among Indigenous Peoples living on Turtle Island. This has been largely achieved by the purposeful positioning of myself, articulation of our Two-Eyed Seeing approach, sharing of our methodologies, positioning of the project and the discussion of the obstacles we faced, and the presentation of results which demonstrated data complementarity. As cautioned by Iwama et al. (2009), it is not just the blending of Indigenous and Western worldviews that define Two-Eyed Seeing but the “thoughtful integration of the best each perspective has to offer to solve problems and benefits others” (Wright et al., 2019a). To thoroughly accomplish Aim 1, I will discuss how the six components of Two-Eyed Seeing, identified by Wright et al. (2019a), manifest within this project. The first component speaks to authentic relationships between researchers and Indigenous communities. Both Phases of our project were built from the inquiry of our community partners. It was not the curiosity of our team that spurred the community relationships and subsequent project proposal. Rather, it was the interest of our Phase-One community partners that led to the development of the project and an Indigenous-led team. Phase-Two holds a similar narrative. Representatives of Zagimē Anishinabēk had heard of the study we had carried out, in partnership with Woodland Cree First Nation and Indigenous Bloom, and were interested in learning more about the perceptions of cannabis use among their community members. This first component stretches beyond the relationships with Indigenous partners and includes relationships with respondents. Some may see the participation of respondents as a means to an end or as just another data point. I, however, viewed each individual’s inquiry to participate as an invitation to listen to their story. I was invited to meet people’s partners, their kids, and their animals. I was 79 shown the beautiful lands where they live. I listened to the stories of people on their worst days and their best days. I view each of these relationships as a gift, one that cannot be repaid solely by a $50 honorarium. The second component is reciprocal research, ensuring that the respondents benefit from their participation in the research. In my experience, some respondents shared their gratitude for holding space for them to talk about their experience with cannabis. One of the respondent’s quotes, under prompt 4.3.6 speaks to this. The third component is relational accountability, meaning the researchers are responsible for the health and well-being of all involved in the research including, the research team, community, and respondents. Wright et al. (2019a) suggest that this is accomplished by involving Elders in the research process. The group of us who carried out the interviews and were responsible for the institutional tasks took the role of learners and listeners, which also speaks to the sixth component (i.e., deferring to Indigenous leadership throughout the research process). Thus, if our community partners wanted involvement from specific Elders, it is most definitely something that would have been prioritized. Relational accountability was carried out in other ways. In Phase-One, the group of us that carried out the interviews met almost weekly for the duration of data collection. Respondents from both Phases were invited to share their thoughts on the interview. Additionally, respondents from Phase-One were sent preliminary findings, if they consented to this during the interview. They were also invited to speak with an RA about the preliminary findings if they wanted to. In Phase-Two, Dr. Walsh and I had frequent meetings with the community representatives to discuss the progress of recruitment and data collection. Once data collection ended, I compiled a brief set of preliminary findings which was presented to Chief and Council by our community representative. The fourth component is the involvement of the Indigenous communities within the research process. This has been spoken to, but I will add that 80 our research team consisted of members and representatives of the community partners. Further, one of our RAs was a community member of Woodland Cree First Nation. In Phase-Two, Chief and Council oversaw all aspects of the study including, the co-creation of a data-sharing agreement, the restructuring of the interview script, providing approval of our strategy to overcome Indigenous Identity Fraud, and were involved data analysis plan. Recognition of, and prior guidance from, local Indigenous customs is the fifth component. One way this was carried out was in the construction of the interview script. Open-ended questions were added to the beginning of the interview to facilitate more of a conversational, relational, storytelling approach. The last component speaks to Western researcher’s role as a follower, a listener, and a learner. Our non-Indigenous members systematically deferred to our Indigenous members to lead the research. Additionally, although I am an Indigenous researcher, I took the role of a follower, a listener, and a learner throughout every aspect. My Indigenous identity does not preclude me from my affiliation with UBC, nor does it inherently familiarize me with the Indigenous knowledge and ways of knowing of those from other communities. For me, Two-Eyed Seeing was not just an approach to the project, it gives voice to my experience as an Indigenous person with settler ancestry and as an Indigenous researcher within a colonial institution. The second aim of the study was to provide qualitative and descriptive quantitative findings across several domains including, cannabis use perceptions, motivations for use, substitution practices, modes and patterns of use, impacts of cannabis regulation, and experiences with discrimination within health care. This was achieved through data complementarity which involved the concurrent presentation of quantitative descriptive findings (e.g., frequency counts and percentages) and qualitative findings (e.g., themes and quotes) (Watson-Singleton et al., 2023, p. 4). To begin our discussion, I will first provide a board 81 overview of the existing literature and the current gaps. Following, I will discuss our key findings within the context of the existing literature. Previous research has been primarily conducted by non-Indigenous researchers, excluded certain groups of Indigenous Peoples, and focused on deficits from the perspectives of Western knowledge systems ((Blake et al., 2023; Hyett et al., 2018 & 2019) Statistics Canada, n.d., 2018, 2023; TCPS-2, 2022). Specifically, within cannabis use research, this has led to a lack of studies that center Indigenous voices and the lived experiences of Indigenous Peoples, that explore motivations for cannabis use among Indigenous Peoples, and that employ strength-based approaches for their exploration (Blake et al., 2023; Gunning et al., 2022; Halseth & Cappe, 2023; Schaffrick et al., 2023). Consequently, studies have problematized the use of cannabis among Indigenous Peoples (Davis et al., 2020; Diem et al., 1994; Ehlers et al., 2008; Elton-Marshall et al., 2011; Gfellner, 1994; Hop Wo et al., 2020; Lemstra et al., 2013; O’Connell et al., 2011; Sikorski et al., 2019; Spence et al., 2014; Wennberg et al., 2021; Zuckermann et al., 2019). These gaps guided our study’s aims which led to the following findings. In contrast to a deficit-centered approach, we found that the vast majority of RCU thought that cannabis could be a medicine. Respondents supported their belief by their personal experience of benefits from using cannabis, the natural properties of the plant, the versatility of cannabis consumption and the lack of side effects, and research evidence. Personally experiencing the benefits of cannabis, whether that be a reduction of an individual’s symptoms or viewing the benefits within loved ones, appeared to be the main driver of respondent’s perception that cannabis can be a medicine. This finding, in conjunction with the respondent’s acceptance of CTP because it is a plant medicine, aligns with the findings of Blake et al. (2023). The authors found that Indigenous participants spoke about the use of CTP as a part of a holistic approach to their health, with the 82 understanding of cannabis as an herbal, traditional medicine, and an alternative to Western pharmaceuticals. Additionally, some of the participants used CTP as an alternative to pharmaceuticals because it worked better for them and had fewer negative side effects (Blake et al., 2023). Our respondents too spoke about the lack of side effects but added to the findings of Blake et al. (2023) by the additional justification of CTP by way of the versatility or customizability of cannabis consumption (e.g., variety of strains with differing cannabinoid concentration, terpene profiles, and delivery methods). Interestingly, research evidence appeared to hold the least among our respondents in the belief that cannabis can be a medicine. Consistent with this finding, Wiese et al. (2023) found some Indigenous Peoples felt a distrust of the current cannabis evidence due to biases in academia and a lack of research that provides a nuanced understanding of the effects of cannabis. The stability of the respondent’s perception that cannabis can be a medicine was anchored in familial CTP and in its status as a plant medicine. Lee et al. (2004) shed light on the familial influence of complementary and alternative medicines (CAM) usage among Asian participants, finding that the use of CAM by family members was significantly associated with CAM use among participants. Among a sample of German participants, Welz et al. (2018) found that family tradition was among the most important reasons for preferring herbal medicines. Although these studies focus on non-Indigenous populations, their findings, along with ours, highlight the impact of familial and cultural beliefs on the perception and use of medicines. The familial and cultural influence on the stability of respondents’ perception that cannabis is a medicine may speak to differing medicinal epistemologies between Indigenous and non-Indigenous Peoples. 83 The majority of respondents thought that cannabis could be both a medicine and used for pleasure (i.e., recreational use). Respondents spoke about the ways they use CTP and CRP within themselves. The difference between CTP and CRP depends on several factors including, time of day, type of strain, amount used, and intention. Some spoke about using CTP during a certain part of the day to manage their symptoms and then used CRP to enhance other activities such as relaxing, watching a movie, cleaning, hanging out with friends, or going camping. Our findings suggest that an individual’s motivation for use is more influenced by the context they are in and the intentions they have within that context. Although the amount of cannabis used was mentioned as a distinction between CTP and CRP for one participant, this was not in relation to the frequency of use. Rather, it was akin to an internal threshold. These findings help us to better understand the limitations of the reliance on frequency of use data when distinguishing between CTP and CRP (Hakkarainen et al., 2019 & Temple et al., 2011). Additionally, these findings speak to the inadequacy of differentiating medical from recreational use based on a physician’s recommendation of cannabis (Lin et al., 2016) or relying solely on a measure with predetermined motivations to select from (Bohnert et al., 2018; Davis et al., 2020). Given that we, in Canada, now exist in a post-legalization context, it is not enough to assume CTP by the recommendation or authorization of a physician. This is especially true when considering the barriers Indigenous Peoples face when accessing health care (Smye et al., 2023 & Goodman et al., 2017). The use of predetermined motivation measures may be a helpful way to examine why people use cannabis. However, only Davis et al. (2020) have explored the use of one predetermined motivation measure which showed that items function differently between American Indian and White youth. 84 The majority of RCU endorsed both CTP and CRP, with an average of 8 different cannabis use motivations. The most endorsed main motivation for cannabis use was to help with sleep. The vast majority of respondents, who reported CTP as a main motivation, used cannabis at least daily. The majority of these respondents considered their CTP to be at least very helpful and provided 80% to 100% relief for their main motivation. These findings are consistent with those of Kvamme et al. (2021) and Walsh et al. (2013), who found that those who use CTP endorsed multiple reasons for use and experienced considerable symptom relief from using CTP. However, our findings differ slightly with respect to the number of motivations endorsed. Kvamme et al. (2021) and Walsh et al. (2013) report an average of 5 and 7 motivations, respectively, while we found that respondents endorsed an average of 8. This finding suggests that Indigenous respondents in our study may be motivated to use cannabis for a wider variety of reasons due to their longstanding perception that cannabis is a medicine and a greater acceptance of plant medicines. Cannabis was liked by participants for a multitude of reasons including, stress relief and relaxation, pain relief, increased mental well-being, its ability to help with sleep, the feeling of being high, pleasure, appetite stimulant, increased motivation, the ability for cannabis to aid in connection, and an overall increase in day-to-day living. In contrast, respondents disliked the stigma associated with cannabis use which was typically increased with public cannabis use and the subsequent smell. Some respondents spoke about a dislike of anxiety, paranoia, and getting too high. An increased tolerance and a feeling of dependency were disliked by others. The irritation of an increased tolerance was tied to the current price point of cannabis. The disappointment with the high costs of cannabis overlays the dissatisfaction with the quality of cannabis accessed through dispensaries, the limited access to dispensaries in certain areas, and 85 the lack of medical coverage. These findings relate to the common concerns of feeling too high, the cost of cannabis, and the social stigma reported by (Ko et al., 2016) Almost half of the respondents reported using cannabis as a substitute for other substances. Most commonly, it was reported as a substitute for alcohol. It was also used as a substitute for cocaine, opioids, crack, methamphetamine, commercial tobacco, benzodiazepines, opioid replacement therapies, sleeping medication, and prescription stimulants. Most respondents agreed that cannabis has more tolerable side effects than alcohol, opioids, and stimulants. Additionally, most respondent’s use of alcohol, opioids, stimulants, and commercial tobacco and nicotine did not increase while using cannabis. Notably, most respondents reported that they would use cannabis in place of opioids if it were more available. These findings relate to previous studies that have shown the use of CTP reduces the use of alcohol, opioids, benzodiazepines, stimulants, commercial tobacco, and other prescription medications (Beaugard et al., 2024; Lucas, 2017; Lucas et al., 2021a; Lucas et al., 2016; Lucas et al., 2021b). Smoking flower was the most common and frequently used mode of cannabis consumption, with half of respondents reporting at least daily use. Edibles were the second most common mode of consumption followed by, vaping, topicals, other oral preparations, and concentrates. These findings contradict those of Kvamme et al. (2021), who found that cannabis oil was the most frequently used form of CTP. However, the majority of respondents in our study considered cannabis to be a medicine regardless of the form it is consumed. The majority of RCU used cannabis before legalization and felt that the risks associated with cannabis use remained the same or decreased since legalization. Respondents spoke positively about the increased variety of cannabis products they are able to access, the increased accessibility of cannabis, the increased confidence in the quality and safety of cannabis, and the 86 increased acceptability of cannabis following legalization. Legalization was mentioned by a few as a past experience that shifted their perspectives about cannabis. Typically, this was not a shift in the perception that cannabis can be a medicine. Rather, the positive anticipation of those who saw cannabis as a medicine, prior to legalization, shifted towards disappointment with the current regulations including, a limited ability to personally produce cannabis and the increased price of cannabis. The disappointment in legalization that we heard from respondents in our study echo the numerous calls that Indigenous Peoples have not been properly included in the development or amendments of the Cannabis Act (Crosby, 2019; FNLC, 2023; Koutouki & Lofts, 2019; Standing Senate Committee on Indigenous Peoples, 2023; Valleriani et al., 2018; Wiese et al., 2023). An Indigenous cannabis dispensary was the most endorsed source of cannabis within the L6M, the most frequented source, and the most preferred source. The most significant factors that contributed to making a source most preferred were the price, the quality of the products, and the location of the source. These findings are similar to those from Wadsworth et al. (2022) who found that the top four factors influencing the source of cannabis among Canadians were price, safety, quality, and convenience. Cannabis with a greater THC concentration was perceived to be more medicinally beneficial and of higher quality. Most respondents felt that the source of cannabis did not impact their perception of cannabis as a medicine. However, some felt safer buying products from a dispensary because of the required adherence to regulations and the lack of potential cross-contamination. In contrast, some shared a distrust of government-regulated dispensaries. The disappointment with the cost of cannabis and distrust of government-regulated dispensaries among respondents in our study parallel the findings from Wiese et al. 87 (2023), who found that Indigenous participants shared concerns about the cost of legal cannabis and expressed discomfort when the source of cannabis was external to their community. Just over half of the respondents in our study discussed cannabis with a health care professional. The remaining, however, did not feel comfortable enough to discuss the topic of cannabis and almost half of the respondents reported feeling discriminated against by their doctor because of cannabis use. It is, unfortunately, not surprising that respondents in our study reported discomfort and discrimination when discussing the topic of cannabis with health care professionals, considering that the In Plain Sight Report (2020) found that 84% of Indigenous respondents had experienced discrimination when receiving health care. Additionally, most felt that cannabis is stigmatized as a medicine with some noting that the stigma has decreased over time. Interestingly, when asked about the perception of cannabis use among five groups of people (i.e., community members, family, friends, similar people, and people they would like to be like), respondents indicated that at least 50% of each group used cannabis. Additionally, respondents felt that these five groups of people, on average, approved of their cannabis use. Despite the overwhelming perception that cannabis is a medicine and the general perceived approval of its use, respondents still expressed their discomfort and uncertainty about discussing the topic of cannabis with their doctors. Considering that the In Plain Sight Report (2020) found that a lack of respect for Indigenous cultural healing practices was the second largest health care issue, this may shed light on the discrepancy between the perception that cannabis is a medicine and the hesitancy to discuss it with a doctor. Although legalization was praised for several reasons, it is not enough to eradicate the roots of colonialism that continue to suffocate Indigenous Peoples who prioritize plant medicines. 88 5.1 Strengths and Limitations There are several strengths and limitations that should be considered. First, the COVID-19 pandemic did impact the development of our study, as it required Phase-One interviews and meetings to be conducted virtually. If I were to do this again, I would prioritize in-person meetings during project development, recruitment, and data collection. The in-person nature could have increased recruitment through Woodland Cree First Nation and Zagimē Anishinabēk in two ways. First, our presence in community may mitigate the barriers related to infrastructure. For example, we would not have to mail tablets instead, we could interview respondents in person. Secondly, the presence of a research team may stimulate community conversation, increase snowball recruitment, and reduce the need to recruit through a community’s Facebook page. Thus, mitigating the potential for non-members to inquire about participation. Second, although we planned to collect a large sample that would allow for the disaggregation of First Nations, Métis, and Inuit perspectives, the obstacles faced during recruitment impaired our sample size. Thus, we were unable to disaggregate our results. Blake et al. (2023) separated their participants into different groups to more accurately represent the unique lived experiences and to avoid pan-Indigenization. This perhaps represents one of the challenges of conducting research with a specific community (e.g., Woodland Cree First Nation and Zagimē Anishinabēk) and urban Indigenous Peoples (e.g., those that we recruited through Indigenous Bloom). There exists a tension between inclusion and exclusion given that prior research has excluded certain groups of Indigenous Peoples (FNIGC, 2018; Statistics Canada, n.d., 2018, 2023). However, an individual community partnership may allow for better representation of that group, decrease the potential of pan-Indigenization, and would provide a better landscape for the use of community-specific methodologies. Similarly, specific Indigenous 89 methodologies were considered for this work. However, similar to Wright et al. (2019b), the inclusion of First Nations, Inuit, and Métis Peoples made it so one specific method would be insufficient to guide the study, as mentioned within section 1.2. The last limitation would be the limited number of non-RCUs who participated in the project. For a more comprehensive perspective on cannabis, it would have been beneficial to have heard from Indigenous Peoples who do not use cannabis regularly. We experienced lower than expected recruitment through community channels (e.g., community email newsletters, word of mouth, posters in the Health Center of Woodland Cree), with greater success through the Indigenous Bloom dispensaries. This likely resulted in an overrepresentation of individuals who respond favourably to CTP. In light of this potential bias, our characterization of the CTP should be interpreted with caution pending replication from research that employs a more systematic recruitment approach. However, these limitations are counterbalanced by several methodological strengths. The first strength was that this project was co-created. Our Phase-One community partners were central to the project’s inception, evidenced by their involvement with the funding application, the creation of the interview script, and respondent recruitment. Similarly, Phase-Two of the project was born out of the interest of the First Nation community partner who sought to better understand the perceptions of cannabis among their community members. Second, the team that conducted the interviews, during Phase-One, was Indigenous-led and included a member from Woodland Cree First Nation. Despite the limited recruitment, our strong relationships with Woodland Cree First Nation, the longstanding interest in CTP for their community members, and the presence of a member on the research team facilitated trust and community involvement. 90 Third, we were able to implement our learnings from Phase-One to better inform Phase-Two. We were led by the principles of OCAP® as our data-sharing framework within Phase-One. Within Phase-two, we opted to co-develop a data-sharing agreement as we felt that it would allow for more specificity. Lastly, our mixed-method study aligned well with our approach of Two-Eyed Seeing. As our interview contained both open-ended and close-ended questions, the presentation of our results using data complementarity facilitated the use of both eyes. It allowed for the voices of participants to be, to the best of our abilities, maintained through the use of quotes. While close-ended questions aided the manifestation of our Western eye by utilizing prior work from our team at UBC. Additionally, as previous literature has predominately been deficit-based, we sought to provide a non-judgmental platform for Indigenous Peoples to share their perspectives on cannabis use. We did not focus on predicting impairments or risks, rather we focused on strengths, relationality, and prioritizing Indigenous perspectives. 5.2 Implications and Future Directions Previous substance use research has been predominately carried out by non-Indigenous researchers without prior community relationships. This work speaks to the application of Two-Eyed Seeing as an approach within substance use research. Although barriers were encountered that limited our recruitment from communities, this work can be seen as a stepping stone for future researchers to use as a guide when working with Indigenous communities. As this is the first Indigenous-led, comprehensive exploration of cannabis use perspectives and motivations, among Indigenous Peoples in Canada, this work lays a foundation for future research to explore the context in which cannabis use or other substance use occurs. Future research should focus on the development of strong relationships with their community partners outside of institutional 91 timelines. This may look like the prioritization of time within the co-creation phase of the project. This will ensure the project moves at the pace of the community and not at the pace of the institution. Future research should focus on community-specific methods to explore the perspectives of substance use, including data analysis. This may allow for greater recruitment of respondents due to increased comfortability and involvement with the research process. Additionally, it may be of greater benefit to the community partner when the research is created, conducted, and analyzed through their ways of knowing. A final consideration for future research would be how Indigenous respondents are identified. As mentioned in section 1.1, Positioning of Self, the relationship between the storyteller and the listener can be enhanced by the positioning of the storyteller. Not only does this apply to researchers but to respondents as well. As Simonds & Christopher (2013) share from their partnership with the Crow Nation, “Taking away the name of the storyteller takes away the life experience of the storyteller, which is boarder than the 1 story that is shared” (p. 2188). As such, the anonymity of respondents should not be assumed but rather questioned and discussed in the context of the Indigenous Knowledges and ways of knowing of that community. This project has implications at a policy level in at least two ways. First, we heard that the increased price of cannabis can be a barrier for some people. As such, this research has the ability to inform policies, such as the financial coverage of CTP for Indigenous Peoples for a wider array of conditions. Further, we saw that there was a preference for Indigenous dispensaries. These findings amplify the numerous calls on the governments to prioritize and facilitate the Indigenous sector of the cannabis industry (Crosby, 2019; FNLC, 2023; Koutouki & Lofts, 2019; Standing Senate Committee on Indigenous Peoples, 2023; Valleriani et al., 2018; Wiese et al., 2023). Many communities are asserting their sovereign and inherent rights to grow, 92 harvest, and distribute cannabis; as we have seen from our community partnerships, Indigenous communities have an interest in CTP and how it fits into the future of their well-being and economic development (Halseth & Cappe, 2023; NIMCA, 2017). However, the lack of appropriate legislative and fiscal frameworks for an Indigenous cannabis sector, within the Cannabis Act, creates a reality for the perpetuation of past injustices (Halseth & Cappe, 2023). Additionally, as BC First Nations continue to experience significant harm as a result of the ongoing toxic drug crisis (First Nations Health Authority, n.d.), the findings of the study have the ability to better inform harm reduction services and medical coverage providers. For example, harm reduction providers could shift their focus to cannabis as a replacement or substitute for other substances to increase the number of options for people seeking replacement therapies. Further, these findings could inform health benefit programs about the perspectives of CTP among Indigenous Peoples, leading to increased coverage of treatment modalities that support their health and well-being in ways that align with their values. 5.3 Conclusion Indigenous Peoples have historically been excluded from research that pertains to them (TCPS-2, 2022). There have been longstanding calls for research to address this disparity (Anderson, 2019; Baydala et al., 2013). This Indigenous-led study employed Two-Eyed Seeing as the approach. This approach asks for both Indigenous and Western knowledge and ways of knowing, in a manner that weaves between the two to meaningfully collaborate. The six components that are typically seen within research that apply Two-Eyed Seeing were evident within our study. The components include, authentic relationships between researchers and the Indigenous community, the researchers and participants benefit from the research process, responsibility of the research team for the well-being of those involved in the research, the 93 Indigenous community is involved in the research process, recognition of, and prior guidance from, local Indigenous customs, and Western researchers take the role of follower, listener, and learner. The translation of our approach and the barriers faced aimed to provide future researchers and Indigenous communities with the knowledge from our experience to better inform their undertaking of similar projects. Our second aim was to provide a platform for Indigenous perspective of cannabis. We heard that the vast majority of RCUs have longstanding beliefs that cannabis is a medicine. In addition, most respondents used both, CTP and CRP. Respondents used and enjoyed cannabis for a multitude of reasons and predominately disliked the stigma associated with cannabis use. Respondents used CTP to reduce the use of, and cravings for, other drugs including alcohol, stimulants, opioids, commercial cigarettes, benzodiazepines, and opioid replacement therapies. Smoking flower was the most common and frequently used form of consumption. The majority of respondents considered cannabis to be a medicine regardless of the form or the source. However, some felt safer buying their medicine from a dispensary due to the adherence to regulations but some felt a distrust towards government-regulated dispensaries. Most people equated the quality and efficacy of CTP to the percentage of THC. Most respondents used cannabis prior to legalization and felt that the risks of cannabis use remained the same or decreased once it became legalized. Respondents spoke positively about the increase in the variety of products, the accessibility of cannabis, the increased perception of safety, and the decrease in stigma following legalization. Others shared a dissatisfaction with the price of legalized cannabis. Most respondents accessed their cannabis from an Indigenous cannabis dispensary due to the price, the quality, and the location. 94 Taken together, this Indigenous-led research, guided by the approach of Two-Eyed Seeing, begins to mitigate the gaps within research by fostering community partnerships and prioritizing Indigenous perspectives of cannabis using a strength-based perspective. This work does not mark a finish line. Rather, it is the beginning of relationships that I will continue to foster and carry with me. 95 References Adamson, S. J., Kay-Lambkin, F. J., Baker, A. L., Lewin, T. J., Thornton, L., Kelly, B. J., & Sellman, J. D. (2010). 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T. (2019). Prelegalisation patterns and trends of cannabis use among Canadian youth: Results from the COMPASS prospective cohort study. BMJ Open, 9(3), e026515. https://doi.org/10.1136/bmjopen-2018-026515 112 Appendices Appendix A - Interview Script CANNABIS USE ON TURTLE ISLAND QUESTIONNAIRE Participant Code: Interviewer: ______________________ Date of Interview: ___________________________ MM/DD/YEAR Location of interview: ____________________________________ (READ) Thank you for contributing to this study. This study is intended to explore the experiences and perceptions of cannabis use amongst Indigenous Peoples. While the focus on this study is on cannabis, we will also be asking other questions about your use of other substances, your health, and your day-to-day life. Before we start this interview, I want to remind you of a few important things: 1. There are no wrong answers. It’s very important that you answer as honestly as possible. 2. I realize that some of these questions might be sensitive. If you do not want to answer a question, just let me know and we will move on. It is better for you to refuse to answer a question rather than to give a false answer. 3. There will be some questions about the COVID-19 pandemic during this interview. If you say “yes” now, you can still change your mind later. 4. We take your privacy very seriously. All the personal information that you provide will only be kept between you and me and the study team. We never report any personal information. 5. If there are any questions you don’t understand, please ask me for clarification. 6. The questionnaire should take about 45-60 mins. Any question may be answered as: D R N Don’t know Refused Not applicable Quality assurance: Scrutinized by: DATE: Corrected by: DATE: DATE: 113 Section A: Qualitative Intro CURRENT LIFE SITUATION “We are interested in learning about your current life situation…” Questions Probes Do you self-identify as Indigenous? • That is, First Nation, Métis or Inuit? • Or other? Where are you from? • What community or territory are you from? • Treaty territory or registered Band? Can you describe where you are currently living? • How would you describe where you are living? i.e. house, apartment, low-income, etc? • On or off reserve • Home community? What kind of supports do you have in your life? • Are you connected with family? • What kind of supports do you find are missing in your life? • How do you define family? What are you currently doing for money? • How do you mainly support yourself? • Can you describe what a typical day is like for you when making money? In general, would you say your health is? • Excellent ;Very Good; Good; Fair; Poor 114 DEMOGRAPHICS (ask if not clear from above discussion) A2. What is your Year of Birth? A3. What is your marital status? - Married - Never married (single) - Divorced - Common-law - Widowed - Separated - Other A4. How would you describe your gender? - Man - Woman - Transgender - Two-spirit - Other A5. What do you identify as your sexual orientation? - Straight - Gay - Lesbian - Bisexual - Queer - Two-spirit - Other A6. What language(s) do you speak at home? (You may choose more than one) A7 Province/Territory of residence: ___________________ A8. City/town/village: ______________ . A9. Do you currently live in a - rural or remote area - suburban area - urban area A10. What is the highest level of education that you have completed? - elementary school (grade school) - secondary school (high school) - technical and non-university education (college; CEGEP) - university (undergraduate – bachelor’s degree) - university (graduate school – master’s degree; doctorate degree; post-doctorate degree) 115 A11. What is your yearly household income? - < $10,000 - $10,000 - $19,999 - $20,000 - $29,999 - $30,000 – $39,999 - $40,000 - $49,999 - $50,000 - $59,999 - $60,000 and over A12. In the past year, were there times when you worried that you would not have enough food in your household before there was money to buy more? - Never - At the end of the month - Sometimes - Often - Always 116 CANNABIS USE BACKGROUND AND PERCEPTIONS “We are interested in learning more about the role of cannabis in your life” Questions Probes How old were you when you first used cannabis? How has your use changed since that time? Change in rate, amount, Intention Type of cannabis? i.e. uptake of CBC, medical cannabis Why do you use cannabis? • Is it mostly for medical reasons, recreational or pleasure reasons? Or both? Do you think cannabis can be a medicine? Why or why not? • Have you always felt this way about cannabis? • Have you had any past experiences which changed your mind about cannabis? • Can cannabis be both a medicine and used for pleasure? Why or why not? • Do you think cannabis use is stigmatized (e.g. looked down upon) as a potential medicine? Why or why not? • Does availability or access of cannabis, such as where you buy it, shape how you feel about cannabis as a medicine or not? • Does quality of the cannabis accessed shape how you feel about cannabis as a medicine or not? • Does the form cannabis comes in shape how you feel about cannabis as a medicine or not? (i.e. oil, dried, etc.) What do you like about using cannabis? What do you not like? • i.e. pain relief, pleasure, motivation, drowsiness, appetite, stress • i.e. dependence, anxiety, stigma, etc.? Has legalization changed your cannabis use attitudes or habits? • Do you use more or less • Different products • Has the way you think about it changed? 117 COVID-19 Qs Have you been tested for COVID? What was the result? If positive: What were your primary symptoms? How severe? Has the pandemic and response (i.e. isolation) changed how you use medicines, drugs, or alcohol Which ones? What effect? (more/less…how much change? 118 Section B: Cannabis Use Details B1 - A = never; B = less than 1x month; C = 1-3x Month D = 1-3 x week; E = Daily Cannabis use frequency If daily use Duration of daily use over L6M (in months) Avg # of uses per day A B C D E <1 1 to 3 3 to 6 >6 Smoking bud/ flower (joint, pipe, bong, etc.) Vaping (vape pen, vaporizer, etc.) Concentrates (dabs, shatter, budder, etc.) Edibles (cookies, gummies, etc.) Other oral preparations (tinctures, oils, capsules, spray) Topical (creams, salves) Other (specify): B1.1. How much cannabis do you usually use? (avg. joint =.3-.5 grams, eighth = 3.5 grams, quarter = 7 grams,1 oz. = 28 grams) a. per session of use: grams b. per day: grams c. per week: grams B1.2. Do you use cannabis for: Recreational purposes: yes/no Medical purposes: yes/no B2. In the last 6 months, where did you get your cannabis? Most often? Preferred? Source Last 6 months Most (Check one) Preferred (Check one) Dealer Friend, family member, etc. Private grower (you or another person) An Indigenous cannabis Dispensary A non-Indigenous cannabis Dispensary Legal retail store Online legal cannabis Licensed producer of medical cannabis (i.e., mail-order from a company like Tilray, Spectrum, CanniMed, etc.) Illegal online or mail-order 119 Other Specify: B2.1. Why is this your preferred source? (Select all that apply) Source Last 6 months Most (Check one) Price Location Loyalty / habit Quality Variety Good service To avoid police Indigenous-owned Safety Other Specify: ______________________________________________________ B3. Have you had any interaction with law enforcement regarding cannabis (possession, use, or distribution, etc.)? Yes* No Local? Provincial? RCMP? *If yes, what happened during this interaction? I was arrested I was charged Given a ticket Other (i.e. warning, drugs seized?) B4. In the last 6 months, what are the reasons why you use cannabis (in general)? Last 6 months (Check all that apply) Most (Check one) To get high* * To have fun* * Peer pressure* * To cope with trauma To relieve pain including MS, arthritis, etc. To help with sleep To help with anxiety To treat nausea or loss of appetite To help with depression To relieve stress To treat a mental health concern other than anxiety To reduce or stop the use of other substances including opioids, coke, meth, or alcohol 120 Other Specify: *If no medical use is identified here or in Section A qualitative go to Section C B4.2 How often do you use cannabis for the main reasons you indicated above? Cannabis use frequency If daily use Duration of daily use over L6M (in months) Avg # of uses per day A B C D E <1 1 to 3 3 to 6 >6 B4.3. For the reasons you indicated above how helpful is it, from ‘not at all helpful’ to being ‘extremely helpful’? • B4.4. For the main reason that use you use cannabis, what percentage of relief do you get from cannabis? 0% 10 20 30 40 50 60 70 80 90 100% No Relief Complete Relief • B4.5. For the main reason you indicated, can you usually afford to buy enough cannabis to relieve your symptoms? - always - often - sometimes - rarely - never - cannabis does not relieve my symptoms Not At AllA littleModeratelyVeryExtremelyr r r r r 121 Section C: Substance Use/ Medications C1 What medications have you used in the past year? (illicit, non-illicit, both?) (Antidepressants? Painkillers (opioid/non)? Sleeping pills/ benzos…etc… C1.1 Have you ever used cannabis to replace, reduce or improve those medications. For any medications noted ask the below questions 1. Have you ever taken ------- together with cannabis? (If no, SKIP section) YES/NO 2. When I use cannabis, I don’t need to use as much ---------- 3. When I use cannabis, I use more --------------- 4. Cannabis has more tolerable side effects than--------------- 5. Cannabis has no effect on -------- use 6. When I use cannabis, I don’t use ---------- 7. Cannabis negatively interferes with --------- (i.e., decreases the effect or creates an adverse effect) 8. If cannabis were more available, I would use it in place of the--------- I am taking. C1 What unregulated (e.g. drugs you buy from the “streets”), or alcohol have you used in the past year? C1. What substance do you use the most? Second most? First Second Third Alcohol beverage/non-beverage tobacco Cannabis Psilocybin (Mushrooms) Heroin Fentanyl powder/pills and analogues Down unspecified Cocaine (non-injection) Crack Sleeping pills Crystal methamphetamine 122 ASK THE BELOW QUESTIONS IF USE IS ENDORSED IN ITEM ABOVE C2.1. Substitution Alcohol Questions Participant responses for the following questions go on the 5-point Likert Strongly disagree Somewhat disagree Neither agree nor disagree Somewhat agree Strongly agree 1 2 3 4 5 9. Have you ever taken alcohol together with cannabis? (If no, SKIP section) YES/NO 10. When I use cannabis, I don’t need to use as much alcohol 11. When I use cannabis, I use more alcohol 12. Cannabis has more tolerable side effects/ hangover than alcohol 13. Cannabis has no effect on alcohol use 14. When I use cannabis, I don’t use alcohol 15. Cannabis negatively interferes with alcohol (i.e., decreases the effect or creates an adverse effect) 16. If cannabis were more available, I would use it in place of alcohol Heroin and cocaine (speedball) Heroin and crystal meth (goofball) Ecstasy / MDMA / Molly Dilaudid Morphine Codeine Suboxone Ketamine (Special K) Benzos (benzodiazepines) Prescription stimulant Specify: Gabapentin Other Prescription opioids Specify: Other Specify: 123 C2.3. Substitution Opioid Questions Participant responses for the following questions go on the 5-point Likert Strongly disagree Somewhat disagree Neither agree nor disagree Somewhat agree Strongly agree 1 2 3 4 5 17. Have you ever taken opioids together with cannabis? (If no, SKIP section) Yes___ No____ 18. When I use cannabis, I don’t need to use as much of my opioids 19. When I use cannabis, I need to use more of my opioids 20. Cannabis has more tolerable side effects than the opioids I am taking. 21. Cannabis has no effect on the opioids I am taking. 22. When I use cannabis, I don’t take opioids 23. Cannabis negatively interferes with the opioids I am taking (i.e., decreases the effect or creates an adverse effect) 24. If cannabis were more available, I would use it in place of the opioids I am taking. C2.4. Substitution Stimulant Questions Participant responses for the following questions go on the 5-point Likert Strongly disagree Somewhat disagree Neither agree nor disagree Somewhat agree Strongly agree 1 2 3 4 5 1. Have you ever taken stimulants together with cannabis? (If no, SKIP section) YES/NO 2. When I use cannabis, I don’t need to use as much of my stimulants 3. When I use cannabis, I need to use more of my stimulants. 4. Cannabis has more tolerable side effects than the stimulants I am taking. 5. Cannabis has no effect on the stimulants I am taking. 6. When I use cannabis, I don’t take stimulants. 7. Cannabis negatively interferes with the stimulants I am taking (i.e., decreases the effect or creates an adverse effect) 8. If cannabis were more available, I would use it in place of the stimulants I am taking. 124 C2.5 Substitution Tobacco Questions Participant responses for the following questions go on the 5-point Likert Strongly disagree Somewhat disagree Neither agree nor disagree Somewhat agree Strongly agree 1 2 3 4 5 1. Have you ever used tobacco together with cannabis? (If no, SKIP section) Yes___ No____ 2. When I use cannabis, I don’t need to use as much tobacco 3. When I use cannabis, I need to use more tobacco 4. Cannabis has no effect on my tobacco use 5. When I use cannabis, I don’t use tobacco 6. If cannabis were more available, I would use it in place of tobacco C2.4 Have you ever used cannabis to help reduce cravings for other drugs? Yes* No *If yes, what other drugs? Section D: Access D.1 Have you discussed the use of cannabis with a medical doctor? - Yes - I raised the issue - The doctor/specialist raised the issue - No - I don’t have a doctor Discussed with other health professional? (who?) D.2. Has your doctor ever recommended you try cannabis? Y/N D.3. Has your doctor ever refused to assist you with getting authorization? Y/N D.4. Have you felt discriminated against by your doctors because of cannabis use? _ Never_ rarely _ sometimes _ often _ always 125 D.5. Have you ever wanted to discuss cannabis for medical purposes with your doctor, but not done so? ___ Yes ____No D.5.1 If not, why have you not discussed using cannabis with your doctor? ___I use other medication(s) and it/they work(s) to relieve my symptoms. ___I want to, but I don’t feel comfortable talking to my medical doctor about it. ___I don’t believe cannabis has any medicinal benefits. ___I cannot afford cannabis. ___I simply do not want to use cannabis. ___I do use cannabis but not for medical purposes. other reason: _______________________________ 126 Section E: Social Norms E.1. What % of each of the following groups do you think use cannabis? 0% 10 20 30 40 50 60 70 80 90 100 People in my community People in my family Close friends Others like me People I would like to be like E.2. How much would each of these groups approve of you using cannabis? Strongly Disapprove Disapprove Neutral Approve Strongly Approve People in my community People in my family Close friends Others like me People I would like to be like E.3. Partner Cannabis Use: • Do you have a romantic partner? • Does your partner use cannabis? Yes/No If yes: o How frequently do they use cannabis? 1x/month 2-3x/month 2-3x/week 1x/day 2-3x/day 4x/day or more • Do you use cannabis together? If yes: o How frequently do you use cannabis together? Always Almost Always Sometimes Rarely Never • What effect does cannabis have on your relationship? Very Positive Positive Neutral Negative Very Negative 127 Section F: Legalization see notes* Canada legalized cannabis for adult use in October of 2018. How has this effected your attitudes and behaviour?: • I did not use cannabis before legalization and I do not intend to use it in the future. • I did not use cannabis before legalization but I expect to use it now that it is legal. • I did not use cannabis before legalization but I have used it since it became legal. • I used cannabis before legalization and have used it less since it became legal. • I used cannabis before legalization and have used it more since it became legal. • I used cannabis before legalization and have used it at the same level since it became legal. *Following asked if: Use: I used cannabis before legalization and have used it less since it became legal. Is Selected. Or Use: I used cannabis before legalization and have used it more since it became legal. Is Selected Or Use: I used cannabis before legalization and have used it at the same level since it became legal. Is Selected. *Access: o I find that it is easier to access cannabis now that it is legal. o I find that it is harder to access cannabis now that it is legal. o I find that accessing cannabis is just as difficult now that it is legal. *Following section asked if: Use: I used cannabis before legalization and have used it less since it became legal. Is Selected. Or Use: I used cannabis before legalization and have used it more since it became legal. Is Selected Or Use: I used cannabis before legalization and have used it at the same level since it became legal. Is Selected. Cost: o I find that cannabis is less expensive since it became legal. o I find that cannabis is more expensive since it became legal. o I find that cannabis is the same price since it became legal. Risk: How much do you think people risk harming themselves (physically or in other ways), if they… 1. Occasional Users No risk Slight risk Moderate risk Great risk Can’t say, drug unfamiliar 2. Regular Users No risk Slight risk Moderate risk Great risk Can’t say, drug unfamiliar 3. Every Day Users No risk Slight risk Moderate risk Great risk Can’t say, drug unfamiliar 128 How has your perception of the risks of cannabis use changed since cannabis was legalized? o I believe cannabis is much less risky now. o I believe cannabis is less risky now. o It has stayed the same. o I believe cannabis is more risky now. o I believe cannabis is much more risky now. 129 Section G: Standardized assessments Brief Composite Cannabis Assessment Tool (BCCAT) INSTRUCTIONS: Please choose the options that best describe your cannabis use over the past six months. 1 Almost Never/Disagree 5 Almost Always/Agree 1. How often do you use cannabis instead of using other drugs (i.e., alcohol, recreational drugs, prescription or non-prescription pharmaceuticals)? 2. How often do you use cannabis to relieve pain? 3. How often do you use cannabis to improve sleep? 4. How often do you have difficulty stopping or controlling your use of cannabis? 5. How often do you use cannabis to relieve nausea? 6. How often do you refrain from taking part in leisure time activities that you originally wanted to do, e.g. going out, sports, hobbies, etc., because of using cannabis? 7. How often do you find that you were not able to stop using cannabis once you had started? 8. How often do you use cannabis to improve mood? 9. How often do you use cannabis because you like the feeling? 10. How often do you use cannabis to think differently? 11. How often do you use cannabis to relax? 12. How often do you feel bad about your cannabis use? 130 131 QUESTIONNAIRE COMPLETE READ: This is the end of the questionnaire. Would you be interested in being contacted for further opportunities like this? Y/N If yes: How should we try to reach you? Contact #1 (phone/email/other) ___________________ Contact #2 (phone/email/other) ___________________ Is there someone else we can contact who could put us in touch with you if you are not at available at that location/ phone # / email Other contact (relationship/ phone/email/etc…) We also welcome your comments and suggestions about your experiences in our study or suggestions for improvements of the treatment system for people who use drugs. Your answers will help to improve our study and also the treatment system. We appreciate your time. 132 Appendix B - Data Sharing Agreement INFORMATION SHARING AGREEMENT – CANNABIS USE ON TURTLE ISLAND: ZAGIME COHORT THIS AGREEMENT is made as of the _______ day of ____________, 20__________. BETWEEN: Zagime Anishinabek ( “Zagime”) AND: Zach Walsh PhD, Psychology, UBC (Okanagan Campus) IK Barber School of Arts, (“UBCO”) (Collectively, the “Parties”) WHEREAS: A. Zagime represents the collective rights and interests of its members, including with respect to their Aboriginal and Treaty rights, title and interests, including the exercise of laws, customs, and traditions; B. Zach Walsh is a Professor of Psychology in the UBC Department of Psychology within the IK Barber School of Arts – Okanagan Campus and leads the UBC research team that will act as stewards of the data. Dr Walsh is a co-lead investigator on a prior UBCO Behavioral Research Ethics Board (BREB)-approved and externally funded (by the Canadian Centre on Substance Use and Addiction (CCSA)) study of cannabis use among self-identified Indigenous adults in Canada titled the Cannabis Use on Turtle Island (CUTI) project. The proposed study is an extension of that study that will recruit participants from Zagime. The new relationship between Zagime and UBC will undergo review by the UBCO BREB as an amendment to the authorized study – this document will be included in the submission. The research results will be analyzed by Dr Walsh and his team and will be combined and compared with the data already collected. These data may comprise part of publications and an MA thesis to be completed by a graduate student with Dr Walsh’s supervision. All analyses using data from Zagime will be reviewed and authorized by representatives of Zagime. Dr Walsh and his team will conduct analyses requested by Zagime and assist with the development of research reports and related materials as specified by Zagime. C. The Parties have mutual needs for a common information base to support understanding of cannabis use for therapeutic purposes among Indigenous adults in Canada. Specifically, determining the extent to which cannabis use serves as a strategy to address unmet health needs such as chronic non cancer pain and to reduce use of other medications and drugs is essential to accurately estimating the true public health consequences of changes to cannabis regulation and access. To date, little to no 133 research has explicitly examined the extent to which cannabis use among Indigenous individuals represents medical or substitution intentions. The process of legalizing cannabis in Canada has been criticized for excluding and overlooking the concerns and perspectives of Indigenous communities. Despite this marginalization, Indigenous communities located across Canada have developed independent and distinctive approaches to regulating cannabis. Optimization of these approaches requires appropriate data. D. Zagime has indicated interest in partnering with Dr Walsh and his team to make use of the existing study infrastructure (materials, interviewers, BREB etc…) to collect information from their citizens and to inform future directions in Indigenous-led and all other cannabis research. Zagime representatives will assist with recruitment of citizens to complete the interviews. Dr Walsh and his team will collect and analyze the data. The data will be stored for long term by Zagime. E. UBCO wishes to use the Information for the purposes of extending ongoing research and providing research training opportunities for students. F. The Parties wish to ensure that Zagime’s data is managed in a manner that meets applicable laws and standards regarding personal privacy, and meets Zagime’s expectations and interpretation of First Nations’ Ownership, Control, Access and Possession (OCAP®) of First Nations’ data; G. Zagime is compelled to state and reinforce the principles of Bimadiziwin concerning the shared burdens of responsible use and stewardship of knowledge in this exchange of knowledge throughout the relationships that transpire. H. by way of this Agreement, the Parties will manage the use and disclosure of certain data, including Zagime’s data. NOW THEREFORE THE PARTIES AGREE AS FOLLOWS: DEFINITIONS 1. For the purposes of this Agreement, a. "Information" means any Traditional Knowledge or Raw Data whether commercial, technical or cultural, including, know-how, data, processes, databases, tables, lists, designs, photographs, drawings, specifications, samples, geographic, co-ordinates, spatial information, species numbers and names, whether disclosed in writing, orally, by visual means, or in any other form, to UBCO by or on behalf of Zagime, either directly or indirectly, or otherwise learned or obtained by UBCO from its dealing with the disclosing party in Cannabis Use on Turtle Island (CUTI) – Zagime Cohort, but not including information that was already known to UBCO as evidenced by written record pre-dating disclosure by Zagime. b. "Project" means all data and associated analyses using data collected from citizens of Zagime. The project will include academic publication and theses to be completed by Dr Walsh and his team. These data will also be analyzed according to the needs of Zagime representatives. 134 c. “Raw Data” means all survey responses. A copy will be held in accordance with BREB privacy requirements (i.e. password protected secure computer) by Dr Walsh’s team at UBC for sufficiently long to complete analyses (approximately 3 years), after which time they will be erased. A copy will also be held by representatives of Zagime for at least 5 years and as long as they see fit. d. “OCAP®” refers to First Nations principles of Ownership, Control, Access and Possession (OCAP®), which represent the assertion of First Nations rights to govern information collected from and pertaining to First Nations. OCAP® mandates that First Nations control why, how and by whom information is collected, used or shared. It respects community privacy rights in the same way that individual privacy rights are valued. e. ‘First Nations’ for the purpose of this agreement refers to Zagime Anishinabek First Nation. PURPOSE FOR DATA SHARING 2. Dr Walsh and his team are engaging in this project to further knowledge on Indigenous medical and nonmedical cannabis use as this is a recognized gap in the literature. These data will supplement the recently completed data collection as part of the CUTI project. The analyses may be part of a MA thesis for an Indigenous student health researcher from the CUTI project team and may also be part of publications and other knowledge translation products. AUTHORITY TO SHARE 3. Dr Walsh and his team will ensure that all research processes are reviewed and approved by the University of British Columbia Okanagan campus – Behavioural Research Ethics Board (BREB). Research will be conducted in accordance with OCAP. DESCRIPTION OF DATA 4. A preliminary copy of the interview – as approved in the initial CUTI study and a copy of the BREB application are attached as Appendices. a. Data to be Disclosed by Zagime: Citizens of Zagime will complete confidential interviews with Indigenous researchers supervised by Dr Walsh. b. Data to be Disclosed by the UBCO: Dr Walsh and his team will provide Zagime with all analyses prior to dissemination and will conduct analyses requested by Zagime. Data will be returned to Zagime for long term storage. 135 c. The Parties agree that the Information shared in this Agreement may be collected, stored, disclosed and used strictly for the limited purposes set out in this Agreement. DURATION OF AGREEMENT 5. This Agreement will commence on the date upon which the last of the Parties affixes the signature of an authorized representative and shall terminate on December 30, 2025 or earlier as provided herein. a. The term (the "Term") of this Agreement will commence as of December 30, 2022 and will continue until December 30, 2025 unless terminated sooner under the terms of this Agreement. b. This Agreement may be renewed upon the written agreement of the Parties, for such Term as the Parties agree. c. Either party may terminate this Agreement by giving no less than 30 days notice to the other Party. TRANSFER OF DATA 6. Data will be securely transferred using password protected transfer. AUTHORIZED USE & DISCLOSURE OF ZAGIME DATA 7. Information shall be utilized by UBCO solely for any of the following purposes: Data collected will be combined with extant data for analyses that will form the basis of publications, an MA thesis, and for other knowledge translation products of data sheets and community-facing summaries. SUBSEQUENT USE & DISCLOSURE OF ZAGIME DATA 8. Data requests that might be made subsequent to the initial analysis will be made to representatives of Zagime by Dr Walsh and his team at UBCO. LIMITATION ON COLLECTION, USE, DISCLOSURE AND RETENTION 9. The Parties agree and warrant that the Zagime Data shall be used and disclosed only and strictly for the purposes specified in this Agreement. 10. UBCO shall not, without the prior written consent of Zagime, a. Use or permit the of Zagime Information to be used or disclosed to any person or body, other than as specifically authorized by this Agreement; or b. Directly or indirectly disclose, allow access to, transmit, transfer or make available to any individual, for any use whatsoever, the Information other than to a person who is: 136 i. an employee, independent contractor, research assistant of UBCO, who has a need to know such Information solely for one of the Authorized Uses; or ii. agents or third parties participating in the Project, who has a need to know such Information solely for one of the Authorized Uses; or 11. UBCO shall not, without the prior written consent of the of Zagime, use the Information for any other purposes not authorized by this Agreement, including, but not limited to, any matter being litigated or negotiated by or with Zagime, any First Nation or other Indigenous group. CONFIDENTIALITY & SECURITY 12. All parties are responsible for the security of the Data entrusted to them under this Agreement and shall safeguard the Data against accidental or unauthorized access, disclosure, use, modification and deletion. 13. Upon request, each Party shall provide the other Party with a description of how the security and confidentiality of the Data are protected. 14. The Parties agree to respect and maintain the confidentiality, security and privacy of information according to applicable legislation, policy and standards. 15. The Parties agree that of Zagime data shall be protected in the same manner, and according to the same privacy standards and security measures as if it were personal information. BREACH AND TERMINATION NOTICE OF BREACH 16. Mandatory Self-Reporting of Breach: If a Party breaches any term or condition contained in this Agreement, or becomes aware of any breach by its agents, representatives or third party contractors, it shall immediately notify the other Parties in writing, and the breaching Party shall immediately take steps to remedy the breach. 17. Notice by Non-Breaching Party to Remedy Breach: If a Party has breached this Agreement, any one or more of the non-breaching Parties may by notice in writing, require the breaching Party to immediately remedy the breach. TERMINATION FOR BREACH 18. Notwithstanding section (21), if the breaching Party does not remedy the breach to the satisfaction of the other Parties, any one of the nonbreaching Parties may, by notice in writing, immediately terminate this Agreement. TERMINATION FOR CONVENIENCE 19. Any Party may terminate this Agreement at any time, without cause, upon delivery of not less than one month notice to the other Parties RETURN OR DESTRUCTION OF DATA 20. Upon expiry or termination of this Agreement UBCO will delete the data collected from Zagime, who will retain a copy of the data. 137 21. The Data Steward shall send a letter to the Parties confirming that the destruction/return of data has been completed according to this section. INTELLECTUAL PROPERTY, COPYRIGHT, AND PUBLICATION 22. The data collected from Zagime will be the property of Zagime. As the UBCO Data Steward, Dr Walsh and his team will maintain the data for sufficient time to conduct analyses to incorporate as part of an MA thesis project, academic publication, and other knowledge translation products. The UBCO team will present all results/research to Zagime prior to any dissemination and will provide Zagime pre-publication notices with the right of dissent. GENERAL 23. SURVIVAL OF TERMS: Terms and conditions relating to: creation, use, disclosure and destruction of Zagime Data; and Confidentiality and Data Governance, shall survive the termination and expiry of this Agreement. 24. AMENDMENTS: This Agreement may be amended or terminated upon mutual agreement, in writing, by the Parties. 25. WHOLE AGREEMENT: This Agreement, plus schedules, constitutes the whole Agreement between the Parties unless duly modified in writing and signed by both Parties. 26. LIVING DOCUMENT: The Parties recognize that this Agreement constitutes a living document, with the intention that necessary amendments be made according to the terms herein, as circumstances warrant. NOTICES IN WITNESS whereof, this Agreement has been executed by the Parties by their duly authorized representatives: SIGNED on behalf of Zagime By:________________ Authorized Signatory Name: Title: SIGNED on behalf of UBCO By:________________ Authorized Signatory Name: Zach Walsh, PhD 138 Title: Professor, Psychology, IK Barber School of Arts, University of British Columbia, Okanagan Campus 139 Appendix C - Phase-One Preliminary Results Closing the Gaps Cannabis Research –Report 12-15-2022 For internal CCSA use pending completion of participant consultation Section 1: Key findings List key takeaways (in point form) of the study; how have these results address current knowledge gaps and contribute new evidence towards cannabis policy and regulation - Responders were primarily status holding members of First Nations communities from diverse regions and Nations. In addition to First Nations we also collected responses from a substantial number of Métis respondents - Smoking cannabis flower was the most popular mode of use, followed by edibles. Use of vapes and concentrates was relatively infrequent - We observed roughly equivalent levels of medical and recreational motives among our sample of Indigenous cannabis users, with a large majority of respondents reporting both medical and recreational motives - The most prominent medical motives were similar to those reported in prior studies of medical cannabis users. Key motives were to improve sleep, reduce pain and reduce anxiety - Although there were generally low levels of non-cannabis substance use, using cannabis instead of other drugs and alcohol was a prominent motive for use - A large proportion of respondents discussed medical cannabis use with their physicians - The legalization of cannabis was perceived to reduce stigma and provide access to a greater variety of products, although price remained a barrier - Respondents reported stigma but also reported relatively high levels of acceptance of cannabis use among their own communities - A large proportion of respondents discussed medical cannabis use with their physicians 140 Section 2: General Information PROJECT TITLE: Cannabis use among First Nations Peoples of Turtle Island: Motives for use, substitution and impacts of legalization. 2.1 Original study research questions/objectives In light of these knowledge gaps the proposed study has four interrelated aims: 1) Increase understanding of motives for cannabis use among Indigenous individuals living in BC and Alberta, with an emphasis on assessing both risk for problematic use and potential benefits of therapeutic use for symptoms of chronic pain, anxiety and sleep. 2) Investigate how cannabis use effects the use of other medications and drugs among Indigenous individuals, with an emphasis on potential substitution for opioids. 3) Investigate Indigenous individuals’ perceptions of cannabis access including federal cannabis legalization and Indigenous involvement in the cannabis industry. 4) Assess whether the above are modified by age, gender and residence (e.g. on or off reserve). Section 3: Research Findings Demographics: Most respondents identified as status holding members of First Nations communities (61%), with remaining respondent identifying as Métis (19%) and non-status holding First Nations (18%). Most respondents also identified as residing in an urban area (66%) and a minority reported living on a reserve (16%). A substantial number of respondents reported speaking an Indigenous language at home (22%), including Cree, Wet’suwet’en, Squamish, Nlaka’pamuxcheen, Gitxsanimaax, Mic Maw and Ojibway. The diversity of home communities is reflective of the diversity of Indigenous communities living within the region and included over 40 distinct responses with the most frequent being Treaty 6, Wet’suwet’en, Squamish, Penticton and Ojibway. 141 Motives and modes of use Medical use was reported by 85% (n = 45) of respondents and recreational use was reported by 91% (n = 48) of respondents; 75% of respondents reported both medical and recreational use (n = 40). Consistent with high levels of medical intention 57% (n = 35) of respondents reported discussing medical cannabis use with their doctor. Use of opioids was reported by too few participants to allow for specific examination of opioid substitution as per our initial aims. The following quotes highlight medical and non-medical motives: “A bit of both, helps me deal with mental issues when I am really struggling, trying to just have fun and relaxed when I’m feeling stressed.” “I would say recreational and helps my health, it helps me to be able to function. I think about it as a PTSD survivor so having overcome so many things in my life, I think that probably why I started, and now later this is how I choose to still take care of myself.” Demographics % N Age 18 – 29 32 20 30 – 39 24 15 40 – 49 18 11 50 + 26 16 Gender Female 66 41 Male 31 19 Two-Spirit/Other 13 8 Residence Rural or Remote 23 14 Suburban 10 6 Urban 66 41 Reserve On Reserve 16 10 Off Reserve 84 52 Education High School 21 13 Post-Secondary (Non-University) 24 15 University (Undergraduate) 8 5 University (Graduate) 7 4 Other 40 25 Household Income Less than $30,000 34 21 $30,000 – $60,000 34 21 $60,000 + 11 13 142 “For sure a mood control, it allows me to focus. Otherwise, I have too many things coming at me at once. I feel I can really focus; I feel like I can do a great job. I also smoke it so I can taper the alcohol, and it's been really working.” “Medical mostly, it’s been really rough losing out mom and then COVID and then the residential school and then fires and then the floods. I still don’t feel strong enough to not use it medically.” “Recreational for sure. I've always had back pain, and cannabis is the only thing that has helped. But also, to get high.” “Being a little stoned, pain relief is relaxing, helps me sleep. I am a novelist, it helps me create, cuz I don't feel pain it allows me to do more.” 0102030405060708090100% used monthly or moreModes of useSmoked flower Edible Vape Concentrates02468101214161820% reportingMain reason for useSleep Pain Reduce other substance use Anxiety Trauma Get High 143 Legalization and Stigma I think it’s changed a lot (legalization), somehow, it’s helped a lot of the stigma with older people like my parents - it has helped them accept that 'oh my daughter doesn't want to get drunk every weekend, she just wants to get high.' I also feel safer going in and buying from a dispensary than from a friend or a dealer. I'm happy its legalized but the prices are too much. I'm near a dispensary that has really good prices but now it got raided and shut down. The prices are too crazy. I think it’s important that it became legal, comparing it to alcohol, it didn't make sense. I get my cannabis through provincial cannabis store. It is so much easier; it was hard to get when it was illegal. The selection in the store is huge. Yes absolutely - there will always be that stigma from that older generation because it's always been looked down upon. Having education out there is important on how it can be used properly. Yes - just because of the properties that it has to alter your mind. That's where the elders have that stigma. Sweetgrass is used for external medicine (cleansing rooms and bodies) and cannabis is used for internal state alteration. I come across elders that want to try it. whereas those same people 20 years go would not have agreed with weed. It's looked down upon. There's a stigma around "pot smoker" or "potheads". People who smoke weed are often categorized as space headed or slow or dazed out. Yes, people try to give me lectures on why I shouldn't use it, because I was an outreach worker before and people would say “how can you do this job and smoke cannabis?” It helped me calm down. Descriptive social norms of cannabis use How much would each of these groups approve of you using cannabis? N Mean Standard Deviation My community 61 3.74 .95 My family 61 3.93 1.12 My friends 61 4.62 .64 Others like me 61 4.28 .93 Others I admire 61 3.56 1.13 Approval Scale: 1 = Strongly Disapprove, 2 = Disapprove, 3 = Neutral, 4 = Approve, 5 = Strongly Approve 144 Section 4: Conclusions & Implications 5.1 Interpretation of findings and areas to expand on work; how has this study helped close the knowledge gap in cannabis research? This study is the largest to date to provide a detailed and nuanced account of cannabis use motives and practices among Indigenous individuals. Our findings of high levels of both medical and recreational motives are generally consistent with findings from studies of medical users. High levels of medical intentions among Indigenous cannabis users in our sample suggest the need for further research to refine strategies to accentuate benefit and mitigate risk. This work is a beginning, but we feel it is an important step. 5.2 Address research impact of these findings; how does it affect target population or select communities? This research is novel and used a small and diverse sample. As such findings should be seen as preliminary and indicative of the need for further research in the area. In general, these findings suggest the importance of considering medicinal intention and well-being motives in research on cannabis use among Indigenous individuals. 5.3 Address policy impact of these findings; is there support for current regulations or should certain policies be improved, or new ones set in place? Despite legalization of cannabis use and growing acceptance of medical cannabis use across society, respondents nonetheless identified stigma related to cannabis use. Efforts to reduce stigma may result in more effective communication to reduce harms and maximize potential benefits. Price was also identified as a barrier that should be addressed to ensure equitable access to those who might benefit from cannabinoid therapies. 145 References 1. Diem EC, Mckay LC, Jamieson JL. Female adolescent alcohol, cigarette, and marijuana use: Similarities and differences in patterns of use. Int J Addict. 1994;29(8):987-997. doi:10.3109/10826089409047922 2. Gfellner BM. A Matched-Group Comparison of Drug Use and Problem Behavior among Canadian Indian and White Adolescents. J Early Adolesc. 1994. doi:10.1177/0272431694014001003 3. Elton-Marshall T, Leatherdale ST, Burkhalter R. Tobacco, alcohol and illicit drug use among Aboriginal youth living off-reserve: Results from the Youth Smoking Survey. CMAJ. 2011. doi:10.1503/cmaj.101913 4. Spence N, Wells S, George J, Graham K. An Examination of Marijuana Use Among a Vulnerable Population in Canada. J Racial Ethn Heal Disparities. 2014. doi:10.1007/s40615- 014-0031-5 5. Lake S, Walsh Z, Kerr T, et al. Frequency of cannabis and illicit opioid use among people who use drugs and report chronic pain: A longitudinal analysis. PLoS Med. 2019. doi:10.1371/journal.pmed.1002967 6. Lake S, Kerr T, Buxton J, et al. Does cannabis use modify the effect of post-traumatic stress disorder on severe depression and suicidal ideation? Evidence from a population-based cross-sectional study of Canadians. J Psychopharmacol. 2020. doi:10.1177/0269881119882806 7. Kandel DB. Does marijuana use cause the use of other drugs? J Am Med Assoc. 2003. doi:10.1001/jama.289.4.482 8. Lucas P, Walsh Z, Crosby K, et al. Substituting cannabis for prescription drugs, alcohol and other substances among medical cannabis patients: The impact of contextual factors. Drug Alcohol Rev. 2016. doi:10.1111/dar.12323 9. Lucas P, Walsh Z. Medical cannabis access, use, and substitution for prescription opioids and other substances: A survey of authorized medical cannabis patients. Int J Drug Policy. 2017. doi:10.1016/j.drugpo.2017.01.011 10. First Nations Information Governance Centre. Ownership Control Access and Possession. https://fnigc.ca/www.fnigc.ca/OCAP. Published 2020
Thesis/Dissertation
eng
Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Walsh, Zachary
“It’s a plant and that’s why I think it’s a medicine” : Indigenous perspectives of cannabis use on Turtle Island
Text