Analysis: Thousands of Australians are forced to break the cannabis laws. It doesn’t have to be this way.

In his first post for Cannabiz, editor-at-large Rhys Cohen analyses the findings of the 2019 National Drug Strategy Household Survey to find out more about the 97% of Australians who still source their medical cannabis from the black market.

As of July 2020, there are now more than 50,000 Australians who have at some time been approved to be prescribed a medical cannabis product. And the number of active, current prescribed cannabis patients is around 20,000.

It’s relatively straightforward to account for these people because they’ve all been formally assessed by a doctor and approved for use by the regulators. But does seeing a doctor or getting an approval define you as a medical cannabis patient?

What if you’ve tried to find a doctor but none of them have been interested in considering a cannabis prescription? Or the doctor has agreed to seek an approval but you’ve declined because the medication would be too expensive? Perhaps you live in a rural/regional area with limited access to medical services and you know it will all be too hard, so you don’t even bother? Or perhaps you have some other medical, philosophical, or social reason to not pursue a prescription?

Definitions matter

The definitions we use to identify medical vs non-medical cannabis users are important. The more restrictive our definition is, the fewer people are captured in that definition, and the less important medical cannabis becomes. And when assessing medical cannabis policies, if we only consider prescribed users to be ‘true’ medical cannabis patients, we can easily ignore all the many reasons why otherwise perfectly eligible people are excluded, or choose to exclude themselves, from the prescription framework.

At the other extreme, some argue that all cannabis use is medical by definition, but this should be understood as a political argument. It fails to distinguish why certain people use cannabis in particular ways, places, and times, which from a policy standpoint makes it rather useless.  Let’s call this definition ‘it’s all medical’.

Perhaps you, the person using cannabis, are best placed to decide if your use is medical? There are some issues with this definition of course. In particular, very heavy users who experience harm from cannabis might like to believe their use is non-problematically medical. Let’s call this definition ‘self-identification’.

2.5 million Australians used cannabis last year

The National Drug Strategy Household Survey is a large, government-funded survey of Australians which asks them about their drug use. It has been published regularly every three years since 1995 and its findings help inform drug policy development in Australia.

The 2019 survey, published in July 2020, included, for the first time, questions about people’s self-identified medical cannabis use over the prior 12 months. And it helps paint a picture of what a ‘true’ medical cannabis user looks like. The Australian Institute of Health and Welfare has produced a great, plain-English summary of the survey results and you can download it for free here.

You might be surprised to learn that in the 12 months prior, more than 10% of the Australian population over the age of 14 used cannabis at least once. If we subscribe to the ‘it’s all medical’ definition, that’s about 2.5 million Australians who are ‘medical’ users of cannabis.

But when asked about why they use cannabis, 16.3% of respondents said their cannabis use was ‘sometimes medical’. That’s about 400,000 Australians who use cannabis for both medical and non-medical reasons. And most interestingly, 6.8% of cannabis users said they only use cannabis for exclusively medical purposes. That’s about 170,000 people.

If we’re going by the ‘self-identification’ definition, we could argue there are currently 600,000 medical cannabis patients in Australia. And only about 3% of those people (~20,000) are currently prescribed medical cannabis.

Types of Australian cannabis users	Estimated number of users
Used cannabis for any reason (in prior 12 months, age 14+)	2,500,000
Used cannabis exclusively for non-medical reasons (in prior 12 months, age 14+)	1,900,000
Used cannabis for medical and non-medical reasons (in prior 12 months, age 14+)	400,000
Used cannabis exclusively for medical reasons (in prior 12 months, age 14+)	170,000
Current prescribed cannabis users (any age)	20,000

Medical cannabis users are more likely to live in poor areas

If we compare people who use cannabis for medical reasons to people who use cannabis exclusively for non-medical reasons, we can see some interesting trends that might help guide our approach to medical cannabis policy.

Medical cannabis users live in poorer regions than non-medical cannabis users. Some 29% of medical cannabis users live in the poorest regions of Australia, compared with 20% of people who use cannabis for exclusively non-medical reasons.

Why would this be the case? There are several plausible explanations. People often turn to medical cannabis as a last resort for their chronic health condition, and living with a chronic condition can be financially debilitating. This cuts both ways – growing up poor makes you more likely to experience both trauma and chronic illness, which people might end up treating with cannabis.

Beyond the household, poorer regions also have worse healthcare and educational services, which can reduce people’s likelihood of engagement with medical practitioners in general. It’s not hard to image how that kind of environment might lend itself to more informal, community-based caregiving such as medical cannabis. Especially if there are established community beliefs about herbal/non-pharmaceutical therapies.

Medical cannabis users are older and more likely to have a health condition

Medical cannabis users are much more likely than non-medical users to be living with a health condition. If we narrow our focus and only compare non-medical users with those 170,000-odd Australians who use cannabis exclusively for medical reasons, we see our exclusively-medical users are:

• 7.7 times more likely to be living with chronic pain
• 2.4 times more likely to be living with a mental illness
• 2.8 times more likely to be living with very high levels of psychological distress

However, our exclusively medical cohort are also much older than our non-medical cohort, which would contribute to the prevalence of health conditions. In our exclusively medical group, 43% of people are aged 50+, compared with our exclusively non-medical cohort, where only 16% of people are aged 50+.

Does this mean that living with a chronic illness drives older people to seek out cannabis for the first time? There would surely be some people who fit that description. But given how widespread cannabis use continues to be in Australian society, it seems more likely that many of these older, exclusively medical people have used cannabis in some capacity during their life. And as they’ve grown older and their health has deteriorated, they have re-engaged with cannabis and/or their reasons for using cannabis have changed.

Medical cannabis users use different types of cannabis

So the more medical someone’s cannabis use is, the more likely they are to be older, sicker, and living in a poorer area. But to play devil’s advocate, isn’t it possible that these people who claim they only use cannabis for medical purposes are actually just using it for recreation?

Probably not, and for a number of reasons.

One of the other interesting differences between our cohorts is the type of cannabis they use. Some 23% of our exclusively medical cohort report using cannabis oils, compared with only 4.5% of our exclusively non-medical cohort. And on the other side of that coin, 27% of our exclusively medical cohort use flower, versus 51% of non-medical users.

Cohort	Use oil	Use flower
Exclusively medical	23%	27%
Exclusively non-medical	4.5%	51%

This is the same trend we see in the legal prescription system, where oils are vastly more prescribed than flower products. It looks like, even without clinical oversight, non-prescribed medical cannabis users tend to prefer oil products in the same way doctors do.

What does this mean for medical cannabis policy?

A good question to ask when assessing a policy framework is ‘who is this policy for?’ If we limit our definition of a medical cannabis patient to only those who have successfully run the gauntlet of legal access, the framework appears to be working very well. Some people drop off due to cost or a lack of efficacy, but generally speaking, medical cannabis patients (all ~20,000 of them) are quite well served in Australia.

But what about the 170,000 other Australians who use non-prescribed cannabis exclusively for medical purposes? Let alone the 400,000 others who use cannabis for both medical and non-medical reasons? We don’t know how many of these people have tried unsuccessfully to get access, but there are major barriers to their reasonable, clinically approved use of prescribed cannabis medicines. Considering the cohort we are discussing here – older, sicker, and poorer people – these are not trivial issues.

170,000-odd Australians don’t want to be known as criminals. They just want some relief from their pain.

Like many people in our industry, I frequently get referred on to friends of friends whose family member is sick or in pain and looking for relief. They know enough about medical cannabis to think it might help and want to know more about it. A shocking number of them have no idea you can get it legally prescribed. Of those that do, few of their regular doctors (GPs or specialists) would consider even discussing it. And when I explain the costs involved in legal access, they are usually disheartened.

I don’t pretend to know the solutions to all of these issues. But we can start by more comprehensively understanding the scale of the problem. The challenge with non-prescribed medical cannabis use is that it’s illegal and these 170,000-odd Australians don’t want to be known as criminals. They just want some relief from their pain.

And many of them are pursuing this in secret, from the police of course, but also from their doctors. Hundreds of thousands of Australians living with health conditions are taking illegal, unregulated drugs to help deal with medical symptoms, despite a legal and clinically guided process being technically available.

Some 97% of Australians using cannabis for medical reasons are still sourcing it from the black market. It doesn’t need to be that way.

• Rhys Cohen is a cannabis industry thought leader and consultant to the industry. This article also appears on rhyscohen.com.

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