Medical cannabis use in the Australian community following introduction of legal access: the 2018–2019 Online Cross-Sectional Cannabis as Medicine Survey (CAMS-18)

Background In 2016, the Australian federal government passed legislation enabling a range of cannabis-based products to be prescribed to patients by registered healthcare professionals. An online survey conducted immediately prior to these legislative changes found that the vast majority of respondents at the time were illicitly sourcing cannabis plant matter, smoking was the preferred route of administration and mental health, chronic pain, and sleep conditions were the most frequently cited reasons for medical cannabis use. This manuscript reports the results of a follow-up survey conducted in 2018–2019, the Cannabis As Medicine Survey (CAMS-18). The goal of this second questionnaire was to examine patterns of use and consumer perspectives regarding medical cannabis use in Australia, 2 years after the introduction of legal access pathways. Methods Anonymous online cross-sectional survey with convenience sample, recruited mainly through online media between September 2018 and March 2019. Participants were adults (18 years or over) residing in Australia who reported using a cannabis product for self-identified therapeutic reasons during the preceding 12 months. The survey measured consumer characteristics, indications and patterns of medical cannabis use, routes and frequency of administration, perceived benefits and harms, experiences and preferred models of access to medical cannabis. Results Data were available for 1388 respondents. The main categories of condition being treated with medical cannabis were pain (36.4%), mental health (32.8%), sleep (9.2%), neurological (5.2%) and cancer (3.8%). Respondents reported using medical cannabis on 15.8 (11.2) days in the past 28, by inhaled (71.4%) or oral (26.5%) routes and spending AUD$82.27 ($101.27) per week. There were high levels of self-reported effectiveness, but also high rates of side effects. There was uncertainty regarding the composition of illicit cannabinoid products and concerns regarding their possible contamination. Few respondents (2.7%) had accessed legally prescribed medical cannabis, with the main perceived barriers being cost, disinterest from the medical profession and stigma regarding cannabis use. Conclusions Chronic pain, mental health and sleep remain the main clinical conditions for which consumers report using medical cannabis. Despite 2 years of legal availability, most consumers in Australia reported accessing illicit cannabis products, with uncertainty regarding the quality or composition of cannabis products.

1. You: your age, gender, level of education and current living and work situations 2. Conditions you have used medical cannabis to treat/cure in the last 12 months 3. How you access and administer cannabis for medical purposes 4. The extent to which you experience benefits (e.g. symptom relief) and/or problems (e.g. side effects, social or legal problems) from your use of medical cannabis. 5. How you would like cannabis products to be available for medical reasons in the future 6. Your general health and recent use of other substances.
For further details and instructions please read the participant information statement attached here.
[Attachment: "ParticipantInformationStatement_CAMS18.pdf"] Please indicate your eligibility for the study below: I am an Australian resident over the age of 18 who has used cannabis for MEDICAL reasons in the last 12 MONTHS. Click here to confirm.
I have read the Participant Information Statement Informed consent and understand the nature of my involvement in this study. I understand that I can withdraw from involvement at any time by exiting the server browser. In this case my data will not be saved or analysed. I also understand that I can save my responses and return to complete this study at a later time. To do so I must record the User ID code provided when I select the "save and return" option at the end of any page. Click here to agree.

3.2.calc __________________________________
The age you entered as the age you first used cannabis for MEDICAL reasons is lower than the age you first tried cannabis for ANY reason. This does not make sense. Please think carefully and adjust your answers accordingly.
3.3 How old were you when you first started using cannabis REGULARLY for ANY reason? (at least once __________________________________ per week for a period of three months or longer).
(years old (in numbers). If you have never used cannabis regularly please enter '0') If you have never used cannabis REGULARLY please enter '0'

3.3.calc __________________________________
The age you entered as the age you first used cannabis REGULARLY is lower than the age you entered as the age you FIRST TRIED cannabis. This does not make sense. Please think carefully and adjust your answers accordingly.
3.4 How old were you when you first started using cannabis REGULARLY for MEDICAL purposes? (at least __________________________________ once per week for a period of three months or longer).
(years old (in numbers). If you have never used cannabis regularly for medical reasons please If you have never used cannabis REGULARLY for MEDICAL enter '0') reasons please enter '0' __________________________________ __________________________________ The age you entered as the age you first used cannabis REGULARLY for MEDICAL purposes is lower than the age you entered as the age you FIRST used cannabis for MEDICAL purposes. This does not make sense. Please think carefully and adjust your answers accordingly.

3.4.calc __________________________________
The age you entered as the age you first used cannabis REGULARLY for MEDICAL reasons is lower than the age you entered as the age you first used cannabis REGULARLY for ANY reason (medical reasons are included in any reason). This does not make sense. Please think carefully and adjust your answers to these questions accordingly. In the previous question you entered '0', indicating that you had NEVER used cannabis for ANY reason REGULARLY, yet you have given a value greater than 0 for the age you began using cannabis REGULARLY for MEDICAL reasons. This does not make sense. Please think carefully and adjust your answers to these questions accordingly.
3.5 Which of the following best describes your use of I had not used cannabis before using it for cannabis before you used it for medical reasons? medical reasons I had used cannabis for non-medical reasons but had quit for a year or more before taking up cannabis use for medical reasons. I was using cannabis for non-medical purposes at the time I started using it medically. (select one option) 3.5.aPlease estimate the time, in months, between your last non-medical use of cannabis and starting __________________________________ medical cannabis (number of months (e.g. if one year and two months enter '14')) 3.6 In the last 28 days, please estimate how many days you used cannabis for ANY reason: __________________________________ (enter (0-28)) 3.7 On an average day that you use cannabis for ANY reason, on how many occasions do you usually use __________________________________ cannabis (how many times a day)?

3.8.a __________________________________
The value you entered for number of days using cannabis for MEDICAL reasons is greater than your entry for the number of days using cannabis for ANY reason (i.e. including medical). This does not make sense (days' use MEDICAL can only ever be equal to or less than days' use for ANY reason). Please adjust your answers to these questions accordingly.
3.9 On an average day that you use cannabis for MEDICAL reasons, on how many occasions do you usually use __________________________________ cannabis (how many times a day)?

3.9.a __________________________________
The value you entered for number of times per day you use cannabis for MEDICAL reasons is greater than the value you entered for number of times per day for ANY reason. This does not make sense (times used per day for MEDICAL reasons must always be equal to or less than times per day for ANY reason). Please adjust your answers to these questions accordingly. 3.18 When using your usual dose of medical cannabis how long does it take to achieve its MAXIMUM effect __________________________________ (e.g. relief from symptoms)?

3.18calc __________________________________
The time you entered as the time it takes for you to feel the MAXIMUM effect of cannabis is lower than the time you entered as the time it takes you to feel ANY effect. This does not make sense. Please adjust your answers accordingly.
3.19 When using your usual dose of medical cannabis how long would you estimate its effects last for (i.e. __________________________________ how long before you no longer feel any effects)?

__________________________________
The time you entered as the time it takes until you NO LONGER FEEL ANY EFFECTS is less than the time you entered as the time it takes for you to feel ANY effect. This does not make sense. Please adjust your answers to these questions accordingly.

4.4.aYou indicated you have used Opioids to treat health
Markedly decreased (by 50% or more) conditions that you now use medical cannabis to Moderately decreased (by 20-50%) treat. Which of the following best describes how More or less stayed the same (no change greater your use of Opioids has changed since using medical than 20% each way) cannabis?
Moderately increased (by 20-50%) Markedly increased (by 50%) Since using medical cannabis my use (either frequency (select one option) and/or dose) of Opioids has:

4.4.aYou indicated you have used Benzodiazepenes to treat
Markedly decreased (by 50% or more) health conditions that you now use medical cannabis Moderately decreased (by 20-50%) to treat. Which of the following best describes how More or less stayed the same (no change greater your use of Benzodiazepenes has changed since using than 20% each way) medical cannabis?
Moderately increased (by 20-50%) Markedly increased (by 50%) Since using medical cannabis my use (either frequency (select one option) and/or dose) of Benzodiazepenes has:

4.4.aYou indicated you have used Antidepressants to treat
Markedly decreased (by 50% or more) health conditions that you now use medical cannabis Moderately decreased (by 20-50%) to treat. Which of the following best describes how More or less stayed the same (no change greater your use of Antidepressants has changed since using than 20% each way) medical cannabis?
Moderately increased (by 20-50%) Markedly increased (by 50%) Since using medical cannabis my use (either frequency (select one option) and/or dose) of Antidepressants has: 29-10-2018 12:17pm www.projectredcap.org Confidential Page 21 of 38 4.4.aYou indicated you have used Antipsychotic medications Markedly decreased (by 50% or more) to treat health conditions that you now use medical Moderately decreased (by 20-50%) cannabis to treat. Which of the following best More or less stayed the same (no change greater describes how your use of Antipsychotic medications than 20% each way) has changed since using medical cannabis?
Moderately increased (by 20-50%) Markedly increased (by 50%) Since using medical cannabis my use (either frequency (select one option) and/or dose) of Antipsychotics has: 4.4.aYou indicated you have used Anticonvulsants to treat Markedly decreased (by 50% or more) health conditions that you now use medical cannabis Moderately decreased (by 20-50%) to treat. Which of the following best describes how More or less stayed the same (no change greater your use of Anticonvulsants medications has changed than 20% each way) since using medical cannabis?
Moderately increased (by 20-50%) Markedly increased (by 50%) Since using medical cannabis my use (either frequency (select one option) and/or dose) of Anticonvulsants has:

4.4.aYou indicated you have used Gabapentinoids to treat
Markedly decreased (by 50% or more) health conditions that you now use medical cannabis Moderately decreased (by 20-50%) to treat. Which of the following best describes how More or less stayed the same (no change greater your use of Gabapentinoid medications has changed than 20% each way) since using medical cannabis?
Moderately increased (by 20-50%) Markedly increased (by 50%) Since using medical cannabis my use (either frequency (select one option) and/or dose) of Gabapentinoids has:

4.4.aYou indicated you have used Non-Steroidal
Markedly decreased (by 50% or more) Anti-Inflammatories (e.g. ibuprofen, paracetamol) to Moderately decreased (by 20-50%) treat health conditions that you now use medical More or less stayed the same (no change greater cannabis to treat. Which of the following best than 20% each way) describes how your use of Non-Steroidal Moderately increased (by 20-50%) Anti-Inflammatories medications has changed since Markedly increased (by 50%) using medical cannabis?
(select one option) Moderately decreased (by 20-50%) More or less stayed the same (no change greater than 20% each way) Moderately increased (by 20-50%) Markedly increased (by 50% or more) (select one option) 4.6 On how many of the last 28 days did you consume alcohol __________________________________ ((0-28)) 4.6.aPlease estimate how many standard drinks you consumed per day (on days when you drank). __________________________________ (In standard drinks. ) Guide: 285 ml of beer, 425 of light beer, 100ml of wine, 60ml of fortified wine and 30 ml of spirits, all = 1 standard drink.

SIDE EFFECTS
Indicate below whether you have experienced any of the following side effects in the last 12 months when using medical cannabis, and, if so, how serious these side effects were.

Note: 'Mild and Tolerable' = symptoms that caused only mild impairment of function and do
not require specific treatment (e.g. other medications or stopping medical cannabis); 'Severe and/or intolerable' = symptoms that caused impairment of function, and/or resulted in either other treatment (e.g. other medications) or resulted in stopping medical cannabis use.

GENERAL HEALTH and QUALITY OF LIFE
The following three questions assess your psychological health, physical health, and overall quality of life over the last 28 days.
Please answer on a scale from 0 to 10, with 0 being very poor and 10 being very good. Is there anything we have not asked that you would like to add in regards to your experience of medical cannabis? (Please do not disclose identifying __________________________________________ information such as names) Please feel free to attach any further comments/feedback on this study