Views and practices on medical cannabis of unlicensed providers in Thailand: a qualitative study

Study design

This study is a part of a larger two-phase study; using a mixed-method approach among medical cannabis users and providers in Thailand. The phase-1 study was conducted between October 2019 and February 2020; the first year of the medical cannabis legalization, followed by phase-2 between November 2020 and February 2021. Both phases comprised of a quantitative cross-sectional study, using respondent-driven sampling among medical cannabis users, and a descriptive qualitative approach involving in-depth interview of medical cannabis providers and users and observation of the providers’ practices and their medicines. Data of the qualitative part of both phases were used for thematic analysis. The descriptive qualitative approach, often used to discover the nature of the specific events under study, allows for a comprehensive summarization of views and practices of illegal providers and their services experienced by medical cannabis users, a topic about which little is currently known.¹⁴

Participants

We included 36 medical cannabis providers, who had not been certified by the MoPH as licensed folk doctors in this study. They included 15 folk healers, 9 growers or clandestine producers, who also provided treatment and counseling on using their products, and 12 workers of civil society networks or social media administrators that provided medical cannabis products and advice. Folk healers wishing to get prescription licenses need to be certified by the head of the provincial public health office or the Department of Thai Traditional Medicine and Alternative Medicine of the Ministry of Public Health. Those that meet the following criteria can be nominated by the village committee or local administrative organization for certification: aged at least 35 years, living in the community where the nomination takes place for more than 10 years, having knowledge and competence in promoting and caring for the health of people in the community using Thai traditional medicine wisdom according to their community culture for more than 10 years with admiration of the people in that community, being sane of mind and never having been incarcerated. Although, some of our participants had been practicing as folk healers for many years, they had not been certified; due to inadequate eligibility criteria or they just did not want to; said participants were recruited as unlicensed providers. Participants were eligible for the study if they were aged 18 years or over and willing to participate in the study. Exclusion criteria were set as being intoxicated, cognitively or mentally impaired, or too ill to be interviewed. However, we did not exclude any subject because of any of these reasons.

Purposive sampling was used to recruit participants. First, some key informants, e.g., folk healers who practiced in the community and workers in non-government cannabis advocacy organizations were identified. These informants were then asked to provide contact information of other providers, which could be approached for an interview. In addition, some medical cannabis users, participating in this research, also provided us with the contact information of their providers.

In addition, seven licensed providers, including five medical doctors and two Thai traditional and alternative medicine doctors were also interviewed. Further, 25 medical cannabis users were recruited through snowball sampling, starting from some well networked individuals who were known by the researchers as being medical cannabis users. Participants were recruited until enough participants had been interviewed to achieve saturation of data.¹⁵

Data collection

Participants were first contacted by telephone and invited to participate in the study. Each of four research assistants, who were at least bachelor’s degree graduates with previous experience in qualitative data collection with people who use drugs or people living with HIV in our other research projects, together with DS, KT or MT, who were experienced qualitative researchers, then visited the participants at a location set by them, e.g., home or workplace, and conducted the interviews.

Before the interview, verbal informed consent was obtained, and all interviews were audio recorded. At the times of data collection, most providers and consumers of medical cannabis were considered illegal, the use of written consent form might be perceived by participants to be threatening and treated with considerable skepticism by some participants. Signed informed consent form is the only record linking the subject and the research, and the principal risk would be potential harm resulting from a breach in confidentiality. To ensure the anonymity of participants, eliminating the risk that signatures could be linked to responses, verbal informed consent was obtained before the interview. In addition, the interview involved no more than minimal risk to subjects; therefore, the waiver of document of consent did not affect the rights and welfare of the subjects. Our Institutional Review Board thus waived the requirement for documentation of informed consent and allowed for verbal informed consent for both phases of the study.

The interviewers also made notes on nonverbal communications, which were used to supplement the audio-recorded information during transcriptions to ensure extensiveness of data. The interview was conducted in private and took up to one hour. Some follow-up interviews were also conducted for participants whose data from the initial interview were not complete, or when more clarification was required. The interview guide with open-ended questions and themes developed by the research team was used. We first tested questions included in the interview guide with some medical cannabis providers, such as two folk healers and two staff of not-for-profit medical cannabis organizations, and two users of medical cannabis. The guide covers content on the participants’ practicing experiences in providing, producing or using medical cannabis, source of cannabis, knowledge regarding diseases treated with cannabis, how they obtained this knowledge, and opinions towards medical cannabis laws and policies in Thailand. The guides can be found as Extended data.²⁵ DS, KT and MT participated in the interviews and supervised the process of data collection and data transcriptions.

Data analysis

All interviews were transcribed verbatim by the research assistant who did the interview. DS, KT and MT also listened to some randomly selected interview recordings while reading through the respective transcribed data and field notes to ensure completeness and accuracy of the transcriptions. Qualitative data analysis was conducted manually. DS and SA then read the interview transcripts and notes repetitively, coded and aggregated transcribed text into meaningful themes and subthemes. The other members of the research team then read and discussed initial themes and subthemes until agreement was reached. For each subtheme, supporting quotes were selected to illustrate key points in the findings.

Ethical approval

Both study phases were approved by the Research Ethics Committee (REC) of Faculty of Medicine, Prince of Songkla University [REC.62-205-18-1, dated 7 October 2019] and [REC.63-449-18-1, dated 3 December 2020]. The approval of the waiver of written consent was also documented in the REC approval documents.

Why unlicensed/illicit providers were still popular

Overall, six main reasons were identified for people choosing unlicensed providers and products: 1) easy accessibility to unlicensed or illegal sources; 2) familiarity with the unlicensed providers; 3) favorable characters of the providers; 4) affordable treatment fees; 5) trust in the quality of the medicines; and 6) a lack of knowledge, confidence and negative attitudes towards cannabis from healthcare professionals.

Easy accessibility. Although medical cannabis clinics have been opened nationwide indications for treatment with medical cannabis oil extracts are limited, and accessibility has been poor and slow. Therefore, unlicensed or underground providers, who were more easily accessible, became their best available choice. Folk healers usually opened their practice within their own home where patients could visit them anytime without prior appointment. Some providers allowed their patients to contact them by Line application or telephone for consultation concerning health problems and medication adjustment; making patients feel supported and confident. Some even provided home visits or home delivery of medicine to their patients with limited mobility, such as the elderly or those with physical disabilities.

Familiarity. In some areas, folk healers had been well-known and accepted long before the boom of medical cannabis use in modern society. Using cannabis plants in folk and traditional medicine regimens has been regarded as ancient Thai wisdom. These folk healers, therefore, had already had follow-up with their patients for many years, and these patients preferred to continue treatment with their respectful and trustful doctors, rather than changing to new doctors in MoPH hospitals.

Providers’ characters. The folk healers that were interviewed appeared to be natural counselors, who understood and empathized with their clients’ illness and suffering. They were volunteer-minded and had the same goal as that of to help people. Patients also found the folk healers to be non-judgmental and non-stigmatizing. Almost all folk healers did not record their patients’ information systematically and did not make follow-up appointments with their patients. They just memorized the information and told patients to come back as needed, or they visited their patients at home when convenient. This surprisingly made patients more comfortable, as their information was confidential.

Affordability. Some folk healers - for example, Buddhist monks and those working in some civil society not-for-profit organizations - provided medical cannabis products free of charge for those who could not afford to pay. Folk healers who have been practicing in a conventional way do not usually ask for treatment fees; they accept only a “teacher worship fee”, which is very small. Although medical cannabis treatment in the MoPH hospitals was also free, as it was covered under the universal coverage or other medical insurance schemes, patients had to pay the transportation fee by themselves. Additionally, at the time of data collection of this work, MoPH medical cannabis clinics had yet been opened in every province, so some patients had to travel far to receive treatment. Nonetheless, some unlicensed providers charged for their products and treatment cost was very high; especially those who advertised their services and products through social media.

Quality of the medicines. Some patients believed that the medical cannabis oil extract provided from the MoPH hospital was too low in concentration (say, 1.7%) of active ingredients to be effective, while the oil extract from unlicensed sources was of better quality and could treat more diseases. Most conventional folk healers used the parts of raw plants to make their medicine mixture or extracted the crude oil in their home-kitchen. They may also grow, or suggest patients grow their own cannabis plants, to assure quality, and to keep the plants free from contamination. However, some patients as well as providers also worried about the quality of the illegal products as their sources were unknown, so they might be contaminated, and the production process might neither be so qualified.

Healthcare providers’ lack of knowledge and negative attitudes. One of the main reasons for medical cannabis being limited in prescriptions at public hospitals was due to the clinicians’ attitudes coupled with their readiness to provide it. Although medical cannabis training courses have been organized for doctors, pharmacists and other healthcare professionals to provide knowledge and grant certification for prescribing medical cannabis since the legalization, not many practitioners attended the courses; hence, most clinicians were not well enough prepared for medical cannabis practice. The general attitudes of medical professionals; in particular psychiatrists and pharmacists, were negative, due to concerns over adverse effects of mental health from cannabis use. Additionally, they were of the opinion that safer and more evidence-based medicines were already available for any indications wherein cannabis was to be used. Most medical professionals learn to practice medicine based on scientific evidence and from what they learn in medical schools. However, medical cannabis was new for them and supporting evidence was still limited, while conflicting evidence of benefits and harms was abundant. They were thus reluctant to prescribe medical cannabis. Moreover, there were strict regulations to follow and many forms to fill out when prescribing cannabis; medical cannabis prescription in a public hospital was still very restricted. An experienced and licensed doctor, who supported medical cannabis, expressed that medical professional might be the one who referred patients to the unlicensed or illegal system, because they refused to learn and prepare themselves to prescribe medical cannabis; despite their full awareness that their patients were using it.

How unlicensed providers practiced medical cannabis treatment

Six subthemes were derived, including: 1) how they started their career as medical cannabis providers; 2) roles of the providers; 3) health conditions for which medical cannabis was used; 4) types of products and dosing; 5) use of modern medicine while using cannabis; and 6) progression of illness after treatment with cannabis.

Starting the career. Most providers started their role as medical cannabis service providers from using cannabis as a self-medication for their or their relative’s health problems. After success in treating themselves or their relatives, they felt confident in using cannabis for other people. Some providers were full of interest and enthusiasm in acquiring knowledge on medical cannabis obtained from international published literature, social media, training courses and actual case studies. Moreover, cannabis has been a medicinal herb in Thai traditional medicine pharmacopeia since ancient times. Folk healers have acquired knowledge regarding medical cannabis from their ancestors, who were often folk healers as well. Therefore, folk healers were knowledgeable and experienced in medical cannabis treatment long before the start of medical cannabis within modern healthcare systems.

Providers’ roles. The providers had varied roles, including providing assessment, treatment and counseling as folk doctors, providing knowledge concerning medical cannabis summarized from published literature, being active advocators for legalizing cannabis, and growing, producing and selling medical cannabis products. Buddhist monks played active roles in not only being a spiritual center for local people, but also providing holistic care to patients, from the beginning to the terminal phase of illness; especially those classified as beyond available conventional treatment. Some providers believed that anyone could be a medical cannabis provider, if they cared about people and continued acquiring knowledge about diseases, by learning from research documents and by observing patients’ symptoms and progression.

Health conditions. The health conditions for which cannabis was prescribed by folk healers included: cancers of various organs, Parkinson’s disease, epilepsy, muscle aches, headaches, insomnia, stress, depression, nausea, vomiting, psoriasis, acnes, ringworm, hemorrhoid, diabetes, hypertension, gout, HIV, and as a substitute for other drugs of abuse (methamphetamine and crystal methamphetamine). Terminal stage cancers, such as breast and brain cancers were the most common diseases patients sought out for cannabis treatment; especially when they were beyond available modern treatment or when they were to receive chemotherapy or radiotherapy. Their perception was that cannabis would help prepare the body to tolerate the side effects of such modern treatments. Most providers and their clients believed that cannabis could treat all diseases. Some providers indicated that cannabis balanced the system inside human body and could help relieve all symptoms that patients were suffering, for example: pain, fatigue, low appetite and sleep difficulty. If patients improved from these symptoms they would feel well and have the energy to fight the disease.

Products and dosing. The products forms were various, such as extract oil in liquid form for sublingual administration or in a capsule for swallowing or for rectal suppository, tea made from dried raw plants which was claimed to be a good remedy for insomnia, topical skin cream and soap for skin diseases, toothpaste for toothache and caries, and a mixture bolus of the cannabis plant with other Thai herbs. Some folk healers also prescribed dried plants for smoking. Information related to product forms, route of administration, actions, dosing and sources is widely available on the Internet, through social media and word of mouth, for both providers and patients to learn and adaption of use for themselves, or when prescribing to others.

Some healers advised their clients to start off with a test dose of one small drop of extract oil. If there was no sign of an allergic reaction, the patients were advised to step up the dosage slowly until they found a suitable dose for themselves. They were then advised to maintain that dose until their symptoms subsided, then decrease the dose and finally stop when the symptoms disappeared. Females were advised to take a smaller dose than males. Morning and/or bedtime doses were usually recommended. Most providers emphasized that their clients should not take a second dose of oral extract oil within four hours after their first dose. They said that the action of the oral form was slow: approximately 30 minutes; therefore, if the second dose was taken shortly after the first dose their clients could easily get intoxicated. However, in a smoked form it was fast acting; approximately 5-15 minutes; thus, it was recommended for cases of cancer or severe stress, and for those who had pains or sleep difficulties.

Use of modern medicine. Most folk healers advised their patients to stop or reduce their dose of modern medicine which they had used before. They explained that modern medicine contained a lot of chemicals, causing imbalanced body function, and might impair liver and renal functions. However, some said cannabis and modern medicine should be used together, as cannabis would enhance the effects of modern medicine. Some folk healers viewed that terminally ill cancer patients who required morphine to relieve pain should receive supplementary cannabis, while tapering off morphine until stopping and then maintaining treatment with cannabis alone. Some folk doctors advised their patients to take cannabis and modern medicine at different times, so they would not interact with each other. Some even knew that cannabis was contraindicated for patients with cardiac arrythmia, bipolar mood disorders and those who used psychiatric medicines.

Progression of illness and side effects. After use of medical cannabis, most patients felt markedly better or cured, while some no longer returned to the hospital for treatment. The participants, either providers or patients, believed that cannabis helped users to acquire deep sleep, an increase in appetite and a decreased pain, so the patients’ health and quality of life improved, their symptoms subsided, or their disease was cured. A number of folk doctors were aware of the negative health effects of cannabis; for example, intoxication when overdosing and toxicity when using low-quality products that were contaminated with insecticides or other toxic agents. However, most patients and folk doctors we interviewed had never experienced adverse effects of cannabis use by themselves.

Limitations

Only data from a limited number of medical cannabis providers and users were included. Although we recruited sample to saturation and stopped interviewing new participants when no additional themes emerged in our last interview, our sample might subject to volunteer bias as most of the respondents were positive towards medical cannabis use. This may have led them to report only the positive side of cannabis use, and the unlicensed or illegal services. Snowball sampling was used to reach the participants, so this might limit the participants to the group of those who had similar values towards medical cannabis, and overrepresent supporters of medical cannabis.

Underlying data

The interview transcripts cannot be shared publicly as they contain personal and sensitive information, which could identify the participants. The interview transcripts are all in Thai. Anyone wishing to read the summary report of the data, including quotes may contact the corresponding author (savitree.a@psu.ac.th), who will do translation of the parts requested.

Extended data

Open Science Framework: Views and practices on medical cannabis of unlicensed providers in Thailand: a qualitative study. https://doi.org/10.17605/OSF.IO/PBRHJ.¹⁹

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).