The impact of non-medical cannabis legalization and other exposures on retention in longitudinal cannabis research: a survival analysis of a prospective study of Canadian medical cannabis patients

Abstract

Background Despite repeated calls by medical associations to gather evidence on the harms and benefits of cannabis, there are ongoing methodological challenges to conducting observational and clinical studies on cannabis, including a high rate of patients that are lost to follow-up (LTFU). This study explores factors potentially associated with retention in a large prospective study of Canadian medical cannabis patients, with the goal of reducing the probability that patients will be lost to follow-up in future cannabis research. Methods The Tilray Observational Patient Study (TOPS) was a multi-site, prospective study assessing the impact of medical cannabis over 6 months in a broad population of authorized Canadian cannabis patients. The study took place from 2016 to 19, and we conducted a series of exploratory analyses including a Kaplan–Meier survival analysis and logistic regressions to assess the potential association between study retention and variables including patient characteristics, cannabis and prescription drug use, quality of life, and the legalization of non-medical cannabis. Results Overall, 1011 participants were included in this analysis, contributing 287 patient-years of data. Retention was 728 (72%) at 3 months, and 419 (41.4%) at 6 months. Our analyses found significantly lower adjusted odds of retention following legalization (AOR 0.28, 95% CI 0.18–0.41), and in patients that used prescription opioids at baseline (AOR 0.62, 95% CI 0.46–0.85), while increased odds of retention were found in patients with a higher baseline psychological score (AOR 1.43, 95% CI 1.08–1.90) or that used anti-seizure medications at baseline (AOR 1.91, 95% CI 1.30–2.81). Discussion TOPS provided a unique opportunity to examine patient characteristics and other variables that may be associated with retention in prospective medical cannabis studies. Our findings highlight some of the challenges of conducting medical cannabis research at a time when patients have a multitude of cannabis access options, including legal adult dispensaries and a robust illicit market. High LTFU rates can impact the validity of studies, and potentially lead to misestimations of the harms and benefits of medical cannabis use. Despite being a multi-site prospective study, this was a convenience sample, thereby limiting the generalizability of these findings. Additionally, data regarding the use of cannabis was self-reported by patients, so is subject to potential recall bias. Conclusion We found evidence that external policy changes that affect access to cannabis such as the legalization of non-medical adult use and patient characteristics associated with patient physical/psychological capacity can impact retention in prospective medical cannabis studies. Evidence-based strategies to reduce study burden on participants, such as minimizing in-person visits by providing digitized internet-based surveys and phone or telemedicine follow-up options as well as ensuring adequate participant compensation could improve retention. Additionally, policy-related changes aimed at improving access to medical cannabis, including increased cost-coverage and community-based distribution, could encourage patients to remain in the federal medical cannabis program and thereby reduce LTFU in associated studies.

The evolving culture of medical cannabis in Canada for the management of chronic pain

“…There is progressive attrition in numbers noted in cohort studies of MC (Lucas et al, 2021;Sotoodeh et al, 2022). In a Canadian cannabis producer lead cohort study, initiated prior to recreational legalization and extending into the time period of recreational legalization, the retention rate for 1,011 subjects fell to 41.4% at 6 months, with lower odds of retention following legalization (AOR 0.28, 95% CI 0.18-0.41) (Lucas et al, 2021). Similarly, an attrition rate of 75% was noted over a 12-month period for a cohort study of 323 patients with fibromyalgia followed in Canada (Sotoodeh et al, 2022).…”

“…Given the easy access to cannabis, patients see little value to enrolling in a robust scientific study in which a placebo arm is a 50% or 33% possibility depending on the number of treatment groups. There is progressive attrition in numbers noted in cohort studies of MC (Lucas et al, 2021;Sotoodeh et al, 2022). In a Canadian cannabis producer lead cohort study, initiated prior to recreational legalization and extending into the time period of recreational legalization, the retention rate for 1,011 subjects fell to 41.4% at 6 months, with lower odds of retention following legalization (AOR 0.28, 95% CI 0.18-0.41) (Lucas et al, 2021).…”