Views on and experiences with medicinal cannabis among Canadian veterans who live with pain: A qualitative study

Figures & data

Table 1. Veterans’ demographic characteristics.

Demographic characteristics	Participants	%
Gender
Woman	4	33
Man	8	67
Race
White	12	100
Age
20 to 39	4	33
40 to 59	6	50
60+	2	17
Years served in the Canadian Armed Forces^a
<20 years	3	25
≥20 years	6	50
Element^b
Army	5	42
Navy	2	17
Air Force	4	33
Trade^c
Combat arms	2	17
Support	10	83
	Range	Mode
Years using cannabis medicinally^d	1–10	4

N = 12, across four focus groups; focus groups 1 and 2 consisted of 4 men each, and focus groups 3 and 4 consisted of 2 women each.

^aThree veterans did not report the number of years served.

^bOne veteran belonged to a purple trade (i.e., a trade not tied to a specific element) and did not specify the assigned element.

^cBelonging to a combat arms trade is no guarantee that a soldier saw combat, nor is belonging to a support trade a guarantee that they did not. For example, a supply tech (a support trade) recounted experiences of coming under enemy fire in Afghanistan during supply runs.

^dTwo veterans did not report the precise number of years they have been using cannabis medicinally.

Table 2. Emergent themes.

Theme
Cannabis use behaviors
1. First time using cannabis is reported to have occurred outside of the military, either before or after military service.
2. Typical duration of cannabis use for veterans is reported to be 4 years.
3. Most veterans report using ingestible forms of cannabis.
Reasons for cannabis use
4. Veterans report using cannabis to manage symptoms of preexisting—often comorbid—medical conditions, chronic pain foremost among them.
5. Veterans report initiating cannabis use to avoid undesirable side effects from prescription opioids and other pharmacological treatments for comorbid chronic pain and mental health concerns.
Outcomes from cannabis use
6. Veterans report being able to replace a number of pharmacological treatments with cannabis, which has led to improvements in their overall quality of life, sleep, relationships, and mood and a reduction in their symptoms.
7. Veterans report experiencing a number of negative side effects from using cannabis, as well as disliking the taste or smell of cannabis oils.
Facilitators of cannabis use
8. Veterans report that the VAC financially supported their request for medicinal cannabis.
9. Veterans report receiving support for obtaining medicinal cannabis from private medical cannabis clinics and the public system.
10. Veterans report receiving most of their information about cannabis from peers.
Barriers to cannabis use
11. Veterans report difficulties locating a family doctor, accessing health care services, and obtaining a stable supply of medicinal cannabis due to supply chain issues, as well as delays in access as a result of switching providers.
12. Veterans report challenges around cannabis travel legislation that limit their travel or restrict their ability to drive.
13. Veterans report lack of support/knowledge within the civilian health care system around cannabis use.
14. Veterans report unclear packaging and product information, as well as difficulty opening the packaging that their medicinal cannabis arrives in.
Stigma around cannabis use
15. Veterans report experiences of systemic stigma in the public health care system, public stigma, and self-stigma.
Questions and concerns about cannabis use
16. Veterans report having questions and concerns about the lack of clarity surrounding proper dosage and how to go about finding the correct dosage to treat specific symptoms without resorting to a trial-and-error approach.
17. Veterans report having questions about the long-term effects of cannabis use and the different terpene profiles found in cannabis.

Table 3. Summary of findings.

Subthemes	Subtheme description	Most representative quote	Count^a
Cannabis use behaviors
Theme 1: First time using cannabis is reported to have occurred outside of the military, either before or after military service.
1.1 First time using cannabis	Veterans report using cannabis for the first time outside of the military, with some using before entering the military (N = 3, n = 4) and others first using after leaving the military (N = 2, n = 3).	“I used a lot of cannabis when I was younger before I joined, completely stopped while I served, and I restarted maybe a month after release.” (F2, V6)	N = 3, n = 4
		“I got it 2013 or 2014, so it was a long time after I left the military, because we didn’t talk about pot in the military.” (F4, V11)	N = 2, n = 3
Theme 2: Typical duration of cannabis use for veterans is reported to be 4 years.
2.1 Duration of current use	Veterans report using cannabis for the past 3 to 7 years (mode = 4 years)	“It’s been about four years now.” (F1, V2)	N = 2, n = 6
Theme 3: Most veterans report using ingestible forms of cannabis.
3.1 Capsules/pills	Veterans report ingesting cannabis capsules/pills.	“I’m taking CBD gel caps.” (F3, V10)	N = 4, n = 5
3.2 Edibles	Veterans report ingesting cannabis edibles.	“I started with the plant smoking and I found that my throat was aggravated by that throat and sinus is so I switched to vaping and that didn’t help much either so I switched to edibles.” (F1, V3)	N = 2, n = 3
Reasons for cannabis use
Theme 4: Veterans report using cannabis to manage symptoms of preexisting—often comorbid—medical conditions, chronic pain foremost among them.
4.1 Chronic pain	Veterans report using cannabis to manage symptoms of chronic pain.	“I find it useful, it controls the pain for me.” (F1, V1)	N = 4, n = 8
4.2 Comorbid conditions	Veterans report using cannabis to manage symptoms from multiple medical conditions.	“My whole body is pretty much just broken from head to toe, same as Veteran 3, you know, crawling under aircraft lift and everything, the whole bit. So I’ve got bad knees, bad feet, bad back, neck, migraines, depression, and that was what got me into the cannabis.” (F1, V2)	N = 3, n = 7
4.3 Musculoskeletal injury	Veterans report using cannabis to manage symptoms resulting from a musculoskeletal injury.	“The legalization of cannabis came at probably a perfect time for me because I was dealing with all the back issues.” (F1, V3)	N = 3, n = 6
4.4 Sleep disturbances	Veterans report using cannabis to manage sleep disturbances and/or improve sleep quality.	“Smoking more or less helps me sleep.” (F1, V4) “The THC for me helps me sleep.” (F3, V9)	N = 2, n = 5
4.5 PTSD	Veterans report using cannabis to manage symptoms of PTSD.	“So with that medical marijuana definitely has impacted me greatly in my progress in dealing with PTSD symptoms, symptom treatment for mental health. […] So this stuff is incredibly effective.” (F2, V7)	N = 3, n = 4
4.6 Depression	Veterans report using cannabis to manage symptoms of depression.	“Five years ago I was suffering from depression which I didn’t know it at the time ’cause I was always angry pushing my family and people away from me stand in my basement and stuff and it was through my psychologist that she—she suggested it because the antidepressant meds just weren’t working.” (F1, V2)	N = 1, n = 4
4.7 Anxiety	Veterans report using cannabis to manage symptoms of anxiety.	“I mostly use CBD for either anxiety, relaxation throughout the day.” (F2, V6)	N = 2, n = 3
Theme 5: Veterans report initiating cannabis use to avoid undesirable side effects from prescription opioids and other pharmacological treatments for comorbid chronic pain and mental health concerns.
5.1 Undesirable side effects from prescription opioids	Veterans report negative side effects resulting from prescription opioid use such as stomach pain, endocrine dysregulation, flat affect, suicidality, and addiction.	“Just like Veteran 11, I cannot do those drugs for pain, it just killed my stomach. So between having pain in my stomach and pain in my joints and everything else, I’m just going to choose the pain in my joints because it’s … at least I know why I have it.” (F4, V12)	N = 3, n = 7
5.2 Undesirable side effects from Gabapentin	Veterans report negative experiences with or effects from using gabapentin for pain management such as suicidality, mental fog, and exacerbation of PTSD symptoms.	“The doctor put me on a drug called gabapentin. It has side effects so I suffered through the minor side effects but I never really read the instructions on it fully and one of the severe side effects is suicidal thoughts … one day driving along I just started driving toward a big truck coming toward me, so that made me realize something is not correct here … went and saw a therapist and she said, ‘This is your problem. That medication.’ … But the problem with the gabapentin made me realize like this isn’t the way to go. So I said to my doctor, … “What about this cannabis stuff? Would that help me?” (F2, V8)	N = 3, n = 3
Outcomes from cannabis use
Theme 6: Veterans report being able to replace a number of pharmacological treatments with cannabis, which has led to improvements in their overall quality of life, sleep, relationships, and mood and a reduction in their symptoms.
6.1 Replaced other pharmacological treatments	Veterans report that they were able to replace multiple pharmacological treatments with cannabis.	“I feel good on this. I have stopped over-the-counter meds, have stopped other medications, so I’m just strictly right now on cannabis. I think that’s good.” (F2, V8)	N = 3, n = 10
6.2 Improved overall quality of life	Veterans report using cannabis has improved their overall quality of life.	“When I’m coming along good and I’m walking, I’m out with the dog and doing my yard work and having … the best day of my life, I’m really happy that the CBD is working its magic.” (F4, V11)	N = 3, n = 7
6.3 Improved sleep	Veterans report that using cannabis has improved their sleep quality and/or duration.	“I use a bit of THC at night because it’s a bit better for the nightmare portion.” (F2, V6)	N = 4, n = 6
6.4 Improved relationships	Veterans report that using cannabis has had a positive impact on relationships with friends and family.	“One thing I’ve found using cannabis is getting my life back, as I’m actually now able to enjoy my grandkids. I’m able to get on the floor play with them and stuff.” (F1, V2)	N = 2, n = 5
6.5 Improved mood	Veterans report using cannabis has improved their mood.	“For my mood, my anxiety, it really helps down. Like, that’s going to calm me down.” (F4, V12)	N = 3, n = 4
6.6 Managed symptoms effectively	Veterans report perceiving cannabis to be an effective medication for the management of their symptoms of chronic pain, PTSD, and tremors.	“I have tremors, oil is going all over the place. So I found CBD capsules. So I started taking them, they’re nice and easy and very helpful. I found the high doses of CBD in them help in calming down the tremors I used to have—bolts of lightning shoot down into my hands my feet and all of that kind of stuff. Ninety percent gone.” (F2, V8)	N = 3, n = 3
Theme 7: Veterans report experiencing a number of negative side effects from using cannabis, as well as disliking the taste or smell of cannabis oils.
7.1 Unpleasant taste or smell specific of cannabis oils	Veterans report that they found the smell or taste of cannabis oils to be unpleasant or unpalatable.	“I started with oil and the taste and the smell was disgusting, so I went with gel caps and it’s basically all I use right now.” (F1, V2)	N = 3, n = 4
7.2 Anxiety, paranoia, and intoxication associated with high cannabis dosage	Veterans report that taking too high a dose of cannabis made them feel intoxicated, anxious, and/or paranoid.	“I get paranoid if I take too much, so I will get paranoid really easy, so that’s always finding that little perfect sweet spots. But, yeah, it’s usually decent.” (F2, V6)	N = 3, n = 4
7.3 General side effects associated with cannabis-use irrespective of dosage	Veterans report that they may experience dry mouth, throat/sinus irritation, increased appetite, and weight gain when using cannabis.	“For me, it’s weight gain. I get the munchies really bad, ’specially in the evening if I’ve been on the cannabis all day, I–my weight has gone up I guess a good 25 to 30 pounds.” (F1, V1)	N = 2, n = 4
Facilitators of cannabis use
Theme 8: Veterans report that VAC financially supported their request for medicinal cannabis.
8.1 VAC coverage	Veterans report obtaining financial coverage for medical cannabis with relative ease through VAC.	“Weirdly enough, getting coverage was super easy. It’s three months of struggle to get my driveway clean, but $1000 bucks of cannabis a month was not even hard. I find it weird, but who am I to judge?” (F2, V6)	N = 4, n = 5
Theme 9: Veterans report receiving support for obtaining medicinal cannabis from private medical cannabis clinics and the public system.
9.1 Private medical cannabis clinics for veterans	Veterans report their experiences with private medical cannabis clinics, which specifically serve the needs of veterans, facilitating prescriptions, reimbursement, scheduling, and the coordination of health care, as well as providing information, social activities, and peer support for veterans.	“I went through CannaConnect here in Kingston just because they helped with all the paperwork, getting the doctor, you know, getting the prescription with Veterans Affairs and the whole bit right, so I didn’t really have to do anything other than show up for doctors’ appointments and still with [CannaConnect] if I have questions or anything you know that there’s a point of contact. I contact her and she’s really quick to respond, give me the answers I need, that sort of thing, and she’s been really helpful.” (F1, V2)	N = 3, n = 7
9.2 Public system	Veterans experience support from the public systems mostly reported in mental health care providers including psychiatrists and psychologists (N =4, n = 4); some also report support from health care professionals including physicians and nursing committees (N =1, n = 2).	“[reading prompt] So who recommended or prescribed it? I believe it was my psychiatrist originally. I was still in … because of my neurological problems, and then also because I was diagnosed with PTSD, severe PTSD. He initially prescribed. …” (F3, V10)	N = 4, n = 4
		“My family doctor was quite prevalent in getting me involved with the medical marijuana.” (F1, V1)	N = 1, n = 2
Theme 10: Veterans report receiving most of their information about cannabis from peers.
10.1 Peers	Veterans report that their primary source of information on cannabis is from peers, family, and/or friends.	“I still have my friends that I see, they’re all using cannabis now, too, so we’re all in the same boat, we’re all getting older, or pain is starting to develop more. We’re all ex-military and sort of been used hard and put away wet and we didn’t get the proper brush down we should have been getting. [I imagine you probably learn a little bit from each other’s experiences using cannabis is that fair to say.] “Oh, yes, yeah, we play on each other’s past the benefits and downfalls as well. I know the edibles really don’t […] work too well for me, but the capsules and the oil do and I’ve got friends where it’s the opposite way, […] so we just use each other.” (F1, V1)	N = 2, n = 4
Barriers to cannabis use
Theme 11: Veterans report difficulties locating a family doctor, accessing health care services, and obtaining a stable supply of medicinal cannabis due to supply chain issues, as well as delays in access as a result of switching providers.
11.1 Difficulty accessing health care	Veterans report experiencing difficulty finding a family doctor or accessing health care services.	“Trying to find a family doctor is next to impossible, they’re totally busy and doctors here right now, we’re actually doing telephone calls, so there’s no office work anymore.” (F1, V1)	N = 4, n = 8
11.2 Supply issues	Veterans report difficulties obtaining a stable supply of cannabis.	“I have a hard time filling [prescriptions] because the only provider … originally my provider was MedReleaf but then MedReleaf got swallowed by the mother company of Aurora, which is out of BC. … I don’t know if all of a sudden CBD has become so popular that’s why they’re never in stock for the stuff that I usually order.” (F3, V9)	N = 2, n = 4
11.3 Difficulty switching providers	Veterans report issues in access due to the difficulties involved in switching their provider of medical cannabis.	“You can switch providers but there is a delay to it and it messes with your order sequence or order timings, I guess, because when you switch from one provider to another provider, your order date then changes and potentially the product you’re ordering can change too, so if one provider doesn’t have what you had before, you’re trying to figure out what’s going to work for you again and then you could go through 2–3 months of trial and experimentation to figure out what’s going to work for you on a new provider.” (F1, V3)	N = 2, n = 4
Theme 12: Veterans report challenges around cannabis travel legislation that limit their travel or restrict their ability to drive.
12.1 Limits travel	Veterans report cannabis medication limiting or restricting their ability to travel between provinces or internationally.	“Travel is a big negative thing, too, because … we want to sell our place here in Canada and start traveling … and that’s … kind of got me worried because I don’t want to go back on opioids.” (F1, V3)	N = 3, n = 6
12.2 Restricts driving	Veterans report cannabis medication restricting their driving.	“The other problem is driving with this 12 hours bottle a throttle type of thing. I know when I was on Percocet the rules are totally different than if you’re on cannabis since they’ve relaxed the laws for the cannabis use now with the medication or the dosage that I’m not–it’s 12 hour bottle to throttle type of thing and you have to plan your trips, you have to know almost in advance which you’re gonna do, either that or you have to cancel your trip altogether.” (F1, V1)	N = 3, n = 3
Theme 13: Veterans report lack of support/knowledge within the civilian health care system around cannabis use.
13.1 Lack of scientific medical knowledge around cannabis	Veterans report perceived lack of medical and/or scientific knowledge around cannabis and its proper use.	“Went back to my family doctor, said, ‘What about this cannabis stuff, would that help me?’ And she kind of looked at me like a deer in the headlights, like, she didn’t know about cannabis and medical uses. She had heard about it, but she didn’t know the details.” (F2, V8)	N = 4, n = 5
13.2 Lack of guidance	Veterans report the perception that there is a lack of guidance from medical professionals and suppliers on how to use cannabis and how much to take.	“[discussing lack of guidance on dosage when starting cannabis] I was pissed because nobody told me. Because I didn’t know. … I learned very quickly ‘no, no, no’ you take a little bit to start, like, I think, what they say 0.5 mL of the CBD. Do that for about a week, and then increase to the next 0.5 and then. Oh! Well! that would have been nice to know before I ended up stoned out of my tree. Thanks. ‘Oh, we didn’t tell you?’ No! You didn’t even give me booklets, pamphlets, or nothing when it started. And I didn’t get angry, I just more or less laughed it off ’cause, you know, what do you do?” (F3, V9)	N = 3, n = 4
13.3 Overreliance on narcotics for pain	Veterans report experiences of being prescribed far more opioids to manage their pain than they felt they needed and that this was done without giving due consideration to alternatives such as cannabis.	“When I fractured my spine, so I fractured my L4 and L5 vertebrae, they immediately went to oxy’s [i.e., Oxycodone]. They said, ‘Here’s a 30 count of oxy, take it. It’s going to make you feel better.’ … I looked at it, I’m like, ‘Should I actually take this or not?’ Fifteen days go by. I go back to another appointment, they’re like, ‘Oh, so did you take did you take the medication?’ I lied to them said, ‘Yes, I did.’ They gave me another 30 count of boxes. It’s just like, like, what the hell are they doing? You can get addicted after taking 30 of those pills, and they gave me 60 in 30 days. I didn’t take them, but, like, this is how preposterous it is.” (F2, V5)	N = 2, n = 5
Theme 14: Veterans report unclear packaging and product information, as well as difficulty opening the packaging that their medicinal cannabis arrives in.
14.1 Product information and packaging	Veterans report confusion due to unclear product information, poor packaging, and difficulty opening the bottles in which their medicinal cannabis is packaged.	“They take me 5 minutes to figure out how to open them, there are more like a kid’s game. It’s like, this is some business and new kid’s game so, yeah, it’s something, when it comes to packaging we need to—it’s they just applied the same packaging we do with everything else.” (F1, V4)	N = 2, n = 3
Stigma around cannabis use
Theme 15: Veterans report experiences of systemic stigma in the public health care system, public stigma, and self-stigma.
15.1 Stigma within the public health care system	Veterans report stigmatizing experiences within the public health care sector around disclosing cannabis use or requesting a medicinal cannabis prescription (e.g., being dismissed as an addict).	“[During] the intake for my nose surgery when I … went through the list of drugs, cannabis, of course, wasn’t a drug anymore, it’s legal, but then when we got to that point where we had to discuss my cannabis use it went from I was a normal person to the look on her face was—she was … suddenly looking at an addict, and I could feel the temperature in the room change. It was bizarre.” (F1, V4)	N = 2, n = 3
15.2 General experiences of stigma around cannabis use within society	Veterans report general experiences of stigma against cannabis within society largely stemming from a prelegalization “War on Drugs”–era mindset.	“I’ll use the example of … my mother-in-law [who] is against cannabis: it’s a drug. [She has a] little older mentality; it’s been illegal [her] whole life. They still see it as a drug. … At one point I walked out of the base hospital with a patch of fentanyl [on] my shoulder, hydromorphone by mouth, and even Vicodin as a breakthrough. So I had three hardcore narcotics that can easily kill you, especially the three together, but she saw it [as] better than using CBD.” (F2, V6)	N = 3, n = 7
15.3 Self-stigma (i.e., the internalization of systemic and public stigma around cannabis use) has had a divergent impact on decision to use cannabis	There was diverging evidence about the impact of self-stigma on the decision to use cannabis, with some veterans reporting an impact on their decision to use (N = 3, n = 5) and others reporting no impact (N = 3, n = 4).	“[Stigma] impacted my start with [cannabis]. I wish I’d started, you know, a couple of years before I actually did, but that was all delayed because of stigma.” (F1, V3)	N = 3, n = 5
		“[Reading prompt] Do others’ perceptions of cannabis impact your cannabis use? No, I could care less what other people think about it because I’m not taking a long list of drugs anymore and it helps me substantially.” (F3, V10)	N = 3, n = 4
Questions and concerns stemming from a lack of resources to obtain accurate information on cannabis use and potential risk
Theme 16: Veterans report having questions and concerns about the lack of clarity surrounding proper dosage and how to go about finding the correct dosage to treat specific symptoms without resorting to a trial-and-error approach.
16.1 Challenges surrounding proper dosage	Veterans are concerned by a lack of clarity surrounding proper dosage, difficulty finding the right dosage, and/or having to use trial-and-error to find the correct dosage.	“I think I had some ups and downs with it to get the dosage right, but now that it is [right] it seems to be working fairly well. Not as good as I wanted it to, but I think it’s just a matter of tweaking other things too.” (F1, V2)	N = 3, n = 6
16.2 Treating specific symptoms	Veterans report wanting more information about how to use cannabis to more effectively manage specific symptoms.	“That’s the place I would like to be, to see people getting more educated about what is the actual use of cannabis for somebody with PTSD, nightmare, et cetera, compared to ‘OK, so instead of using CBD, we’re going to give you a narcotic for the pain, we’re going to give you an antipsychotic, we’re going to give you this, going to give you this.’” (F2, V6)	N = 3, n = 3
Theme 17: Veterans report having questions about the long-term effects of cannabis use and the different terpene profiles found in cannabis.
17.1 Long-term effects	Veterans report questions and concerns they have about the long-term effects of using cannabis.	“I think the biggest thing that I struggle with is what’s the daily marijuana use going to do to my mind in 30 years? […] I haven’t really been able to see anything or any type of studies or reports actually saying what prolonged marijuana use does to someone’s brain. I don’t know if it’s all just a wives’ tale. I don’t know if they said that to deter people from using marijuana [in the past], right? I think that for me … that’s my biggest question. … Everything else I’m pretty good with, but I think it’s just the long-term impacts of using it [that] I’m interested in.” (F2, V5)	N = 2, n = 6
17.2 Terpene profiles	Veterans report wanting to know more about the different terpenes within cannabis.	“A user’s guide for the terpenes to understand how each one affects the body, because they all have different—they all have different effects.” (F1, V4)	N = 2, n = 3

^aN = number of focus groups in which subtheme was endorsed; n = number of veterans who endorsed subtheme.

Table 4. Themes requiring additional exploration.

Subtheme	Subtheme description	Most representative quote	Count^a
Cannabis use behaviors
Theme 18: Some veterans report taking a moderate quantity of dry cannabis or oil in the morning and/or night, in some cases cannabis alongside other substances, and experimenting with different strains of cannabis.
18.1 Dosage and timing	Veterans report taking 2–3 g of dry cannabis or 0.5 mL of cannabis oil per day, am and/or pm.	“It’s usually after supper around 7:30 and the biggest dose I take on the THC is half a mL is what I take, and that’s enough to help me sleep through the night.” (F3, V9)	N = 2, n = 2
18.2 Polysubstance use	Veterans report using cannabis alongside alcohol or prescription medications for sleep and pain.	“Meanwhile, I was drinking and smoking marijuana the whole time.” (F2, V5)	N = 2, n = 2
18.3 Cannabis strains used	Veterans report using indicas and sativas.	“I went on my voc rehab in September and since then I’ve played around with different sativas and things. I’ve been playing around with different strains and whatnot as well to try and figure out what works better than others.” (F1, V4)	N = 1, n = 2
Theme 19: Some veterans report using multiple forms of cannabis together, as well as using oils, smoking, nasal sprays, and creams.
19.1 Multiple forms	Veterans report using multiple forms of cannabis concurrently.	“So it was basic medical marijuana. There was no fun stuff or anything like that, it was the drops and little vape pens and that was it. Oh, and tablets that had the pot inside it.” (F4, V11)	N = 2, n = 2
19.2 Oils	Veterans report using cannabis oils.	“My main go-to in the cannabis world is CBD oil.” (F3, V9)	N = 2, n = 2
19.3 Smoking	Veterans report smoking cannabis.	“I do smoke—I do smoke a fair bit of flower.” (F1, V4)	N = 1, n = 1
19.4 Nasal spray	Veterans report using cannabis nasal sprays.	“When I get migraines I’m able to manage it with—with a nasal spray meant for migraines, and with the THC it keeps it enough that I’m not going to be lying in my room with a pillow over my head for 8 hours.” (F1, V2)	N = 1, n = 1
19.5 Topical forms	Veterans report using topical cannabis products (e.g., creams).	“I and a lot of other veterans that I know get that go through Spartan Wellness is pain creams. … One is for muscles and one is for joints. … It really does help myself and many others.” (F3, V10)	N = 1, n = 1
Reasons for cannabis use
Theme 20: Some veterans report the need for frequent dose adjustments of their opioid medications as a reason for switching to cannabis.
20.1 Need for frequent dose adjustment of opioid medication	Veterans report that they had to frequently increase the dose of their opioid medication to manage their symptoms.	“The opioids are no longer working, so I go on higher and higher doses, and I was just becoming a BLOB on the couch.” (F1, V3)	N = 1, n = 2
Theme 21: Some veterans report negative experiences with selective serotonin reuptake inhibitors (SSRIs) and nabilone as reasons for switching to cannabis.
21.1 SSRIs	Veterans report negative experiences with or effects from using SSRIs to manage symptoms of depression.	“The SSRIs pretty much turned me into a sociopath. I had almost no emotional—I’m registering with almost anything it would have to be almost through the roof for me to even sort of acknowledge that there should be an emotion reacted with this, whereas with cannabis, you know, what if it’s a sad movie, I’ll cry just straight up. I mean, that’s the biggest thing I’ve noticed is that I’m actually able to feel my emotions.” (F1, V4)	N = 1, n = 1
21.2 Nabilone (synthetic THC)	Veterans report negative experiences with or effects from using nabilone.	“Initially I was on the synthetic THC. […] Nabilone, I think. I was so sick for years, couple of years, because of taking this medicine that was helping me, plus I was taking all kinds of other medicines and gabapentin. […] I had a long slew of medications and I was just desperate to … because I was so rough. I was suicidal, it was all bad. I was desperate for anything. He suggested [cannabis].” (F3, V10)	N = 1, n = 1
Outcomes from cannabis use
Theme 22: Some female veterans report inconsistent effects from cannabis use, which was not reported in male participants.
22.1 Inconsistent effects reported by females	Female veterans report inconsistent effects from using cannabis.	“So, yeah, for me it’s the only thing is barely finding a way to understand how it can help me better, because it’s very sporadic. Sometimes it helps, sometimes it doesn’t.” (F4, V12)	N = 2, n = 2
Theme 23: One veteran reported cannabis interacting with other medications.
23.1 Interactions with other medications	Veterans report having negative experiences with cannabis interacting with other medications.	“So I put in a vape and I started out like 6% THC and stuff like that, and I got up to 13% THC, and at the same time a medical condition, non-military-related one, I had new medication. Well there is a conflict between the CBD or the THC and this new medication. I ended up in hospital. So, like, this was me trying to figure out my doses.” (F2, V8)	N = 1, n = 1
Facilitators of cannabis use
Theme 24: Some veterans report obtaining medicinal cannabis through online cannabis dispensaries.
24.1 Online dispensaries	Veterans report ordering/receiving medical cannabis from private dispensaries.	“Like, I buy my stuff through Shoppers Drug Mart, which is absolutely a godsend because they’re really, really helpful. They’re kind and they will take a lot of time, especially some things when I need it because I’m just trying to navigate through this.” (F4, V11)	N = 1, n = 2
Theme 25: Some veterans report receiving cannabis-related information from cannabis companies and social media platforms.
25.1 Cannabis companies	Veterans report that their primary source of information on cannabis comes from cannabis companies.	“I wish that I had met with the people from Spectrum initially, because they’re very knowledgeable. Like, the nurse practitioner I talked to, she’s so knowledgeable, she also knows my condition, which a lot of people are very uneducated about it. Most people are. So I really appreciate that. And just having that wealth of knowledge from them is really great, and I can phone them anytime and they will answer everything and anything.” (F3, V10)	N = 1, n = 1
25.2 Social media	Veterans report that their primary source of information on cannabis comes from social media.	“I’d like to have maybe like once a month or once a week somebody sends me a notification, ‘Did you try this?’ Like, I’m on some other cannabis pages on Facebook and they talk a lot about different things.” (F4, V11)	N = 1, n = 1
Stigma around cannabis use
Theme 26: Some veterans report an absence of stigma around cannabis use among fellow veterans.
26.1 Absence of stigma among fellow veterans	Veterans report not experiencing any stigma around cannabis use from their fellow veterans.	“Yeah, I don’t think there is any negative impact, either. Like, with the friends it’s the same. A lot of them—of my friends are retired people and they’re doing it for fun or some other people are doing it for pain. So it’s something that everybody is talking about, it’s like having a beer nowadays, really. Which is a good thing, in a way.” (F4, V11)	N = 1, n = 1
Theme 27: Some veterans report experiencing self-stigma (i.e., the internalization of systemic and public stigma around cannabis use) when purchasing cannabis from private medical cannabis clinics that they perceive as shady.
27.1 Experience of self-stigma when buying cannabis from private medical cannabis clinics	Veterans report experiencing self-stigma when purchasing cannabis from private medical cannabis clinics they perceive as shady.	“I don’t like—with CannaConnect is to me it feels like it’s a shady drug deal behind, like, illegal drug deal or something because, you know, you have a doctor you’ve never met through video screen doesn’t know your history, I mean, and they’re just willing to write your prescription. It seems so, you know—it just kind of for me it plays on that stigma.” (F1, V2)	N = 1, n = 1
Questions and concerns about cannabis use
Theme 28: Some veterans report having questions about how to transition from other medications to cannabis, the effects of various ratios of THC to CBD, as well as the timing of cannabis consumption.
28.1 Transitioning from other medications to cannabis	Veterans have questions around how to transition from other medications to cannabis.	“With a treatment plan, weaning off of these, you know, terrible, terrible narcotics. I wanna see some more stuff like that. Safe transitioning centers like they’re doing for heroin in Vancouver. I mean, if there can—they can get that approved for a narcotic like heroin as a transitionary thing, I don’t see how we can have dispensaries and no treatment centers with THC CBD.” (F2, V7)	N = 1, n = 3
28.2 Amount of THC vs. CBD	Veterans have questions about the effects/consequences of different ratios of THC to CBD with respect to symptom management.	“Something I’m curious about is the THC/CBD relationship between the two and that you need to have a little bit of THC with the CBD—is that true or not? Or, like, do they need to be a bit of THC with the CBD to make it work?” (F4, V11)	N = 1, n = 3
28.3 Timing of consumption	Veterans have questions about when the best time to take cannabis is.	“I still would like to have one of you guys [health professional] tell me what to do. Take this in the morning, take this at bedtime. Like, I’d like to have just some clear direction.” (F4, V11)	N = 1, n = 1

^aN = number of focus groups in which subtheme was endorsed; n = number of veterans who endorsed subthemes.

Focus group guide.

Part 1: Welcome and introductions 15 min	Facilitators will introduce themselves and give a quick briefing on the project, its stakeholders, and the end goals. Participants will take a few minutes to introduce themselves and share a bit about themselves. “Tell us your name, a bit about your military background, and what you like to do for fun.”
Part 2: Contextual inquiry 60 min	As “prework”, veterans will be asked to reflect on a series of questions, making note of their answers and taking photographs and collecting artifacts where appropriate to help illustrate their experiences. When do you use cannabis? Why do you use cannabis? How does cannabis make you feel? How does cannabis impact your life? In this first activity, we will ask veterans, one-by-one to share their “prework.” After each individual’s presentation, we will ask the group if they have any comments, questions, or reflections. We will probe with: Does “x’s” experience resonate with you? Did you find anything surprising?
Part 3: Veteran-centered research 40 min	Facilitators will then lead participants on a second activity where we will narrow the focus to uncover the research questions that veterans are most interested in getting answers to. We will begin by giving each veteran some time to reflect on the following questions and jot down notes: Reflecting on your individual experience, what do you wish you better understood or knew more about, with respect to cannabis and cannabis use? Consider: How to use it. How others use it. Its impact on various facets of your life. Its side effects. Other things that are important to you that you want to understand. We will then ask each veteran to share their answers, capturing their ideas on Post-its and affinity mapping them on a virtual whiteboard. Once each veteran has shared, we will reflect on the themes that have arisen and probe deeper to fill in gaps and flesh out thematic areas where necessary.
Part 4: Reflect and close 5 min	Facilitators will give the group time to reflect on their experience in the session and make any final comments. Facilitators will then outline next steps in this project and help participants to understand how their participation will propel this research project forward.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author, JR. The data are not publicly available because they contain information that could compromise the privacy of research participants.