Psychometric properties of a self-administered oral health literacy questionnaire for Brazilian adolescents.

Cannabis is the most used illegal drug in the United Kingdom, with 7.6% and 6.8% of adults in England and Wales reporting past-year use in 2023 and 2024 (Office for National Statistics, ). In addition to using cannabis for nonmedical (or ‘recreational’) use, cannabis can be consumed for therapeutic benefits. Evidence for the effectiveness of cannabis for physical and mental health conditions is limited (Freeman, Morgan, & Hindocha, ; Hsu et al., ; National Institute for Health and Care Excellence, ). Regardless, cannabis is still widely used for potential therapeutic benefits such as pain relief (Kosiba, Maisto, & Ditre, ; Walsh et al., ), with stronger evidence of effectiveness pointing to neuropathic pain, cancer pain, chemotherapy-induced nausea, and multiple sclerosis spasticity symptoms (National Academies of Sciences, ). Cross-sectional surveys among UK adults show that consumers reporting using cannabis for medical reasons were most likely to report using cannabis to manage depression, anxiety, and chronic pain (Couch, ; Erridge, Coomber, & Sodergren, ; Erridge, Troup, & Sodergren, ). Yet systematic reviews and meta-analyses have found no evidence for cannabinoids in treating anxiety and an absence of evidence for depression (Wilson et al., ). In recent years, medical and nonmedical cannabis policies have become more permissive globally (Freeman et al., ). In the United Kingdom, nonmedical cannabis is illegal; however, unapproved/unlicensed cannabis-based products for medical use (CBPM) became legal to prescribe in November 2018. Prescriptions for CBPMs can be obtained from doctors on the specialist register of the General Medical Council, either through the UK’s universal healthcare system, the National Health Service (NHS), or through private, for-profit cannabis clinics (Arjun et al., ). These prescriptions are intended for those who have exhausted other recommended treatment options. Access to prescriptions for CBPMs given through the NHS remains very limited, with the majority accessing through private clinics (UK Parliament, ). Limited prescribing may reflect insufficient evidence of efficacy and safety (NHS England, ). Prescribing an unlicensed product requires the prescriber to accept increased medico-legal responsibilities, which some may be unwilling to undertake (NHS England, ). Moreover, prescribers may be cautious about substances with dependence potential, given historical experiences with drugs such as benzodiazepines, which were widely prescribed before their addictive risks were fully recognized (Lader, ). This legacy may contribute to a more conservative approach among doctors when considering CBPMs prescriptions. In contrast to the small number of consumers accessing CBPMs legally, the use of ‘illegal’ cannabis for medical purposes is widespread (Couch, ; Erridge et al., ). A nationally representative survey estimated that more than one million UK residents consumed cannabis for medical purposes (Erridge et al., ). Thus, there appears to be an unmet demand for medical cannabis among consumers not accessing it legally – perhaps due to limited evidence of efficacy and safety, medical need as assessed by a healthcare professional, affordability, accessibility, or stigma (Case, ; Heeg, Morari, Lynskey, & Turner, ; Wilson & McGrath, ). Beyond patient outcome data from medical cannabis registries, little is known about those accessing cannabis legally via prescription, or those using cannabis for medical purposes but sourcing it illegally, including the types of products consumed. Cannabis contains over 100 cannabinoids, and the primary cannabinoids of interest are Δ9-tetrahydrocannabinol (THC), which is the main psychoactive compound, and cannabidiol (CBD), a compound that is not intoxicating when used alone. The THC concentration of dried flower has increased over several decades (Freeman et al., ). Rising potency is a public health concern due to associations with high-potency products and elevated risk of psychotic disorders and cannabis use disorders (Freeman & Winstock, ; Hall & Degenhardt, ; Petrilli et al., ). The psychoactive effects of cannabis depend on the type of product (e.g. dried flower or ‘processed’ products such as extracts), route of administration (e.g. smoking), and potency. Smoking dried flower with tobacco remains the most common method of cannabis consumption in the United Kingdom; however, evidence suggests diversification toward processed (i.e. non-flower) products, which can enable cannabinoid concentrations higher than those naturally synthesized in the plant (Hammond, Wadsworth, Reid, & Burkhalter, ). It is unclear whether the patterns in the broader UK cannabis market are mirrored among medical cannabis users, or what the implications of such product use may be. Not all product forms are permitted in the legal medical market. Permitted forms of unapproved/unlicensed CBPMs in the UK medical market include dried flower (recommended for vaping), oils/tinctures