Abstract
Background:
Occupational science and occupational therapy typically perceive occupations as promoting health and well-being. However, this perspective overlooks the many occupations that are viewed as illegal, unhealthy, or risky, such as drug use. Due to its negative association with health, drug use is perceived as not holding significance or meaning in people’s lives.
Objective:
This study explores how individuals perceive and describe the meaning of their cannabis use in the context of their lives, from an occupational perspective.
Methods:
A scoping review was conducted using Levac et al.’ modifications to Arksey and O’Malley’s framework. To examine the peer-reviewed literature, 7 databases were searched using terms related to cannabis and meaning. Descriptive statistics were used to describe the selected studies, and reflexive thematic analysis identified cross-study themes.
Results:
Fourteen studies were selected. Most studies have been published since 2008, with 5 published in the last 2 years. Four themes were identified across the studies: (a) preserving life; (b) navigating the routines of everyday life; (c) understanding the self, identity, and belonging; and (d) expanding the view of the world.
Conclusions:
Cannabis use was revealed in this study as a support for navigating occupational routines and enhancing occupational repertoires and engagement, feelings of belonging, and collective user identities. As such, substance abuse treatment practices, including those provided by occupational therapists, should recognize the potential significance of cannabis use within people’s lives. Using a harm reduction approach, occupational therapists can acknowledge the ways in which clients use cannabis to manage their daily routines, while also focusing on supporting clients to reduce the ill-effects of cannabis. As individuals become more engaged in occupations that are significant in their lives, their need for and meaning of cannabis use may change leading to a possible reduction in its use and a shift in their identity construction.
Introduction
Central to the occupational therapy profession are the beliefs that humans are occupational beings and that engagement in occupation promotes health, well-being, and survival.1 Polatajko et al1 define occupation as “an activity or set of activities that is performed [or engaged in] with some consistency and regularity, that brings structure, and is given value and meaning by individuals and a culture” (p. 19, Figure 1; text in brackets added), while Wilcock and Hocking2 describe it as a “synthesis of doing and being, with the purpose of becoming and belonging”(p. 354). Taken together, these definitions imply that individuals have a need to engage in occupations that hold subjective meaning to support their well-being and identity.
Flow chart of all studies searched with inclusion and exclusion criteria applied.
Meaning has been discussed from various perspectives in occupational science. Meaning is how humans individually interpret an experience or event, and it is identified by individuals based on their needs and desires.3,4 Thus, the meaning assigned to a particular occupation does not always comply with societal norms, but arises from “interests, values, and agency, and is subjectively and uniquely experienced and perceived”5 (p. 69). Importantly, not all occupations contribute to health and well-being, nor are they socially acceptable; however, they may still bring meaning to individuals’ lives3 and reaffirm their identity.
Twinley6 and Kiepek et al7 argue that research related to occupation and well-being has been too narrowly focused. Specifically, research has historically emphasized a positive relationship between occupation and health and well-being, thereby overlooking those occupations that are often viewed as “unhealthy.”7,8 However, recent scholarship proposes that occupations that are commonly viewed as antisocial, criminal, illegal, or risky may hold meaning for those who engage in them and may produce positive outcomes and a sense of well-being, even if they do not promote “good health” in the traditional sense.6,9 Kiepek et al7 suggest the term “non-sanctioned occupations” to describe occupations that are widely considered to be unhealthy, socially unacceptable, or immoral. Few non-sanctioned occupations, or recently sanctioned occupations, and the meanings ascribed to them have been studied, highlighting the need for further research in this area.
One such occupation is that of drug use, with some drugs labeled as sanctioned and other non-sanctioned by society. Although most literature focuses on drug use in relation to its negative effects and addiction, some studies emphasize benefits and meanings ascribed to its use. To drug users, drug use is an occupation as it is woven into the patterns of their daily lives and holds an array of possible meanings, with perceived benefits supporting their well-being and identity. An individual who identifies as a drug user “may find it rewarding in giving him a personal sense of identity . . . being someone”10 (p. 36). Drug use has also been associated with increased social connectedness and self-confidence, as well as a sense of freedom.11,12 Women who are survivors of abuse use drugs to alleviate the emotional and physical pain they face and help them survive.13 In these situations, drug use addresses an individual’s need to escape, navigate social connections, and feel a sense of belonging, which suggest that drug use is indeed an occupation that contributes in various ways to individuals’ well-being, despite having negative effects and being viewed as generally “unhealthy.”
More specifically, accounts of cannabis use also acknowledge its use as an occupation that affords meaning. Cannabis can enhance pleasure and experiences while reducing anxiety and negative affect to support well-being.14 However, cannabis is also known to have both acute and long-term negative effects on cognitive, cardiovascular, respiratory, neural, and psychological functions that vary across individuals,15 accentuating its health risks. Yet with more jurisdictions legalizing cannabis around the world, a shift in views, perceptions, and use has occurred. This shift has led to increased use of cannabis over the past few years as many individuals believe it is safer than alcohol and more socially acceptable than cigarettes.16 Steigerwald et al17 reported that residents of states that had legalized recreational cannabis were more likely to attribute some benefit to cannabis, used it more frequently, and viewed it as safer than tobacco than residents of states where cannabis was illegal or only medically legal. Public health professionals have also noted a shift in public opinion toward legalization, which may be affected by the media’s increasingly favorable portrayal of cannabis and decline in perceptions of its risk.18 These changing perceptions on the use of cannabis means that occupational therapists will increasingly find themselves working with individuals who use cannabis within their daily lives and perceive it as a significant part of their occupational repertoire.19 Thus, understanding the meaning that individuals ascribe to their cannabis use will be critical to help them reduce its harmful effects and manage their use to support their health, well-being, and participation in society.
To our knowledge, no review has been completed on cannabis use and the meanings ascribed to its use from an occupational perspective. Therefore, this scoping review examined cannabis use as an occupation, seeking to understand how individuals perceive and describe meaning when using cannabis.
Methods
The scoping review methodological framework as proposed by Arksey and O’Malley,20 and further refined by Levac et al,21 informed a systematic approach to exploring the meanings that individuals ascribe to cannabis use. Scoping reviews “aim to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available and can be undertaken as stand-alone projects in their own right, especially where an area is complex or has not been reviewed comprehensively before”22 (p. 194). Given that the meanings that cannabis use holds for individuals has, to our knowledge, not been comprehensively studied to date, scoping review methodology appropriately allowed for identification of the extent, range, and nature of the available literature on this topic.20
This framework involves (a) identifying the research question; (b) identifying relevant studies; (c) selecting studies for review; (d) charting the data; and (e) collating, summarizing, and reporting the results. The final step, which involves an optional consultation exercise, was not completed as part of this scoping review.
Identifying the research question
The following research question guided this scoping review: How do individuals who use cannabis perceive and describe the meaning of cannabis use? Although understandings of what constitutes meaning are diverse, in the context of occupation, meaning may be defined as the “qualities of subjective experiences associated with human action or doing”23 (p. 101). The meanings ascribed to occupation—in this instance, cannabis use—are at once individually and socially constituted. That is, meaning is “the personal significance of an event as interpreted by an individual”24 (p. 599). However, individuals’ interpretations of the significance of an event are shaped by the broader context in which one lives and does, including social conventions, beliefs, and attitudes about particular forms of doing.4
Identifying relevant studies
Our research team conducted a comprehensive literature search between the dates of September 23, 2021 and November 2, 2021, using the following databases: CINAHL, Cochrane, Embase, Medline, PsycINFO, Scopus, and Sociological Abstracts. Search terms were identified through examination of the background literature on cannabis use. Boolean operators were used to combine the following medical sub-headings (MeSH) and free text terms related to 2 broad concepts of interest: (a) cannabis use—cannabis, cannabinoids, marijuana, pot, THC, and weed; and (b) meaning—attitude*, experience*, meaning*, opinion*, perception*, perspective*, purpose*, sense of purpose, and view*. The initial search strategy was not limited by language, population, study design, or year. Additionally, this literature search was supplemented by scanning reference lists of included studies and relevant reviews. This literature search yielded a total of 3,449 studies.
Selecting studies for review
The results of the electronic database search and scanning of references from relevant reviews were imported into Covidence, an online review software system. Inclusion and exclusion criteria were entered into the software in list form and were used for screening citations (i.e. titles and abstracts) during level 1 screening and full-text articles during level 2 screening. Studies were eligible for inclusion if they (a) detailed individuals’ lived experiences of cannabis use via any method of consumption (e.g. via smoking, edible ingestion); (b) focused on discussion of the meaning of cannabis use as understood by individuals; and (c) focused on individuals’ own perceptions of meaning (i.e. data were rooted in participant voices and discussions of meaning were not limited to predetermined categories). Studies detailing the experiences of individuals of all ages and of any health diagnosis (if any) were also eligible for inclusion. Studies were excluded if they (a) discussed the use of synthetic cannabinoids; (b) discussed multiple forms of drug use (e.g. alcohol use and cannabis use) without specifically differentiating individuals’ experiences of cannabis use; and/or (c) compared cannabis use to another form of drug use (e.g. prescribed medications used for the treatment of pain). These exclusions were applied to ensure that the extracted data were from studies only about cannabis use and not confounded with other drugs or medications.
All authors (EG, KS, and JD) participated in level 1 screening of study titles and abstracts for inclusion. After removing 750 duplicate studies, 2699 studies were eligible for level 1 screening. Each author independently screened approximately 1795 studies, or 2 thirds of the total. Discrepancies among authors were resolved through discussion and consensus. A total of 79 studies were deemed eligible for level 2 screening, while the remaining 2,620 studies were excluded from the review after level 1 screening.
A similar process was followed for level 2 screening of full texts. Each author independently screened approximately 45 full-text studies. Discrepancies among authors were resolved through discussion and consensus. A total of 14 studies were deemed eligible for data extraction, while the remaining 65 studies were excluded from the review after level 2 screening. The study selection process, including reasons for article exclusion, is further outlined in Figure 1.
Charting the data
Using a data collection chart created specifically for this review using Excel software, key information from the studies included in this review were charted,25 which is a “technique for synthesizing and interpreting qualitative data by sifting, charting, and sorting material according to key issues and themes”20 (p. 15). Data extraction (i.e. direct quotations) for all studies was conducted separately by EG and KS. EG and KS then compared the extracted data to ensure consistency in charting; there were no discrepancies. The extracted data corresponded to the following categories: name of first author, date of publication, article title, name of journal, method of data collection, age, sex/gender, occupational role/identity, diagnosis/disorder, socioeconomic status, culture, ethnicity, location, drug characteristics and location of use, meaning, major themes, and notes. We did not appraise methodological quality of the included studies, which is consistent with guidance on scoping review conduct.26
Collating, summarizing, and reporting the results
Following charting, the 3 authors met to discuss the process for synthesizing the data across selected studies. The data describing the selected studies were organized into 2 tables to capture information about the journal and information about the participants and their demographics. Descriptive statistics were used to calculate frequencies for study date and location of first author.
The thematic analysis followed the main steps of Braun and Clarke’s27 framework, was grounded in the authors’ theoretical stance, and involved prolonged engagement with the data and a reflexive coding process.28 The first steps of analysis involved the 3 authors familiarizing themselves with the data (i.e. quotations) by reading the data extraction charts and then meeting to discuss overriding preliminary themes across the data set that were identified independently from the data following extraction. Following a consensus on these themes, they were transferred to Google Jamboard (2 per Jam page), and each data unit from the selected studies was placed onto its own line of an Excel spreadsheet. EG and JD individually coded each quotation and transferred those codes to relevant preliminary themes on Jamboard or created a new preliminary theme. EG and JD then compared their codes and placement in relation to the themes to ensure consistency. A variation of the thematic map presented in Braun and Clarke27 was created and used to explore the relationships that existed between the identified codes and themes. Themes were then reviewed, collapsed, renamed, and described through further discussion among all 3 authors until all agreed upon the final themes and their descriptions.
The findings of this review are presented from a paradigm that views knowledge as socially constructed, partial, and ever-changing. The authors of this review have attempted to provide sufficient details about the selected studies and the research process to support readers of this review in establishing the transferability of the findings to their context.
Findings
The study aimed to explore the meaning that cannabis users ascribe to the occupation of cannabis use. The selected studies are described followed by the themes across the studies.
Studies selected for the synthesis
Fourteen studies were selected for this review (see Table 1 for study details). Thirteen of the studies were published since 2008, with 5 from 2020 to 2021. The 14th study was published in 1987. Most of the selected studies used participant interviews for data collection; other methods included text analysis and observation. Half of the studies (n = 7; 50%) took place in North America (USA = 5; Canada = 2). Three studies were undertaken in Europe (UK = 2; Sweden = 1); 2 studies in Africa (Nigeria = 1; South Africa = 1), and 1 in each of New Zealand and Australia. Most of the selected studies (12 of 14 studies) were conducted in jurisdictions where recreational cannabis use was illegal at the time of the study (see Table 1). Participants included parents, students, workers, and individuals diagnosed with a physical or mental health condition. Smoking was the main method of cannabis use, and most participants were regular or current users (see Table 2 for details of participants in studies selected for review).
Table 1.
Details of studies selected for review.
| Source | First author location | Status of cannabis legalizationa | Stance of jurisdictions on recreational use at time of study | Design | Method of data collection |
|---|---|---|---|---|---|
| Barbosa-Leiker et al29 | Washington, USA | Medical: legalized in 1998 Recreational: legalized in 2012 |
Legal | Qualitative | Participant interviews |
| Boserman30 | United Kingdom | Medical: legalized in 2018 Recreational: illegal |
Illegal | Phenomenology | Diary entries including text responses to prompts and “creative forms of expression” |
| Bottorff et al31 | British Columbia, Canada | Medical: legalized in 2001 Recreational: legalized in 2018 |
Illegal | Qualitative | Semi structured, individual face-to-face, or telephone interviews |
| Bourke et al32 | Christchurch, New Zealand | Medical: legalized in 2018 Recreational: illegal |
Illegal | Qualitative | Anonymous, semi-structured interviews |
| Cathcart33 | Riverside, California, USA | Medical: legalized in 1996 Recreational: legalized in 2016 |
Illegal | Qualitative study employing multi-method ethnography | Direct observation combined with in-depth participant interviews |
| Childs et al34 | Sheffield, United Kingdom | Medical: legalized in 2018 Recreational: illegal |
Illegal | Qualitative | Face-to-face interviews |
| Costain35 | Adelaide, South Australia, Australia | Medical: legalized in 2016 Recreational: illegal |
Illegal | Qualitative | Unstructured interviews |
| Ekendahl et al36 | Stockholm, Sweden | Medical: legalized in 2012 Recreational: illegal |
Illegal | Qualitative | Discussion thread postings during Flashback Forum and participant interviews |
| Haas and Hendin37 | New York, USA | Medical: legalized in 2014 Recreational: legalized in 2021 |
Illegal | Qualitative | Brief structured interviews and questionnaires; 15 participants were invited to participate in five 1-h open-ended interviews and 2 additional unstructured interviews |
| Harwick et al38 | Seattle, WA, USA | Medical: legalized in 1998 Recreational: legalized in 2012 |
Legal | Qualitative | Six focus groups lasting 1.5 h each |
| Moffat et al39 | British Columbia, Canada | Medical: legalized in 2001 Recreational: legalized in 2018 |
Illegal | Ethnography | In-depth interviews |
| Nelson40 | Uyo, Nigeria | Medical: illegal Recreational: illegal |
Illegal | Qualitative | In-depth, individual interviews |
| Prince41 | Minneapolis, MN, USA | Medical: legalized in 2014 Recreational: legalized in 2022 |
Illegal | Phenomenology | Semi structured interviews via telephone |
| Sehularo et al42 | South Africa | Medical: decriminalized in 2018 Recreational: decriminalized in 2018 |
Illegal | Qualitative | Unstructured individual interviews |
Table 2.
Details of the participants in studies selected for review.
| Source | Age (years) | Gender | Participant description | Ethnicity | Location | Method of cannabis use | Type of user |
|---|---|---|---|---|---|---|---|
| Barbosa-Leiker et al29 | 18-39 | Women | 14 Pregnant; 5 post-partum (up to 3 mo) | Predominantly White | Washington, USA | Smoked cannabis 3 times a day | Regular users |
| Boserman30 | 25-30 (mean = 27) | Men and women | Educated at university level | Italian native speakers | N/A | Smoked cannabis at home, outside of work hours, alone | Regular users |
| Bottorff et al31 | At least 19 y of age (mean = 45) | Men and women | Diagnosis of HIV/AIDS, fibromyalgia, arthritis, mood/anxiety disorders, cancer, neurological disorders, gender dysphoria, HCV, epilepsy, MS, or chronic pain | Predominantly White; other groups represented included Aboriginal, South Asian, and Japanese | British Columbia, Canada | Smoking, eating cannabis and using a vaporizer, tinctures, sprays, or poultices | Long-term and current users |
| Bourke et al32 | 20-60+ | Men and women | Individuals with spinal cord injuries (SCI) | European, Māori | New Zealand | Smoking or edibles | Used cannabis after SCI |
| Cathcart33 | Late 20 s and early 30 s | Men and women | Many are parents | Some participants were White | Mid-Orange County, California, USA | Smoking | Many years of experience |
| Childs et al34 | 16-30 | Men and women | Diagnosis of schizophrenia, paranoid schizophrenia, schizoaffective disorder, bipolar disorder, or first-episode psychosis | White-British and White-British-Irish | United Kingdom | Smoking | Regular users or had regularly used cannabis and stopped |
| Costain35 | 18-65 | Men and women | Comorbid diagnosis of schizophrenia and cannabis abuse | N/A | Australia | Smoking | Regular users |
| Ekendahl et al36 | 20-65 | Men and women | Self-employed, government employee, academic, or blue-collar positions | N/A | Sweden | Smoking | Extensive cannabis experience |
| Haas and Hendin37 | 20-56 | Men and women | Professional, white-collar, or blue-collar positions | White | N/A | Smoking | Heavy users |
| Harwick et al38 | 21-77 (mean = 43) | Men and women | Some participants had a diagnosis of a disability | N/A | Washington, USA | Smoking | Regular users |
| Moffat et al39 | 14-18 | Men and women | Full-time students, “honor role” students and youth considered to be “at risk” who were struggling academically | N/A | British Colombia, Canada | Smoking | Current users |
| Nelson40 | 21-34 | Men and women | Highest level of schooling was secondary education | Indigenous Ibibio ethnic group or ethnic migrants | Uyo, Nigeria | Smoking | Current users |
| Prince41 | 20-25 (mean = 22.4) | Men and women | Differentiating levels of education | Various ethnic backgrounds | USA | Smoking | Current users |
| Sehularo et al42 | 15-35 | Men and women | Diagnosis of marijuana-induced psychosis | N/A | Potchefstroom, South Africa | Smoking | Regular users |
Meanings ascribed to cannabis use
Four themes were identified through a synthesis of the findings presented within the 14 selected studies: preserving life; navigating the routine of daily life; understanding the self, identity, and belonging; and expanding the view of the world.
Preserving life
Many studies highlighted that cannabis was viewed as life preserving or lifesaving by their participants, as without cannabis they would not survive: “I cannot stop taking weed ‘cos it is what makes me survive (Okon)”40 (p. 5). The terms, life preserving and lifesaving, were not used by participants to simply imply that taking cannabis stopped them from dying directly. Instead, cannabis helped them manage their pain, nausea—“To work and survive, I have to take medicine. And I’d rather take something that’s more natural [like cannabis] than, um – like I’m prescribed [anti-nausea medication brand name] (Pregnant woman with other children”29 (p. 470),—and emotions and reinstated control of their lives: “One man matter-of-factly stated that it was a ‘necessary product,’ while another positioned cannabis as life preserving because it reinstated his control and the conduit through which he was able to ‘present [himself] to the world’”31 (p. 772). For participants, survival meant not just “being alive” but instead preserving life to allow living.
In a study by Bottorff et al,31 participants who were living with various pain-related disorders spoke of cannabis as a “lifesaver” (p. 772). Participants viewed cannabis use as a necessity, not just for pain management, but for restoring their daily lives: “A woman in her 30s who had used CTP [Cannabis for Therapeutic Purposes] daily for over 15 years suggested that she had no choice in using cannabis because it enabled her to function each day. When asked what she would do if her access to CTP was lost, she replied, ‘I would die, there’s no doubt in my mind that I would die of my disease’”31 (p. 772). Cannabis gave participants their lives back and capacity to function in the world.
Navigating the routine of daily life
Most participants in the selected studies discussed how cannabis offered them a way of navigating the routines of their everyday lives. For some participants, cannabis use meant having the capacity to re-engage in their lives by decreasing the effects of physical and mental health conditions. Participants in a study by Bourke et al32 spoke of how the pain stopped them from engaging in their daily occupations: “Feeling trapped by pain inhibited the participants’ ability to engage in meaningful activities of daily life, family interactions, social situations, or employment” (p. 3). Using cannabis meant being able to do what they needed to do. One participant described how cannabis helped him continue working with chronic pain: “I started doing a lot of the edibles just because of the pain and having to work in construction every day and deal with it, but you know. The interesting thing is that when people look at me and they think construction, oh my god, you can’t be high at work, I’m not high at work, I’m medicated at work. And so when they think of, you know, for me, I don’t get high anymore . . . It doesn’t happen. There’s not that euphoria anymore. To me it’s just medication. It’s just getting me through the day”38 (p. 397). Others spoke of how cannabis supported their capacity to be a better parent: “I felt like it was consistently helping me calm down and be able to function enough – well enough to parent my 6-year-old as a single parent and, um, deal with that – that kind of heartbreaking circumstances that I was in. And I feel like if I didn’t have cannabis, I wouldn’t be able to function working, going to school, and taking care of my child (Participant #9)”29 (p. 470). Some viewed cannabis use as supporting more stable relationships with their children and intimate partners: “Cannabis use was a means to become a ‘good parent’ or a ‘stable partner’, that is, to fit with social situations that required responsibility and stability”36 (p. 372).
Boredom of life was discussed by many participants who found that life without cannabis was repetitive and often anxiety provoking: “Today he [Lui] didn’t smoke at all . . . sometimes he almost got nervous. Everything that was happening around him was experienced as part of the everyday life. And Lui doesn’t like everyday life. He finds it boring and not at all satisfactory. That’s why he feels in disagreement with the repetitive everyday human activities. He even loses his creativity”30 (p. 437). Participants used cannabis as a way of distracting them from the routine of the day-to-day by blocking out the mundane activities: “Being high made the ordinary situations in life like cooking and housework easier to cope with, and helped her to avoid feeling angry, depressed or bored”37 (p. 341). Many participants also spoke about filling empty spaces of time and place through using cannabis while in nature: “Youth provided eager and passionate accounts of the manner in which smoking marijuana in nature created a liberating rupture from the busyness, noise and pressures of their usual routines”39 (p. 89), or being high while working: “He discovered that [smoking cannabis before going to work] was so much better, that the hours [at work] elapsed much quicker. Perhaps it was because [the joints] made him more detached, distant. And what he needed in that job . . . the most boring and sterile job ever . . . was exactly to be detached and to be able to go into his world where, somehow, the time elapsed faster even if with no rush (Messaggero)”30 (p. 437). For others, it helped to pass the time of farming chores: “One boy expressed how using marijuana helped him ‘float through’ his chores on the farm. Stacking hay and feeding the cows were more relaxing when he was high on marijuana”39 (p. 92). While some participants discussed how cannabis meant giving them the capacity to continue their mundane routines in the day-to-day, others viewed cannabis as removing their concerns about completing their mundane routines: “I don’t worry about life, I’m down, I don’t wash, I don’t comb my hair, I don’t worry about money”42 (p. 5). Overall, cannabis use was viewed as “vital to re-equilibrate the loss of balance and to escape from the suffocating jaws of the everyday routine”30 (p. 438).
The participants in 1 study in Nigeria conveyed how cannabis use was the only way to block out the discrimination and exploitation experienced at work: “Like the kind of work that I do, I have to smoke to be able to do it. I work for park. As in ‘area boy.’ You cannot do it without taking strong things . . . Weed is important to us. You take it before you go out, otherwise people will take you play (i.e. take you for granted)”40 (p. 4). For others, cannabis use meant suppressing the feelings of their street work: “Like we that work on the streets, we take it to like get over the things that we experience. All the bad feelings that you feel because of the work you are doing. You take weed to forget about all of those negative things that affect you. So, we tend to take it too much.”40 (p. 4). While not specifically noting feelings of discrimination, participants in other studies discussed using cannabis to wind down from stress after work: “The participants in our study talked about ‘detaching from work’ and ‘stressing down,’ where cannabis use represented a break from a demanding life”36 (p. 371), or from the stress of family: “When the family came and it was more everyday routines and such, when you got less time for everything, then I got easily annoyed. I guess I’m like that. And when I get annoyed I act out. . . . Then I can have a hit [of cannabis], and then I come down and become calm so I can handle the situation”36 (p. 372).
Although many participants used cannabis to manage pain, boredom, exploitation, and stress, for others it meant enhanced pleasure in activities: “Jed talked about his use as something that could enhance pleasurable activities”34 (p. 705). For many participants, using cannabis changed how an activity was experienced: “I have also used it [cannabis] before going out running, and it becomes a totally different experience. You enjoy the moment more”36 (p. 371). The deepened intensity of the occupational experiences was discussed with safe occupations: “I remember I used to like to smoke because the world felt like a video game. Like everything slowed down and we were in virtual reality. The most simple things were weird. Like shooting pool. It was different and harder and funner”33 (p. 65), as well as riskier occupations: “But I find especially with mountain biking, I’m not sure if I’m actually better but it feels better when I’m stoned. It feels like I’m going faster and it feels like I can sort of like flow over everything and it feels really good”39 (p. 92). Cannabis was discussed as removing the fear associated with risky occupations to help with relaxation to enable a pleasurable occupational experience: “It [snowboarding] just kind of like comes easier I guess you could say, like tricks and stuff. You don’t think about it as much. Like you’ll be at the top of a jump or something and if you’re not stoned, you’ll be like thinking ‘Oh I could get hurt’ or whatever and get all kind of scared. But if you have a puff, you don’t really think about that and you just kind of, I don’t know, it’s hard to explain [laughs]. It just makes it more enjoyable, more fun. You just kind of want to go big or go home, it calms you down and you’re just there to have fun”39 (p. 92). For others, cannabis was discussed by participants as a ritual within their lives, demonstrating the significance of cannabis to the routines of their lives: “The joint is a ritual and one has to know it very well before getting to fully appreciate it” (Lui)30 (p. 439)
Understanding the self, identity, and belonging
Many participants revealed that they first used cannabis because they were with friends who were using it: “I used to hang around with some friends and they encouraged me to try it (cannabis). They told me that I should take it, that it will help me forget some of my worries. . . . I started to take it because of my friends that I had back then”40 (p. 4). Many continued to use it as it was something they did together: “I didn’t use to smoke weed. I use to take only alcohol in parties. It was my former boyfriend who made me take it. He used to bring it home to smoke in the house we were living together. I started smoking weed when we were together”40 (p. 4). Others spoke of always using cannabis alone and being unsure about using with others or out in public: “But I have never tried to use it for any other purpose than being home, an ‘at-home-moment’. So I don’t know what it would be like to do it with a group of friends and go out to a bar”36 (p. 371).
Many participants found that cannabis use helped them to reflect on their own selves and supported their socialization to build social connections. Participants found that using cannabis clarified the truths about themselves: “It’s like a mirror that reflects the image of what you are. It makes you feel the truth; it’s like an oracle (SirM)”30 (p. 438), as well as masking certain negative characteristics of their self: “Being high on marijuana allowed him a measure of respite from his otherwise irascible, driving style”37 (p. 339). Using cannabis helped to improve participants daily social interaction: “It makes me more sociable, ugh, it’s easier for me to talk to people”41 (p. 96), and create better bonds among family members: “it is important to note that the marijuana served as a bonding and a connection that he and his father rarely experienced outside of that context”33 (p. 64), and intimate connections: “The high associated with cannabis stimulates feelings of sexuality and makes one feel more connected to their partner”33 (p. 64). Participants “reported being able to enjoy more social functions as a result of engaging in recreational marijuana usage right before the event, or during the event, if it was permissible”41 (p. 100).
The social network that cannabis use creates was discussed as a shared culture or perspective: “Jed’s experiences of cannabis and his desire to continue smoking it appeared firmly rooted in his social network. His views about cannabis appeared to be a ‘collective user perspective’ because he often referred to himself as ‘we’”34 (p. 706). Participants viewed cannabis use as reflecting their identity: “Cannabis use was described as a goal in its own right, as a natural extension of the participants’ identities (‘I’m just that kind of person’)”36 (p. 372). They found that the identity and its culture fit with their world: “The ‘cannabis culture’ seemed attractive and exciting and provided a desirable identity”34 (p. 706).
Expanding the view of the world
Participants spoke of how using cannabis expands how they see the world and their part in it. Many participants referred to cannabis as a facilitator of creativity: “It certainly increases my creativity. I feel more creative. It gives me more concentration, in a sort of an altered state way”35 (p. 231). Other participants agreed that it supported creativity, but it also could negatively impact performance: “Another participant enjoyed smoking cannabis because he felt more ‘creative,’ but realized that it affected his musical performance, so he did not smoke before playing ‘live shows’”31 (p. 396). Those days that participants did not smoke were noted as lacking creativity: “Today he didn’t smoke at all . . . Lui doesn’t like everyday life. . . . He even loses his creativity (Lui)”30 (p. 437).
For some participants, especially those who experienced psychosis either as a result of marijuana use or pre-existing, cannabis use was viewed as an entry into the spiritual: “It seems that these psychiatric patients believe that people who use marijuana for cultural purposes do not become mentally ill from smoking marijuana, but that smoking marijuana enables them to enter into spiritual activities and grants them spiritual power”42 (p. 5). Those without psychosis also experienced how cannabis expanded their world view and the role of the spiritual within their lives: “The group frequently sees cannabis as a path to spiritual enlightenment and smoking as an act of symbolic protest against what they consider to be a corrupt materialistic world”33 (p. 128). While some participants spoke of using smoking as a protest, participants in 1 study discussed how smoking in nature provided a space where they could feel free: “They expanded on how marijuana helped them to escape the confines of the artificial world and be free in nature.”39 (p. 90). The spiritual experiences from cannabis use were described broadly as changing one’s view of the world: “There is really a spiritual side to it [cannabis use]. And I think it opens you up to a different way of seeing things, ways of like interacting like with things differently in the world. You see it a different way. It brings a lot more realization to things around me, like I start to open up to a lot more of what’s going on around me. And you think a lot more”39 (p. 91).
Discussion
The findings of this scoping review provide important insights into the meaning and significance that users of cannabis ascribe to its use, expanding current understandings of drug use as an occupation, generally. Across the 14 studies selected for this review, participants conveyed that cannabis use was an occupation that held significance for their lives. For some participants, using cannabis meant that they could preserve their lives, particularly in the context of living with chronic illness, so that they could work, socialize, and control the way in which they presented themselves to the world. Additionally, using cannabis meant that some participants could endure the routine and mundane nature of everyday life, suppressing feelings of boredom and achieving a sense of pleasure through leisure. For other participants, using cannabis meant that their worlds were expanded through an enhancement of creativity and spirituality.
Historically, cannabis has been viewed as an illicit drug. As a result, research on cannabis use and policy discourse has predominantly focused on its negative associations with health and well-being,9 highlighting cannabis use as a poor means of coping, as a criminal behavior, and/or as a “gateway drug” eventually leading to the use of harder drugs like cocaine or heroin.43 However, recent changes to the way in which drug use is viewed—particularly related to the creation of supervised consumption sites and the legalization of cannabis use in Canada and several states in the US—has led to the emergence of research focused on understanding drug use as an occupation (e.g. Chang,3 Kiepek et al,7 and Stewart et al8), including exploring the complex reasons as to why individuals use drugs in their everyday lives (e.g. Fratila and Berdychevsky44 and Mey et al45). This shift in the way in which cannabis use is viewed, and thus researched, is reflected in the publication dates of the studies selected for this scoping review. The vast majority of studies in this review were published after 2008 (n = 13), with 5 studies published from 2020 to 2021 alone. The increased publication rate since 2020, as well as the relative absence of related research before 2008, suggests that consideration of cannabis use as an activity which can hold meaning or significance in individuals’ lives is a relatively new phenomenon. It would appear that it has only been within the last 15 years that cannabis use begun to be viewed as a multifaceted activity with complex and nuanced meanings, rather than as simply a negative, illness-producing activity with no possibility of pleasure or leisure significance.9
The recent legalization of cannabis in some parts of the world has led to increased use of cannabis for leisure purposes. The findings of this review support previous research that suggests that individuals use cannabis for enjoyment, pleasure, relaxation, and enhancement of experience(e.g. Fratila and Berdychevsky44). For those who use cannabis recreationally, it may be viewed simply as one occupation of many within their repertoires.19 However, for many of the participants in the selected studies, cannabis use went far beyond a form of recreation. Indeed, most participants self-identified or were identified by researchers as “regular,” “frequent,” “extensive,” or “heavy” cannabis users, often engaging in daily cannabis use (see Table 2), although the recreational use of cannabis was illegal at the time of most of the selected studies. Although some of these participants indicated that cannabis use was, for them, a form of leisure, they also suggested that cannabis use was an integral part of their everyday lives, shaping the ways in which they achieved survival, managed their daily routines, enhanced their sense of self, and engaged with their spirituality.
For participants who used cannabis on a regular basis, the “doing” of cannabis use and the meanings it holds may be understood in relation to the “being” (enacting the self), “belonging” (connecting to a group), and “becoming” (developing and transforming the self) of occupation.2 That is, for many participants in the selected studies, being was accomplished through cannabis use by normalizing their feelings about themselves, navigating the routines of their everyday lives, enhancing the pleasure derived from their everyday activities, and ultimately building lives for themselves beyond just being alive. Similarly, belonging was achieved through cannabis use by forming and retaining connections to social networks. Finally, becoming was accomplished by participants through cannabis use by supporting the development of their skills and abilities, enhancing their creativity, and allowing them to grow in their roles as parents and/or partners. Taken together, the findings of this scoping review suggest that participants’ use of cannabis supported the integration of their occupational routines. For many participants, cannabis use played a crucial role in how they constructed and navigated their everyday lives: for some, it was a means of helping them get through the day, while for others, it was a means of enhancing their experiences of the everyday.
The meanings ascribed to cannabis use by the participants in the selected studies parallel those ascribed to the use of other drugs, including methamphetamine (e.g. Gish et al46), and alcohol (e.g. Jennings and Cronin-Davis47). Specifically, previous studies speak to the ways in which methamphetamine and alcohol use may be understood as a means of enabling the successful navigation of everyday routines. For example, in their study exploring methamphetamine use among gay men, Gish et al46 found that participants’ use of methamphetamine meant that they experienced improved focus, self-esteem, and emotional management in difficult situations, as well as an enhanced experience of activities such as dancing and playing pool. Similarly, in their study of one man’s experience of binge drinking, Jennings and Cronin-Davis47 found that drinking meant that he could de-stress, forget about his problems, escape the boredom of his daily life, and relax. However, the findings of our scoping review move beyond understanding drug use as supporting individuals to perform, participate in, or engage in the activities that they need, want, or are expected to do. Our findings also illuminate the ways in which cannabis use is, for some, connected to existential concerns; that is, how cannabis use may afford a sense of identity, belonging, and even survival. When the findings of previous studies are considered with the findings of our scoping review, they speak to an understanding of drug use—whether cannabis, methamphetamine, or alcohol use—as an occupation that not only holds meaning but also can promote individual well-being in some way at certain points in time (e.g. through connection to others, through the enjoyment of everyday activities).
Study limitations and future research
As with any study, there are some limitations associated with this scoping review. This review was limited to articles written in English and French; however, only studies published in English were found to meet the required inclusion criteria. As such, information about the meanings that individuals ascribe to cannabis use published in languages, other than English and French, was not included. Further, only studies with full-text availability were included in this review. Studies that met the inclusion criteria but whose full texts were not available may have been left out. Moreover, a search of the grey literature was not conducted. Taken together, these limitations suggest that it is possible that other publications, including those written in languages other than English, those without full-text availability, and those considered to be part of the grey literature, are missing from our examination of the meanings that individuals ascribe to cannabis use.
During the time that the selected studies were undertaken, legalization of medical and recreational cannabis use was being reviewed within multiple jurisdictions. However, it remains that cannabis production, sale, and use are illegal in most of the world. The studies selected for this review mostly involved participants who obtained and used cannabis within jurisdictions that deemed its recreational use illegal, with approximately half the jurisdictions having legalized medical use. Despite the preponderance of illegal cannabis use in the selected studies, the findings of this review indicate that participants found their cannabis use to hold multiple meanings in their lives. This finding is noteworthy as individuals who live within jurisdictions with cannabis legalization have been found to use it more frequently and view it as safer than tobacco than those living in jurisdictions in which cannabis was illegal or only medically legal.17 Thus, this finding would imply that future research, with a greater number of cannabis users living in jurisdictions where recreational use is legal, may broaden our understanding of the perceived meanings held by users of cannabis.
Implications for occupational therapy and substance abuse treatment practice
Despite research outlining the negatives effects of acute and chronic use of cannabis, participants in this study described how cannabis use helped them manage pain, nausea, depression, anxiety, and boredom so that they could focus on creating a life worth living and engage in occupations that were part of desired and required routines. The changing legalization of cannabis in some jurisdictions, such as in North America and Europe, has led to a shift in societal attitudes and greater cannabis consumption.44 These changes may lead to greater opportunities for occupational therapists to work in substance abuse treatment programs with clients using a harm reduction model to support their clients’ engagement in their desired occupational repertoire. Leppard et al48 found that most programs for women with substance use issues used a harm reduction approach, which aligns well with occupational therapy principles. Using this approach, occupational therapists can focus on helping clients manage their use within the routines of their day by supporting engagement in meaningful activities, or occupations, with a focus on reducing the harm or ill-effects of drug use. As individuals become more engaged in occupations that are significant in their lives, their need for and meaning of cannabis use may shift leading to reduction in its use. Additionally, for those who use cannabis as a means of managing the stress of daily life and work, family and workplace supports may be needed to help reduce demands or negative family dynamics or workplace culture.
For some people, cannabis use is an integral occupation in their lives and is interwoven with other things that they do. Participants in this study spoke to the social connections, feelings of belonging, and collective identities that are formed when using cannabis with others. The identity of “collective user” that was discussed by some participants implies a strong connection to the social environment.34 Substance abuse treatment practices, including those provided by occupational therapists, need to acknowledge the importance of this identity within certain people’s lives. For those who are trying to reduce or stop using cannabis or other drugs, working within a substance abuse treatment program, occupational therapists can work alongside other colleagues to help clients to shift their identity constructions by working on rebuilding new occupational repertoires and community connections that are not based on drug use.
Conclusion
Cannabis use was revealed in this study as a support for navigating daily occupational routines that were perceived as repetitive and mundane by relieving pain, anxiety, and distress. Others viewed cannabis use as a way of enhancing their occupational repertoires and engagement in occupations, as well as affirming social connections and feelings of belonging. These findings can inform occupational therapy practitioners through providing an understanding of the meaning that their clients may ascribe to diverse occupations, both those perceived as healthy and unhealthy.
Footnotes
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Author Contributions: The first and last authors (EG & JD) conceptualized the study, created the search strategy, and ran the search. All authors contributed to the data selection, extraction, and analysis, and writing of the article.
References
