The clinical implications of legalizing marijuana: Are physician and non-physician providers prepared?

Counseling About Cannabis Use During Pregnancy and Lactation: A Qualitative Study of Patient and Clinician Perspectives

INTRODUCTION

Legalization in many jurisdictions has increased the prevalence of cannabis use, including during pregnancy and lactation. Accordingly, clinicians providing perinatal and infant care are increasingly required to counsel about this topic, even if they do not feel comfortable or prepared for this conversation. The aim of this research was to explore how prenatal clinicians and pregnant and lactating women interact with cannabis consumption.

METHODS

Using qualitative description, we conducted semi-structured interviews with 75 individuals in Canada: 23 clinicians who provide pregnancy and lactation care, and 52 individuals who made cannabis consumption decisions during pregnancy and/or lactation. Data were analyzed using inductive content analysis.

RESULTS

Three phases of the clinical encounter influenced decision-making about cannabis consumption: initiation of a discussion about cannabis, sense-making, and the outcome of the encounter. Patients and clinicians described similar ideals for a counseling encounter about cannabis consumption during pregnancy or lactation: open, patient-centered conversation grounded in an informed decision-making model to explore the benefits, risks, and alternatives to cannabis. While clinicians described these values as reflecting real clinical interactions, patients reported that in their experience, actual interactions did not live up to these ideals.

CONCLUSION

Clinicians and pregnant and lactating people report desiring the same things from a counseling interaction about cannabis: sharing of information, identification of values, and facilitation of a decision. Both groups endorse an open, nonjudgemental counseling approach that explores the reasons why a patient is considering cannabis consumption and reflects these reasons against available evidence and alternatives known to be safe.

"Like the Wild West": Health care provider perspectives on impacts of recreational cannabis legalization on patients and providers at a tertiary psychiatric hospital in Ontario, Canada

INTRODUCTION

Legalization has increased cannabis availability in Canada. Research shows complex relationships between cannabis use and mental health, and a need for health care providers to engage with patients about cannabis use. Providers have noted gaps in knowledge and research on the medical effects of cannabis as barriers to service delivery. It is unclear how providers and patients in mental health care settings have been impacted by legalization.

METHODS

From June 1 to July 2, 2021, we conducted a qualitative study involving semi-structured interviews with 20 health care providers in a range of roles (e.g., physicians, pharmacists, nurses) within a psychiatric hospital setting. Participants responded to open-ended questions with follow-up probes on various topics related to cannabis legalization. Topics included impacts on patient mental and physical health, clinical impacts, education and training, legal cannabis retail system and the medical cannabis access system.

RESULTS

Thematic analysis identified several themes in the data. Participants reported that legalization has had some positive impacts relating to clinical care and cannabis safety. They also expressed concerns with increased rates of cannabis use, risks to mental health and ongoing challenges engaging with patients about cannabis. Participants made recommendations for medical educators and regulators (e.g., updated curriculums, clinical guidelines), the mental health care sector (e.g., implementation of standardized screening), government (e.g., public health campaigns, safe use guidelines), the medical cannabis access system (e.g., increased regulation, research), and the legal cannabis system (e.g., zoning changes, point-of-sale information).

CONCLUSIONS

This study begins to address the paucity of data on impacts of legalization from mental health service delivery settings. Findings show that although legalization has had some positive impacts, there are ongoing patient concerns and unmet provider needs. More research is needed to understand the experiences of providers delivering care to populations experiencing mental health and/or substance use concerns who use cannabis in the post-legalization era.

Evidence synthesis of medical cannabis research: current challenges and opportunities

As a wide group of medicines, the effectiveness and safety of 'medical cannabis' products is likely to vary in relation to product-specific dimensions such as potency, dosage, route of administration, and cannabinoid composition. Systematic reviews can perform a crucial role in analysing and synthesising the outcomes of medical cannabis interventions found in empirical research. We analysed 23 contemporary systematic reviews on the effectiveness and safety of medical cannabis to discern the extent to which this body of work aimed to capture, and ultimately captured, the differing outcomes of medical cannabis products by product-specific dimensions of treatment. We further highlighted the methodological reasons given by authors for an inability to describe this granular level of information. We found that a minority of systematic reviews explicitly aimed to perform a subgroup analysis to determine differences in treatment outcomes by product-specific dimensions of medical cannabis, with even fewer subsequently doing so. Authors' stated reasons for this concerned either overly large or overly small levels of variation in the characteristics, compositions, and administrations of medical cannabis products used, rendering subgroup analyses methodologically inappropriate or inapplicable. Furthering systematic reviews' abilities to capture granular information on medical cannabis treatment outcomes in relation to product-specific dimensions of treatments will require further standardisation of treatments in empirical studies.

Prevalence of Cannabis Use Disorder Among Primary Care Patients with Varying Frequency of Past-Year Cannabis Use

BACKGROUND

Valid, single-item cannabis screens for the frequency of past-year use (SIS-C) can identify patients at risk for cannabis use disorder (CUD); however, the prevalence of CUD for patients who report varying frequencies of use in the clinical setting remains unexplored.

OBJECTIVE

Compare clinical responses about the frequency of past-year cannabis use to typical use and CUD severity reported on a confidential survey.

PARTICIPANTS

Among adult patients in an integrated health system who completed the SIS-C as part of routine care (3/28/2019-9/12/2019; n = 108,950), 5000 were selected for a confidential survey using stratified random sampling. Among 1688 respondents (34% response rate), 1589 who reported past-year cannabis use on the SIS-C were included.

MAIN MEASURES

We compared patients with varying frequency of cannabis use on the SIS-C (< monthly, monthly, weekly, daily) to survey responses on the Composite International Diagnostic Interview Substance Abuse Module for CUD (any and moderate-severe CUD) and cannabis exposure measures (typical use per-week, per-day). Adjusted multinomial (categorical) and logistic regression (binary), weighted for population estimates, estimated the prevalence of outcomes across frequencies.

KEY RESULTS

Patients were predominantly middle-aged (mean = 43.3 years [SD = 16.9]), male (51.8%), white (78.2%), non-Hispanic (94.0%), and commercially insured (68.9%). The prevalence of any and moderate-severe CUD increased with greater frequency of past-year cannabis use reported on the SIS-C (p-values < 0.001) and ranged from 12.7% (6.3-19.2%) and 0.9% (0.0-2.7%) for < monthly to 44.6% (41.4-47.7%) and 20.3% (17.8-22.9%) for daily use, respectively. Greater frequency of use on the SIS-C in the clinical setting corresponded with greater per-week and per-day use on the confidential survey.

CONCLUSIONS

Among patients who reported past-year cannabis use as part of routine screening, the prevalence of CUD and other cannabis exposure measures increased with greater frequency of cannabis use, underscoring the utility of brief cannabis screens for identifying patients at risk for CUD.

Factors Associated with Provider Counseling Against Breastfeeding in the Setting of Marijuana Use: A Population-Based Survey

INTRODUCTION

The purpose of this study was to explore patient demographic factors associated with counseling against breastfeeding and concurrent marijuana use.

METHODS

A cross-sectional study derived using data from the Centers for Disease Control and Prevention administered Pregnancy Risk Assessment Monitoring System (PRAMS) in collaboration with state and local health departments. This study sample included survey participants whose responses indicate they received counseling discouraging breastfeeding with concurrent marijuana use. Bivariate and multivariate regression analyses assessed the relationship between factors associated with counseling against breastfeeding and concurrent marijuana use.

RESULTS

Of the 10,911 participants in this sample, 9,695 participants who answered the question about receiving counseling discouraging breastfeeding while using marijuana were included in the analysis (89% response rate for the total sample). Twenty nine percent of participants were advised by a provider not to breastfeed while using marijuana. Participants who received this counseling were more likely to be people of color, age less than or equal to 29, with a high school education or less, unmarried, report governmental or no insurance prepregnancy, and report marijuana use postpartum. In the multivariate analysis, age less than or equal to 20 (P = .001), being unmarried (P = .023), and marijuana use postpartum (P = .034) remained associated with counseling against breastfeeding.

DISCUSSION

Our results suggest that individuals are being counseled differently. Unmarried and young people (age <20 years) were more likely to report receiving counseling against breastfeeding with concurrent marijuana use. Given the growing national acceptability of marijuana use, the known benefits of breastfeeding, and the unclear risks of marijuana in human milk, there is a need to standardize counseling to avoid a missed opportunity to educate breastfeeding populations who use marijuana and to reduce the risk of counseling based on providers' personal attitudes and biases not aligned with evidence-based guidelines.

A national study of clinical discussions about cannabis use among Veteran patients prescribed opioids

BACKGROUND

The Veterans Health Administration tracks urine drug tests (UDTs) among patients on long-term opioid therapy (LTOT) and recommends discussing the health effects of cannabis use.

OBJECTIVE

To determine the occurrence of cannabis-related discussions between providers and patients on LTOT during six months following UDT positive for cannabis, and examine factors associated with documenting cannabis use.

DESIGN

We identified patients prescribed LTOT with a UDT positive for cannabis in 2019. We developed a text-processing tool to extract discussions around cannabis use from their charts.

SUBJECTS

Twelve thousand seventy patients were included. Chart review was conducted on a random sample of 1,946 patients.

MAIN MEASURES

The presence of a cannabis term in the chart suggesting documented cannabis use or cannabis-related discussions. Content of those discussions was extracted in a subset of patients. Logistic regression was used to examine the association between patient factors, including state of residence legal status, with documentation of cannabis use.

KEY RESULTS

Among the 12,070 patients, 65.8% (N = 7,948) had a cannabis term, whereas 34.1% (N = 4,122) of patients lacked a cannabis term, suggesting that no documentation of cannabis use or discussion between provider and patient took place. Among the subset of patients who had a discussion documented, 47% related to cannabis use for medical reasons, 35% related to a discussion of VA policy or legal issues, and 17% related to a discussion specific to medical risks or harm reduction strategies. In adjusted analyses, residents of states with legalized recreational cannabis were less likely to have any cannabis-related discussion compared to patients in non-legal states [OR 0.73, 95% CI 0.64-0.82].

CONCLUSIONS

One-third of LTOT patients did not have documentation of cannabis use in the chart in the 6 months following a positive UDT for cannabis. Discussions related to the medical risks of cannabis use or harm reduction strategies were uncommon.

Planting the seeds for success: A qualitative study exploring primary healthcare providers' perceptions about medical cannabis

BACKGROUND

In Canada, cannabis legalization altered the way that the public can access cannabis for medical purposes. However, Canadians still struggle with finding healthcare professionals (HCPs) who are involved in medical cannabis counselling and authorization. This raises questions about the barriers that are causing this breakdown in care. Our study explored the perceptions of primary care providers regarding cannabis in their practice.

METHODS

Semi-structured interviews were conducted by Zoom with HCPs in Newfoundland and Labrador (NL) to discuss their experiences with medical and non-medical cannabis in practice. Family physicians and nurse practitioners who were practicing in primary care in NL were included. The interview guide and coding template were developed using the Theoretical Domains Framework (TDF). A thematic analysis across the TDF was then conducted.

RESULTS

Twelve participants with diverse demographic backgrounds and experience levels were interviewed. Five main themes emerged including, knowledge acquisition, internal influences, patient influences, external HCP influences, and systemic influences. The TDF domain resulting in the greatest representation of codes was environmental context and resources.

INTERPRETATION

The findings suggested that HCPs have significant knowledge gaps in authorizing medical cannabis, which limited their practice competence and confidence in this area. Referring patients to cannabis clinics, while enforcing harm-reduction strategies, was an interim option for patients to access cannabis for medical purposes. However, developing practice guidelines and educational resources were suggested as prominent facilitators to promote medical cannabis authorization within the healthcare system.

Birth, cognitive and behavioral effects of intrauterine cannabis exposure in infants and children: A systematic review and meta-analysis

BACKGROUND AND AIMS

Δ9-tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, has been implicated in affecting fetal neurodevelopment by readily crossing the placenta. However, little is known regarding the long-term effects of intrauterine cannabis exposure. This systematic review and meta-analysis synthesized prospective and cross-sectional human studies to measure the effects of intrauterine cannabis exposure on birth, behavioral, psychological and cognitive outcomes in infancy until early childhood.

METHODS

Reporting according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, cross-sectional and prospective studies published from database inception until June 2023, investigating developmental outcomes of infants, toddlers and young children with intrauterine cannabis exposure were considered. All articles were obtained from PubMed or PsycINFO databases.

RESULTS

The literature search resulted in 932 studies, in which 57 articles met eligibility criteria. The meta-analysis revealed that intrauterine cannabis exposure increases the risk of preterm delivery [odds ratio (OR) = 1.68, 95% confidence interval (CI) = 1.05-2.71, P = 0.03], low birth weight (OR = 2.60, CI = 1.71-3.94, P < 0.001) and requirement for neonatal intensive care unit (NICU) admission (OR = 2.51, CI = 1.46-4.31; P < 0.001). Our qualitative synthesis suggests that intrauterine cannabis exposure may be associated with poorer attention and externalizing problems in infancy and early childhood. We found no evidence for impairments in other cognitive domains or internalizing behaviors.

CONCLUSIONS

Prenatal cannabis use appears to be associated with lower birth weight, preterm birth and neonatal intensive care unit admission in newborns, but there is little evidence that prenatal cannabis exposure adversely impacts behavioral or cognitive outcomes in early childhood, with the exception of attention and externalizing problems.

Rising Inpatient Utilization and Costs of Cannabis Hyperemesis Syndrome Hospitalizations in Massachusetts After Cannabis Legalization

GOALS

We described the demographics, inpatient utilization, and cost of services among patients hospitalized for putative cannabinoid hyperemesis syndrome (CHS) predating and postdating cannabis legalization in Massachusetts.

BACKGROUND

As the recreational use of cannabis has been widely legalized nationally, the resulting shifts in clinical presentation, health care utilization, and estimated costs of CHS hospitalizations remain unclear in the postlegalization era.

STUDY

We performed a retrospective cohort study among patients admitted to a large urban hospital between 2012 and 2021, before and after the date of cannabis legalization in Massachusetts (Dec 15, 2016). We examined the demographic and clinical characteristics of patients admitted for putative CHS, the utilization of hospital services, and estimated inpatient costs pre and postlegalization.

RESULTS

We identified a significant increase in putative CHS hospitalizations pre and post-cannabis legalization in Massachusetts (0.1% vs 0.02% of total admissions per time period, P < 0.05). Across 72 CHS hospitalizations, patient demographics were similar pre and postlegalization. Hospital resource utilization increased postlegalization, with increased length of stay (3 d vs 1 d, P < 0.005), and need for antiemetics ( P < 0.05). Multivariate linear regression confirmed that postlegalization admissions were independently associated with increased length of stay ( Β = 5.35, P < 0.05). The mean cost of hospitalization was significantly higher postlegalization ($18,714 vs $7460, P < 0.0005), even after adjusting for medical inflation ($18,714 vs $8520, P < 0.001) with intravenous fluid administration and endoscopy costs increased ( P < 0.05). On multivariate linear regression, hospitalization for putative CHS during postlegalization predicted increased costs ( Β = 10,131.25, P < 0.05).

CONCLUSIONS

In the postlegalization era of cannabis in Massachusetts, we found increased putative CHS hospitalizations, with a concomitant increased length of hospital stay and total cost per hospitalization. As cannabis use increases, the recognition and costs of its deleterious effects are necessary to incorporate into future clinical practice strategies and health policy.

A Pragmatic, Person-Centered View of Cannabis in the United States: Pursuing Care That Transcends Beliefs

BACKGROUND

Rates of cannabis use are increasing in the United States, likely as a result of changes in societal attitudes and expanding legalization. Although many patients report wanting to discuss the risks and benefits of cannabis use with their clinical providers, many providers hold conflicting beliefs regarding cannabis use and often do not engage patients in discussion about cannabis. This dilemma is underscored by the limitations imposed on cannabis related research, and lack of empirically based best-practice guidelines for clinicians when addressing cannabis use with patients.

OBJECTIVES

We aimed to briefly summarize clinician and patient attitudes toward cannabis use and review current clinical guidelines and provide suggestions to assist health care providers and clinicians in increasing their comfort and skill in discussing cannabis use with patients.

METHODS

A narrative review on attitudes toward cannabis use and clinical guidelines was performed to summarize the literature and provide evidence-based recommendations.

RESULTS

Attitudes toward cannabis use have been shaped by personal and political factors and contribute to clinician hesitance in speaking with patients about the topic. Administrative barriers have hindered the development of clearer public health guidelines that might enable the dissemination of evidence-based information on the health effects of cannabis use and might ultimately lead to better health outcomes.

CONCLUSION

Not discussing cannabis use with patients may be a crucial missed opportunity for harm reduction. In the absence of empirically supported best-practice guidelines, a person-centered approach can facilitate conversations on the harms and benefits of cannabis use.

Association between cannabis use disorder symptom severity and probability of clinically-documented diagnosis and treatment in a primary care sample

BACKGROUND

Brief cannabis screening followed by standardized assessment of symptoms may support diagnosis and treatment of cannabis use disorder (CUD). This study tested whether the probability of a medical provider diagnosing and treating CUD increased with the number of substance use disorder (SUD) symptoms documented in patients' EHRs.

METHODS

This observational study used EHR and claims data from an integrated healthcare system. Adult patients were included who reported daily cannabis use and completed the Substance Use Symptom Checklist, a scaled measure of DSM-5 SUD symptoms (0-11), during routine care 3/1/2015-3/1/2021. Logistic regression estimated associations between SUD symptom counts and: 1) CUD diagnosis; 2) CUD treatment initiation; and 3) CUD treatment engagement, defined based on Healthcare Effectiveness Data and Information Set (HEDIS) ICD-codes and timelines. We tested moderation across age, gender, race, and ethnicity.

RESULTS

Patients (N=13,947) were predominantly middle-age, male, White, and non-Hispanic. Among patients reporting daily cannabis use without other drug use (N=12,568), the probability of CUD diagnosis, treatment initiation, and engagement increased with each 1-unit increase in Symptom Checklist score (p's<0.001). However, probabilities of diagnosis, treatment, and engagement were low, even among those reporting ≥2 symptoms consistent with SUD: 14.0% diagnosed (95% CI: 11.7-21.6), 16.6% initiated treatment among diagnosed (11.7-21.6), and 24.3% engaged in treatment among initiated (15.8-32.7). Only gender moderated associations between Symptom Checklist and diagnosis (p=0.047) and treatment initiation (p=0.012). Findings were similar for patients reporting daily cannabis use with other drug use (N=1379).

CONCLUSION

Despite documented symptoms, CUD was underdiagnosed and undertreated in medical settings.

Nurses' Attitudes Toward Patients Who Use Cannabis: Does Legal Status or Care Setting Matter?

BACKGROUND

Cannabis has been cited as the most frequently used drug in this country, and intolerance toward substance use is a recognized concern in nursing. The twofold purpose of this descriptive study was to determine (a) what, if any, were the differences between nurses' attitudes of patient cannabis use in states in which cannabis was legal versus illegal and (b) how do nurses working in diverse care settings differ in their attitudes regarding patient cannabis use.

METHODS

A sample of 809 registered nurses from across the United States were recruited to take part in this study in October 2018. A previously validated 20-question survey was used to collect participants' perceptions of and attitudes toward patient cannabis use. Demographic information collected included age, gender, educational level, years in practice, primary area of practice, and legal status of cannabis in state of practice. An independent t test and analysis of variance were used to analyze group differences.

FINDINGS

Findings from this study indicated that there was no significant difference in attitudes of nurses in states in which cannabis use was legal (M = 28.76, SD = 7.83) and states in which it was illegal (M = 29.43, SD = 7.65), t(807) = 1.202, p = .230. In addition, no significant differences were found in attitudes across six areas of practice, F(5) = 1.531, p = .178. Furthermore, nursing attitudes were largely positive toward patient cannabis use (M = 29.04, SD = 7.762; range: 20-100).

CONCLUSIONS

Findings from this study indicate that cannabis use may not carry the same perceived stigma as other illicit substances for nurses and unbiased care may be provided regardless of personal beliefs.

Role of the gut-brain axis in HIV and drug abuse-mediated neuroinflammation

Drug abuse and related disorders are a global public health crisis affecting millions, but to date, limited treatment options are available. Abused drugs include but are not limited to opioids, cocaine, nicotine, methamphetamine, and alcohol. Drug abuse and human immunodeficiency virus-1/acquired immune deficiency syndrome (HIV-1/AIDS) are inextricably linked. Extensive research has been done to understand the effect of prolonged drug use on neuronal signaling networks and gut microbiota. Recently, there has been rising interest in exploring the interactions between the central nervous system and the gut microbiome. This review summarizes the existing research that points toward the potential role of the gut microbiome in the pathogenesis of HIV-1-linked drug abuse and subsequent neuroinflammation and neurodegenerative disorders. Preclinical data about gut dysbiosis as a consequence of drug abuse in the context of HIV-1 has been discussed in detail, along with its implications in various neurodegenerative disorders. Understanding this interplay will help elucidate the etiology and progression of drug abuse-induced neurodegenerative disorders. This will consequently be beneficial in developing possible interventions and therapeutic options for these drug abuse-related disorders.

Knowledge, perception, and beliefs of Saudi physicians at King Abdulaziz Medical City, Riyadh related to medical cannabis: Literature review and a cross-sectional survey

Cannabis is an herbaceous flowering plant, originally an indigenous plant in Eastern Asia, which later spread globally due to widespread agricultural practices. Cannabis was used medicinally until the early twentieth century, but subsequently prohibited due to the psychoactive effects.

Aims

To explore the medical cannabis-related level of knowledge of physicians at King Abdulaziz Medical City, including patient needs, perceptions of therapeutic effects, potential harm, and the willingness to prescribe if legalized in future.

Methodology

The study was a cross-sectional questionnaire-based survey. It was conducted at King Abdulaziz Medical City in Riyadh from February 2020 to February 2021. All physicians from the different specialties, who consented to participate, were included in this study.

Statistical Analysis

Descriptive statistics are presented as mean and standard deviation and proportions. An ANOVA test was applied to measure the association of the beliefs regarding the right to prescribe with overall knowledge. All tests were considered significant at P < 0.05.

Results

A total of 249 physicians participated with the majority (70%) male. The sample was similar regardless of the physician's position in the medical hierarchy, with a mean work experience of 8 years. Almost half of the participants indicated that they do not have good knowledge regarding the effects of MC products and more than half that they are unaware of the different MC products and formulations currently available.

Conclusion

The majority of the sample lacked knowledge about the medicinal use of cannabis for specific indications and felt uncomfortable to discuss the medicinal use of cannabis with their patients.

Alterations in Abundance and Compartmentalization of miRNAs in Blood Plasma Extracellular Vesicles and Extracellular Condensates during HIV/SIV Infection and Its Modulation by Antiretroviral Therapy (ART) and Delta-9-Tetrahydrocannabinol (Δ9-THC)

In this follow-up study, we investigated the abundance and compartmentalization of blood plasma extracellular miRNA (exmiRNA) into lipid-based carriers-blood plasma extracellular vesicles (EVs) and non-lipid-based carriers-extracellular condensates (ECs) during SIV infection. We also assessed how combination antiretroviral therapy (cART), administered in conjunction with phytocannabinoid delta-9-tetrahydrocannabinol (THC), altered the abundance and compartmentalization of exmiRNAs in the EVs and ECs of SIV-infected rhesus macaques (RMs). Unlike cellular miRNAs, exmiRNAs in blood plasma may serve as minimally invasive disease indicators because they are readily detected in stable forms. The stability of exmiRNAs in cell culture fluids and body fluids (urine, saliva, tears, cerebrospinal fluid (CSF), semen, blood) is based on their association with different carriers (lipoproteins, EVs, and ECs) that protect them from the activities of endogenous RNases. Here, we showed that in the blood plasma of uninfected control RMs, significantly less exmiRNAs were associated with EVs compared to the level (30% higher) associated with ECs, and that SIV infection altered the profile of EVs and ECs miRNAome (Manuscript 1). In people living with HIV (PLWH), host-encoded miRNAs regulate both host and viral gene expression, which may serve as indicators of disease or treatment biomarkers. The profile of miRNAs in blood plasma of PLWH (elite controllers versus viremic patients) are different, indicating that HIV may alter host miRNAome. However, there are no studies assessing the effect of cART or other substances used by PLWH, such as THC, on the abundance of exmiRNA and their association with EVs and ECs. Moreover, longitudinal exmiRNA profiles following SIV infection, treatment with THC, cART, or THC+cART remains unclear. Here, we serially analyzed miRNAs associated with blood plasma derived EVs and ECs. Methods: Paired EVs and ECs were separated from EDTA blood plasma of male Indian rhesus macaques (RMs) in five treatment groups, including VEH/SIV, VEH/SIV/cART, THC/SIV, THC/SIV/cART, or THC alone. Separation of EVs and ECs was achieved with the unparalleled nano-particle purification tool ─PPLC, a state-of-the-art, innovative technology equipped with gradient agarose bead sizes and a fast fraction collector that allows high resolution separation and retrieval of preparative quantities of sub-populations of extracellular structures. Global miRNA profiles of the paired EVs and ECs were determined with RealSeq Biosciences (Santa Cruz, CA) custom sequencing platform by conducting small RNA (sRNA)-seq. The sRNA-seq data were analyzed using various bioinformatic tools. Validation of key exmiRNA was performed using specific TaqMan microRNA stem-loop RT-qPCR assays. Results: We investigated the effect of cART, THC, or both cART and THC together on the abundance and compartmentalization of blood plasma exmiRNA in EVs and ECs in SIV-infected RMs. As shown in Manuscript 1 of this series, were in uninfected RMs, ~30% of exmiRNAs were associated with ECs, we confirmed in this follow up manuscript that exmiRNAs were present in both lipid-based carriers-EVs and non-lipid-based carriers-ECs, with 29.5 to 35.6% and 64.2 to 70.5 % being associated with EVs and ECs, respectively. Remarkably, the different treatments (cART, THC) have distinct effects on the enrichment and compartmentalization pattern of exmiRNAs. In the VEH/SIV/cART group, 12 EV-associated and 15 EC-associated miRNAs were significantly downregulated. EV-associated miR-206, a muscle-specific miRNA that is present in blood, was higher in the VEH/SIV/ART compared to the VEH/SIV group. ExmiR-139-5p that was implicated in endocrine resistance, focal adhesion, lipid and atherosclerosis, apoptosis, and breast cancer by miRNA-target enrichment analysis was significantly lower in VEH/SIV/cART compared to VEH/SIV, irrespective of the compartment. With respect to THC treatment, 5 EV-associated and 21 EC-associated miRNAs were significantly lower in the VEH/THC/SIV. EV-associated miR-99a-5p was higher in VEH/THC/SIV compared to VEH/SIV, while miR-335-5p counts were significantly lower in both EVs and ECs of THC/SIV compared to VEH/SIV. EVs from SIV/cART/THC combined treatment group have significant increases in the count of eight (miR-186-5p, miR-382-5p, miR-139-5p and miR-652, miR-10a-5p, miR-657, miR-140-5p, miR-29c-3p) miRNAs, all of which were lower in VEH/SIV/cART group. Analysis of miRNA-target enrichment showed that this set of eight miRNAs were implicated in endocrine resistance, focal adhesions, lipid and atherosclerosis, apoptosis, and breast cancer as well as cocaine and amphetamine addiction. In ECs and EVs, combined THC and cART treatment significantly increased miR-139-5p counts compared to VEH/SIV group. Significant alterations in these host miRNAs in both EVs and ECs in the untreated and treated (cART, THC, or both) RMs indicate the persistence of host responses to infection or treatments, and this is despite cART suppression of viral load and THC suppression of inflammation. To gain further insight into the pattern of miRNA alterations in EVs and ECs and to assess potential cause-and-effect relationships, we performed longitudinal miRNA profile analysis, measured in terms of months (1 and 5) post-infection (MPI). We uncovered miRNA signatures associated with THC or cART treatment of SIV-infected macaques in both EVs and ECs. While the number of miRNAs was significantly higher in ECs relative to EVs for all groups (VEH/SIV, SIV/cART, THC/SIV, THC/SIV/cART, and THC) longitudinally from 1 MPI to 5 MPI, treatment with cART and THC have longitudinal effects on the abundance and compartmentalization pattern of exmiRNAs in the two carriers. As shown in Manuscript 1 where SIV infection led to longitudinal suppression of EV-associated miRNA-128-3p, administration of cART to SIV-infected RMs did not increase miR-128-3p but resulted in longitudinal increases in six EV-associated miRNAs (miR-484, miR-107, miR-206, miR-184, miR-1260b, miR-6132). Furthermore, administration of cART to THC treated SIV-infected RMs resulted in a longitudinal decrease in three EV-associated miRNAs (miR-342-3p, miR-100-5p, miR181b-5p) and a longitudinal increase in three EC-associated miRNAs (miR-676-3p, miR-574-3p, miR-505-5p). The longitudinally altered miRNAs in SIV-infected RMs may indicate disease progression, while in the cART Group and the THC Group, the longitudinally altered miRNAs may serve as biomarkers of response to treatment. Conclusions: This paired EVs and ECs miRNAome analyses provided a comprehensive cross-sectional and longitudinal summary of the host exmiRNA responses to SIV infection and the impact of THC, cART, or THC and cART together on the miRNAome during SIV infection. Overall, our data point to previously unrecognized alterations in the exmiRNA profile in blood plasma following SIV infection. Our data also indicate that cART and THC treatment independently and in combination may alter both the abundance and the compartmentalization of several exmiRNA related to various disease and biological processes.

Assessing Increases in Cannabis-Related Diagnoses in US Hospitals by Regional Policy Status

Cannabis policy is rapidly changing and more individuals are using cannabis nationally. Despite increased use and known adverse outcomes to cannabis use, there is a lack of understanding of health care utilization for cannabis-related conditions. The objectives of this study were: (1) To understand the change in the incidence of cannabis-related diagnoses from 2012 to 2015 nationally and (2) to describe the relationship between regional cannabis policies and changes in the incidence of cannabis-related diagnoses from 2012 to 2015. National Inpatient Sample (NIS) data from the Healthcare Cost and Utilization Project for 2012 and 2015 were analyzed using SPSS software for incidence of cannabis diagnoses. Previously defined NIS regions were assigned a policy status related to medical and recreational cannabis laws. Comparisons were made at the national and regional levels to better understand change in incidence of diagnoses. From 2012 to 2015, there was a 26.7% increase in cannabis-related diagnoses in the inpatient setting nationally. All 9 regions showed increases in the incidence of cannabis-related diagnoses ranging from 15.5% to 41.9% regardless of cannabis policy. As cannabis policy increased legal access, cannabis-related diagnoses increased nationally and regionally across the United States from 2012 to 2015 regardless of cannabis policy. Continued tracking of cannabis-related diagnoses is needed to identify where interventions are necessary to reduce negative impacts of increased cannabis use.

"We want what's best for patients." nurse leaders' attitudes about medical cannabis: A qualitative study

Background

The majority of states have legalized medical cannabis. Nurse leaders must be prepared for an increase in patients' use of the drug across all care settings.

Objectives

To explore nurse leaders' attitudes towards, knowledge of, and experiences with medical cannabis.

Design

: Descriptive qualitative study design.

Participants

28 nurse leaders-19 in four focus groups of 3-7 participants and another 9 in interviews.

Methods

Semi-structured, one-on-one interviews and focus groups of nurse leaders about their attitudes towards and experiences with patients' use of medical cannabis. Thematic analysis was used to identify themes and subthemes.

Results

Four major themes were identified: overwhelming support for legalized medical cannabis; importance of overcoming the stereotype of a gateway drug; problematic mismatch between federal and state cannabis policies; and nursing needs to be move involved.

Conclusions

There was strong support for legalized medical cannabis to meet patients' needs; yet, respondents reported little discussion about or education regarding medical cannabis among nurses. Inconsistent federal and state cannabis policies were viewed as especially problematic and in need of alignment.

Healthcare practitioner perceptions on barriers impacting cannabis prescribing practices

Background

Canadians seeking medical cannabis (MC) may encounter difficulties in finding a healthcare provider (HCP) who authorizes their access to it. Barriers that HCPs face in authorizing MC are unclear. The objectives of this study were to evaluate HCP opinions, knowledge, comfort, and practice in MC prescribing and counseling on recreational cannabis use, and whether the COVID-19 pandemic affected MC prescribing practices.

Methods

Eligible participants included HCPs (e.g., attending physicians, nurses, pharmacists) in Canada. A questionnaire evaluating their knowledge, comfort, and practice in medical and recreational cannabis was designed based on instruments developed in previous studies. Between April 13th-December 13th 2021, ninety-one healthcare associations were asked to distribute the survey to their members, and an advertisement was placed in the online Canadian Medical Association Journal. Descriptive statistics were used to analyze the results.

Results

Twenty-four organizations agreed to disseminate the survey and 70 individuals completed it. Of respondents, 71% were attending physicians or medical residents, while the remainder were nurses, pharmacists or other HCPs. Almost none (6%) received training in MC in professional school but 60% did receive other training (e.g., workshops, conferences). Over half (57%) received more questions regarding MC since recreational cannabis was legalized, and 82% reported having patients who use MC. However, 56% felt uncomfortable or ambivalent regarding their knowledge of MC, and 27% were unfamiliar with the requirements for obtaining MC in Canada. The most common symptoms for recommending MC were pain and nausea, whereas the most common conditions for recommending it were cancer and intractable pain. The strongest barrier to authorizing MC was uncertainty in safe and effective dosage and routes of administration. The strongest barrier to recommending or authorizing MC was the lack of research evidence demonstrating its safety and efficacy. During the pandemic, many respondents reported that a greater number of their patients used cannabis to relieve anxiety and depression.

Conclusions

Our results suggest that HCPs across Canada who responded to our survey are unfamiliar with topics related to MC. The strongest barriers appear to be lack of clinical research, and uncertainty in safe and effective MC administration. Increasing research, training, and knowledge may help HCPs feel more equipped to make informed treatment/prescribing decisions, which may help to improve access to MC.

Assessing Health Care Providers' Knowledge of Medical Cannabis

Introduction: Many health care providers would benefit from greater knowledge and awareness of medical cannabis, even if they choose not to integrate it into their medical practice. Unfortunately, health care providers generally report low knowledge of medical cannabis and cite this lack of knowledge as a barrier to making patient recommendations. It is important to understand health care providers' medical cannabis knowledge and its correlates. However, few studies have rigorously assessed clinically relevant cannabis-related knowledge, instead typically focusing on attitudes toward cannabis and perceived knowledge. Methods: Physicians in a university-affiliated health system completed an anonymous online survey. The survey assessed participants' basic demographics and medical experience, experiences with cannabis education, beliefs about their knowledge of and competency regarding medical cannabis, and knowledge of medical cannabis in relation to the current scientific evidence. Results: The average level of medical cannabis knowledge was 58% correct, with scores ranging from 39% to 78% correct. Perceived cannabis knowledge predicted actual knowledge, and those who pursued self-initiated study or attended a lecture on medical cannabis had higher knowledge levels. Conclusion: Levels of factual knowledge about medical cannabis among physicians were moderate. Our results highlight the mismatch between physician knowledge and cannabis policy. We offer our brief, 10-min assessment as a baseline for characterizing cannabis knowledge, acknowledging that the content and interpretation may change as knowledge advances.

"You still have that fear": Policy constraints on informed decision making about legalized cannabis use during pregnancy and lactation

BACKGROUND

Cannabis is the most commonly used drug during pregnancy, excluding alcohol and tobacco, in the United States. Cannabis consumption during pregnancy is increasing along with greater legal and social acceptance.

METHODS

We conducted a qualitative content analysis of 23 in-depth interviews with pregnant and lactating people in Massachusetts, a state that legalized cannabis for adult use in 2016. Our aim was to explore how policy constrains or facilitates people's ability to make informed decisions about cannabis use during pregnancy and lactation. Our analysis was conducted using an ecosocial approach, recognizing that the implementation and interpretation of cannabis policy can be understood at multiple levels, which interact with each other and shape the health and experiences of individuals. Additionally, this analysis was informed by a harm reduction approach in which we acknowledge the complexity surrounding cannabis use during pregnancy and lactation, while attempting to identify ways to reduce potentially harmful consequences.

RESULTS

Findings revealed that, despite the legal status of cannabis, there continues to be a lack of clarity for pregnant and lactating people regarding the legal implications of cannabis use. Inconsistent state and institutional policies about drug testing of mothers and newborns leave a cloud of fear hanging over the experiences of people who use cannabis and inhibit their ability to obtain expert advice from healthcare providers.

CONCLUSION

Decision makers in public and institutional policy should work to clarify and update policies regarding substance use during pregnancy following legalization of a new substance, and ensure that pregnant and lactating people are afforded the same legal protections as the general population.

Clinician responses to cannabis use during pregnancy and lactation: a systematic review and integrative mixed-methods research synthesis

BACKGROUND

Perinatal cannabis use is increasing, and clinician counselling is an important aspect of reducing the potential harm of cannabis use during pregnancy and lactation. To understand current counselling practices, we conducted a systematic review and integrative mixed-methods synthesis to determine "how do perinatal clinicians respond to pregnant and lactating patients who use cannabis?"

METHODS

We searched 6 databases up until 2021-05-31. Eligible studies described the attitudes, perceptions, or beliefs of perinatal clinician about cannabis use during pregnancy or lactation. Eligible clinicians were those whose practice particularly focusses on pregnant and postpartum patients. The search was not limited by study design, geography, or year. We used a convergent integrative analysis method to extract relevant findings for inductive analysis.

RESULTS

Thirteen studies were included; describing perspectives of 1,366 clinicians in 4 countries. We found no unified approach to screening and counselling. Clinicians often cited insufficient evidence around the effects of perinatal cannabis use and lacked confidence in counselling about use. At times, this meant clinicians did not address cannabis use with patients. Most counselled for cessation and there was little recognition of the varied reasons that patients might use cannabis, and an over-reliance on counselling focussed on the legal implications of use.

CONCLUSION

Current approaches to responding to cannabis use might result in inadequate counselling. Counselling may be improved through increased education and training, which would facilitate conversations to mitigate the potential harm of perinatal cannabis use while recognizing the benefits patients perceive.

Attitudes, beliefs and knowledge about medical cannabis among nurses and midwives in Cyprus: a cross-sectional descriptive correlational study

BACKGROUND

There is a lack of evidence on healthcare professionals' attitudes, knowledge, and beliefs about medical cannabis in Cyprus and across the world. Therefore, the present study aimed to explore the attitudes, beliefs, and knowledge about MC use among nurses and midwives in Cyprus. Special focus was given to differences across gender, age, religion, marital status, and years of work experience.

METHODS

A descriptive, cross-sectional correlational study with internal comparisons was conducted during the 26^th Nurses and Midwives Congress in Cyprus. All active nurses and midwives (convenience sampling), from the private and national healthcare services (n = 526) were eligible to participate. To analyze the data, the Pearson Chi-square test for group differences was employed, and descriptive and inferential statistics were assessed.

RESULTS

The final sample population consisted of 232 nurses and midwives (response rate of 46.4%). In total, 67(28.9%) participants were male, and 165(71.1%) were female. Cypriot nurses and midwives reported lack of knowledge regarding the risks and benefits about MC use to patients. However, specific number of participants believed MC use was considered acceptable for the patients with persistent muscle spasms, insomnia/sleeping disorders, mental health conditions, and terminal illnesses. The vast majority of the participants believed that formal training on MC should be integrated into academic programs, and expressed the necessity of urgent training under the current curriculum, as well as, educational training programs about MC use should be integrated into the practice/clinical practice. Concerning the socio-demographic characteristics of the participants, gender had a statistically significant positive effect on participants' attitudes and beliefs about MC (p < 0.01, 26.8% vs. 13.4%). Male and unmarried participants reported higher frequency about cannabis use for recreational purposes, compared with female group (p < 0.01, 22.8%Vs 11.4%). Unmarried participants agreed that using cannabis might develop serious mental health risks compared with married participants group (p < 0.05, 77.9% vs. 66.8%).

CONCLUSIONS

The conclusions seem to be rather recommending in favor of MC use. Participants proposed enriching nursing curricula with theoretical and clinical/laboratory courses about MC during studies and clinical practice. Additional tailoring interventions should be established to decrease recreational cannabis use among Cypriot nurses and midwives.

Societal Costs and Outcomes of Medical and Recreational Marijuana Policies in the United States: A Systematic Review

Significant support exists in the United States for legalization of marijuana/cannabis. As of 2021, 36 states and four territories approved the legalization of medical cannabis via medical marijuana laws (MMLs), and 15 states and District of Columbia (DC) have adopted recreational marijuana laws (RMLs). We performed structured and systematic searches of articles published from 2010 through September 2021. We assess the literature pertaining to adolescent marijuana use; opioid use and opioid-related outcomes; alcohol use; tobacco use; illicit and other drug use; marijuana growing and cultivation; employment, earnings, and other workplace outcomes; academic achievement and performance; criminal activity; perceived harmfulness; traffic and road safety; and suicide and sexual activity. Overall, 113 articles satisfied our inclusion criteria. Except for opioids, studies on use of other substances (illicit drugs, tobacco, and alcohol) were inconclusive. MMLs and RMLs do not generate negative outcomes in the labor market, lead to greater criminal activity, or reduce traffic and road safety.

Association of Comorbid Behavioral and Medical Conditions With Cannabis Use Disorder in Pregnancy

IMPORTANCE

Prenatal cannabis use continues to increase, yet studies of the demographic, psychiatric, and medical characteristics associated with cannabis use in pregnancy are limited by size and use of self-report, and often do not consider cannabis use disorder (CUD) or concomitant substance use disorders (SUDs). Understanding the factors associated with CUD in pregnancy is paramount for designing targeted interventions.

OBJECTIVE

To examine the prevalence of co-occurring psychiatric and medical conditions of US pregnant individuals hospitalized with and without CUD by concomitant SUDs.

DESIGN, SETTING, AND PARTICIPANTS

The study analyzed restricted hospital discharge data from the 2010 to 2018 Healthcare Cost and Utilization Project State Inpatient Databases in 35 states. Data were analyzed from January to August 2021. Weighted linear regressions tested whether the prevalence of psychiatric and medical conditions differed between individuals with and without a CUD diagnosis at hospitalization. Inpatient hospitalizations of pregnant patients aged 15 to 44 years with a CUD diagnosis were identified. Pregnant patients aged 15 to 44 years without a CUD diagnosis were identified for comparison. Patients were further stratified based on concomitant SUD patterns: (1) other SUDs, including at least 1 controlled substance; (2) other SUDs, excluding controlled substances; and (3) no other SUDs.

EXPOSURES

CUD in pregnancy.

MAIN OUTCOMES AND MEASURES

Prevalence of demographic characteristics, psychiatric disorders (eg, depression and anxiety), and medical conditions (eg, epilepsy and vomiting).

RESULTS

The sample included 20 914 591 hospitalizations of individuals who were pregnant. The mean (SD) age was 28.24 (5.85) years. Of the total number of hospitalizations, 249 084 (1.19%) involved CUD and 20 665 507 (98.81%) did not. The proportion of prenatal hospitalizations involving CUD increased from 0.008 in 2010 to 0.02 in 2018. Analyses showed significant differences in the prevalence of almost every medical and psychiatric outcome examined between hospitalizations with and without CUD diagnoses, regardless of concomitant SUDs. Elevations were seen in depression (0.089; 95% CI, 0.083-0.095), anxiety (0.072; 95% CI, 0.066-0.076), and nausea (0.036; 95% CI, 0.033-0.040]) among individuals with CUD only at hospitalization compared with individuals with no SUDs at hospitalization.

CONCLUSIONS AND RELEVANCE

Considerable growth was observed in the prevalence of CUD diagnoses among individuals hospitalized prenatally and in the prevalence of depression, anxiety, nausea, and other conditions in individuals with CUD at hospitalization. This study highlights the need for more screening, prevention, and treatment, particularly in populations with co-occurring CUD and psychiatric disorders. Research on the determinants and outcomes associated with CUD during pregnancy is needed to guide clinicians, policy makers, and patients in making informed decisions.

Clinician Attitudes, Training, and Beliefs About Cannabis: An Interprofessional Assessment

Background: Medical use of cannabis is growing in popularity across the United States, but medical education and clinician comfort discussing cannabis use for medical purposes have not kept pace. Materials and Methods: A total of 344 clinicians in the state of Pennsylvania (response rate 14%) completed a brief online survey about their attitudes, training, and experiences regarding medical cannabis and certifying patients to use medical cannabis. Results: Only 51% of clinicians reported completing any formal training on medical cannabis. Compared with noncertifying clinicians (pharmacists, nurse practitioners, and physician assistants), physicians were significantly more comfortable with patient use of medical cannabis, saw fewer risks, more benefits, and felt better prepared to discuss its use with vulnerable populations. All clinicians noted significant limitations to their understanding of how medical cannabis can affect patients, and many indicated a desire for more research and training to fill in gaps in their knowledge. Conclusions: Insufficient medical curricula on the medical uses of cannabis are available to interprofessional clinicians across their disciplines, and clinicians report significant deficits in their knowledge base about its effects. Additionally, these data suggest an urgent need to expand training opportunities to the full spectrum of clinicians as all are involved in caring for patients who use medical cannabis.

Chronic Pain Clinical and Prescriptive Practices in the Cannabis Era

BACKGROUND

To explore how health care providers in the United States are adapting clinical recommendations and prescriptive practices in response to patient use of medical cannabis (MC) for chronic pain symptoms.

DESIGN

Literature searches queried MeSH/Subject terms "chronic pain," "clinician," "cannabis," and Boolean text words "practice" and "analgesics" in EBSCOHost, EMBASE, PubMed, and Scopus, published 2010-2021 in the United States. Twenty-one primary, peer-reviewed studies met criteria.

METHODS

Studies are synthesized under major headings: recommending MC for chronic pain; MC and prescription opioids; and harm reduction of MC.

RESULTS

MC is increasingly utilized by patients for chronic pain symptoms. Clinical recommendations for or against MC are influenced by scopes of practice, state or federal laws, institutional policies, education, potential patient harm (or indirect harm of others), and perceived confidence. Epidemiologic and cohort studies show downward trajectories of opioid prescribing and consumption in states with legal cannabis. However, clinicians' recommendations and prescription practices are nonuniform. Impacts of cannabis laws are clear between nongovernmental and governmental institutions. Strategies addressing MC and opioid use include frequent visits, and, to reduce harm, suggesting alternative therapies and treating substance use disorders.

CONCLUSIONS

MC use for chronic pain is increasing with cannabis legalization. Provider practices are heterogenous, demonstrating a balance of treating chronic pain using available evidence, while being aware of potential harms associated with MC and opioids.

Marijuana liberalization policies and perinatal health

We studied the effect of marijuana liberalization policies on perinatal health with a multiperiod difference-in-differences estimator that exploited variation in effective dates of medical marijuana laws (MML) and recreational marijuana laws (RML). We found that the proportion of maternal hospitalizations with marijuana use disorder increased by 23% (0.3 percentage points) in the first three years after RML implementation, with larger effects in states authorizing commercial sales of marijuana. This growth was accompanied by a 7% (0.4 percentage points) decline in tobacco use disorder hospitalizations, yielding a net zero effect over all substance use disorder hospitalizations. RMLs were not associated with statistically significant changes in newborn health. MMLs had no statistically significant effect on maternal substance use disorder hospitalizations nor on newborn health and fairly small effects could be ruled out. In absolute numbers, our findings implied modest or no adverse effects of marijuana liberalization policies on the array of perinatal outcomes considered.

Pregnant people's experiences discussing their cannabis use with prenatal care providers in a state with legalized cannabis

BACKGROUND

As cannabis legalization spreads, so do concerns about potential harms from use during pregnancy. Legalization may facilitate improved patient-provider interactions about cannabis use. Yet little is known about pregnant people's discussions of cannabis use with healthcare providers in an environment where recreational cannabis is legal.

METHODS

In May-August 2019, we conducted semi-structured in-depth interviews with 33 pregnant or postpartum people in California who used cannabis during pregnancy, and explored their discussions with healthcare providers about their cannabis use. We audio-recorded and transcribed interviews, and conducted thematic analysis using inductive and deductive methods.

RESULTS

Participants were diverse by age, race/ethnicity, and socio-economic position. Most reported daily cannabis use, both before and during pregnancy. Most participants did not disclose their cannabis use to their prenatal care providers, due to fears of being reported to child protective services (CPS), or fears of provider judgment. Participants reported that few providers initiated any discussions about cannabis use in pregnancy with them; some participants interpreted this omission as tacit endorsement of cannabis use in pregnancy. When participants and providers did discuss cannabis use in pregnancy, participants heard a wide range of sometimes-conflicting health messages, as well as some legal threats.

CONCLUSIONS

This study documents notable deficits in patient-provider interactions about cannabis. Pregnant patients' fears of being reported to CPS and separated from their children for cannabis use persist despite cannabis legalization. Providers' role as potential reporters to CPS appears to pose a significant barrier to comprehensive, compassionate counseling and education on cannabis use in pregnancy.

Ask Your Provider About Cannabis: Increasing Nurse Practitioner Knowledge and Confidence

Introduction:

Nurse practitioners (NPs) are authorizing providers for medical cannabis in many states, and may serve as a primary care clinician. We report findings from a nationally distributed 2-h continuing education (CE) module aimed to improve knowledge, confidence, and willingness to communicate with patients about cannabis.

Methods:

Data were electronically obtained from the CE platform pre- and post-test (n=289) and a follow-up survey sent within 3 months postcompletion (n=184, 63%). Pre- and post-testing assessed cannabis pharmacodynamics, law, evidence-based use, metabolism, pharmacokinetics, laboratory testing, adverse reactions, and drug–drug interactions. The subsequent survey asked about changes in practice behavior, including willingness and self-identified recommendations for use. Quantitative and qualitative descriptive analysis and repeated-measures analysis of variance were used to analyze CE impact.

Results:

Significant improvement in scores was noted from pretest to post-test for all content with a mean improvement of 39.3% (95% CI: 30.6–47.9%). The greatest increases were for metabolism, pharmacokinetics, and drug–drug interaction content. At follow-up, 52.2% reported that the CE changed their attitudes about cannabis and although 86% had rarely or never applied it yet in practice, 92% reported they were now likely to inquire about cannabis use in their patients and 84% were likely to counsel patients about it. Although self-identified recommendations overlapped by conditions, some were unique to CBD (complex regional pain syndrome, migraine, mood disorder, smoking cessation) and THC products (appetite, cachexia, depression, fibromyalgia, HIV, seizure disorder, stress, and weight loss). Pain was the most common condition for recommendation of both CBD and THC, followed by anxiety and arthritis.

Conclusions:

NPs gained key knowledge about cannabis, which may impact patient care and prescribing practices. The educational module resulted in more willingness to discuss and counsel patients about cannabis, even if practitioner attitudes did not change.

Parent and patient perceptions of medical marijuana in the childhood cancer context

BACKGROUND

Medical marijuana (MM) is legal in 34 US jurisdictions. Yet, little is known about patient and parent perceptions of MM in pediatric cancer care. We examined attitudes, beliefs, and experiences regarding MM among parents of children with cancer and adolescent and young adult (AYA) patients, to help frame future research initiatives.

PROCEDURE

In this qualitative study, we conducted semi-structured, one-on-one interviews with parents and AYAs at a comprehensive cancer center. Interviews were audio-recorded, transcribed, and coded using both descriptive and inductive coding approaches. We used content and framework analysis to identify key themes.

RESULTS

Fifteen parents and 15 AYAs enrolled. Participants were generally receptive to MM use, concurrently weighing benefits and risks. Participants most often endorsed MM use for relief of nausea, anorexia, and pain. Simultaneously, participants identified concerns about MM, including potential physiologic and psychological effects on children and lack of research. However, concerns were frequently minimized, relative to chemotherapy or supportive care medications with perceived greater side effect profiles. Many participants expressed uncertainty regarding legal access, citing complex processes to obtain MM. Few participants had discussed MM with their oncologist, instead seeking guidance from the internet, family, or peers. Importantly, we elicited several misconceptions regarding MM, including its utility as cancer-directed therapy.

CONCLUSION

Patients and families are receptive to using MM, motivated by potential for symptom relief and cancer-directed effects. Yet, lack of empiric evidence is a barrier, underscoring the need for robust clinical trial data to support MM recommendations and use.

Cannabis and the Gut-Brain Axis Communication in HIV Infection

People living with HIV infection (PWH) disclose that cannabis is an effective strategy for alleviating symptoms associated with HIV disease. However, some medical providers feel ill-informed to engage in evidence-based conversations. HIV leads to alterations in the gut microbiome, gut-brain axis signaling, and chronic inflammation. The endocannabinoid system regulates homeostasis of multiple organ systems. When deficient, dysregulation of the gut-brain axis can result in chronic inflammation and neuroinflammation. Cannabis along with the naturally occurring endocannabinoids has antioxidant and anti-inflammatory properties that can support healing and restoration as an adjunctive therapy. The purpose of this literature review is to report the physiologic mechanisms that occur in the pathology of HIV and discuss potential benefits of cannabinoids in supporting health and reducing the negative effects of comorbidities in PWH.

Perception and Belief on Cannabinoids: A Comparative Study of Rheumatology Patients and Primary Care Physicians on the Use of Cannabinoids for Pain Management

Introduction

With the recent increase in popularity of cannabinoids in the management of chronic pain, the inquisitiveness among our patients and health care professionals are probably now at its peak. Many treating health care professionals in their clinical practice come across patients who either use cannabinoids or are interested in their efficacy and side effects. As there is paucity of data and research about their use in rheumatology, patient's self-reported responses and experience of primary care physicians (General Practitioners [GPs]) can guide in expanding our knowledge.

Methods

Ours was an observational, cross-sectional study among rheumatology patients and GPs in the Leicestershire area. Initial questionnaire was designed by authors addressing demographics, knowledge, experience and perception. This was piloted among patients and GPs and improvised, redesigned and used for the study. The study design consisted of two arms: first arm including GPs and second arm rheumatology patients.

Results

Arm 1 consisted of 100 GPs with median age group of 30-40 years. 34% GPs experienced their patients inquiring about cannabinoids. 78% did not believe cannabinoids benefited the patients. On a scale of 0-10, the mean benefit in managing pain 3.2 + 2.5. Arm 2 consisted of 102 patients. 16% reported using cannabinoids for managing their chronic pain. The users reported significant improvement in pain compared to non-users (p=0.002). On comparing the perception of cannabinoids between GPs and patients, there was a statistically significant difference regarding awareness and effectiveness (p<0.001).

Conclusion

With the paucity of data and research about the use of cannabinoids in rheumatology, the patient self-reported responses provided an estimate as to their efficacy. This was significantly different from the GP perception. Disease and drug-focused research is need of the hour. To our knowledge, this is the First Single Centre study in the UK evaluating GP and rheumatology patient perception on cannabinoids.

Medical cannabis attitudes, beliefs and knowledge among Greek-Cypriot University nursing students

OBJECTIVES

We aimed to explore the attitudes, beliefs and knowledge of nursing students about medical cannabis use in Cyprus. Special focus was given on gender differences and the year of studentship.

DESIGN

A descriptive, cross-sectional study with internal comparisons was performed on undergraduate nursing students in Cyprus. Pearson chi-square test for group differences was employed. A total of 252 questionnaires were anonymously and voluntarily completed. Descriptive and inferential statistics were assessed.

RESULTS

21 % male and 79 % female were included in the sample (response rate 62.7 %). Third year student participants reported more frequent use of cannabis for all reasons - for themselves, friends and family (p < 0.05). Furthermore, they reported more positive statements on the effectiveness of medical cannabis in treating medical conditions (p < 0.05). Moreover, female students reported more frequently the necessity of incorporating medical cannabis training into academic curricula (p < 0.05).

CONCLUSIONS

Given the reported lack of knowledge, enrichment of nursing curricula with medical cannabis related courses and lectures, both theoretical and clinical/ laboratory, are proposed. The associations of attitudes with gender and years of studentship point to the need of taking these factors into consideration for relevant education and training.

Survey of Pharmacists' Knowledge of Connecticut's Medical Cannabis Program

Introduction: Over the last few years, a growth in research and interest in medical cannabis (most often referred to as medical marijuana) use have occurred nationally. Medical cannabis has become a treatment option for disease conditions, such as epilepsy, wasting syndrome associated with AIDs, and post-traumatic stress disorder, when traditional medication is ineffective. Objectives: The objectives were to identify knowledge deficits of the medical cannabis program (MCP) in Connecticut among Connecticut pharmacists and the impact of MCP on Connecticut pharmacy practice and concerns Connecticut pharmacists have regarding medical cannabis use. Methods: A cross-sectional survey through an online platform, Google forms, was administered for 2 months (October 15, 2017-December 15, 2017). An e-mail containing the link to the survey was e-mailed to all pharmacists whose e-mail addresses were available from the State of Connecticut's Commission of Pharmacy database (n = 6182). Of those with available e-mail addresses, only 5653 pharmacists received the e-mail; the others were rejected upon receipt of our e-mail. Our survey consists of 16 items related to pharmacist demo- graphic information, knowledge assessment, impact on pharmacists' practice, and concerns stemming from medical cannabis. Results: Only 51 (15.2%) respondents believed that Connecticut MCP would impact their practice. Only 39 (11.6%) respondents selected the two correct requirements for patient registration and correctly identified the wrong choices. Only 81 (24.2%) respondents identified the correct approved dose (maximum allowable monthly amount of 2.5 ounces) of medical cannabis. Sixty-eight (20.2%) respondents correctly identified all three approved conditions and all other incorrect conditions. Sixty-five (19.40%) respondents correctly identified all roles of dispensary pharmacists. Majority of respondents, 243 (72.5%), expressed their concern about federal laws regarding cannabis. A total of 98 (29.3%) respondents thought that they were knowledgeable enough about the side effects of medical cannabis to provide appropriate counseling to patients. Conclusion: Overall, the results of our survey found that Connecticut licensed pharmacists had lack of complete and accurate knowledge regarding the state's MCP. As more states legalize medical cannabis, it will be imperative that education of pharmacists and other health care professionals about the MCP and the clinical use of cannabis occur.

Medical cannabis education among healthcare trainees: A scoping review

OBJECTIVES

It has been previously demonstrated that healthcare professionals would like additional education on medical cannabis. However, there has not yet been a review of the status of medical cannabis curriculum for medical and allied healthcare trainees worldwide, even though future healthcare workers will be placed on the forefront of patient care and must be prepared to counsel patients. This study was designed to address this gap in knowledge.

DESIGN

A search syntax was generated and databases PubMed, ERIC, CINAHL, and Web of Science were searched for relevant articles. A grey literature search of Google Scholar, MedEd, Medline, and the Proquest Dissertations and Theses section was also performed. All titles and abstracts were screened. Selected articles were subsequently screened using predetermined inclusion and exclusion criteria.

RESULTS

Allied healthcare trainees lacked sufficient knowledge about medical cannabis and did not feel prepared to counsel patients on this subject. Additionally, they expressed a growing interest in medical cannabis and would like more standardized education on the topic. Finally, faculty and deans in various institutions agreed on the need to educate students on the subject, and aimed to implement courses on medical cannabis or expand their existing curricula.

CONCLUSIONS

While the medical cannabis landscape is developing, medical and allied health students are not properly educated and knowledgeable on this emerging field of clinical care. The findings suggest that the implementation of competencies-based curricula on medical cannabis is essential for medical and allied healthcare trainees to have the appropriate level of knowledge to counsel and educate their patients.

Review of NIOSH Cannabis-Related Health Hazard Evaluations and Research

Since 2004, the National Institute for Occupational Safety and Health (NIOSH) has received 10 cannabis-related health hazard evaluation (HHE) investigation requests from law enforcement agencies (n = 5), state-approved cannabis grow operations (n = 4), and a coroner's office (n = 1). Earlier requests concerned potential illicit drug exposures (including cannabis) during law enforcement activities and criminal investigations. Most recently HHE requests have involved state-approved grow operations with potential occupational exposures during commercial cannabis production for medicinal and non-medical (recreational) use. As of 2019, the United States Drug Enforcement Administration has banned cannabis as a Schedule I substance on the federal level. However, cannabis legalization at the state level has become more common in the USA. In two completed cannabis grow operation HHE investigations (two investigations are still ongoing as of 2019), potential dermal exposures were evaluated using two distinct surface wipe sample analytical methods. The first analyzed for delta-9-tetrahydrocannabinol (Δ9-THC) using a liquid chromatography and tandem mass spectrometry (LC-MS-MS) method with a limit of detection (LOD) of 4 nanograms (ng) per sample. A second method utilized high performance liquid chromatography with diode-array detection to analyze for four phytocannabinoids (Δ9-THC, Δ9-THC acid, cannabidiol, and cannabinol) with a LOD (2000 ng per sample) which, when comparing Δ9-THC limits, was orders of magnitude higher than the LC-MS-MS method. Surface wipe sampling results for both methods illustrated widespread contamination of all phytocannabinoids throughout the tested occupational environments, highlighting the need to consider THC form (Δ9-THC or Δ9-THC acid) as well as other biologically active phytocannabinoids in exposure assessments. In addition to potential cannabis-related dermal exposures, ergonomic stressors, and psychosocial issues, the studies found employees in cultivation, harvesting, and processing facilities could potentially be exposed to allergens and respiratory hazards through inhalation of organic dusts (including fungus, bacteria, and endotoxin) and volatile organic compounds (VOCs) such as diacetyl and 2,3-pentanedione. These hazards were most evident during the decarboxylation and grinding of dried cannabis material, where elevated job-specific concentrations of VOCs and endotoxin were generated. Additionally, utilization of contemporary gene sequencing methods in NIOSH HHEs provided a more comprehensive characterization of microbial communities sourced during cannabis cultivation and processing. Internal Transcribed Spacer region sequencing revealed over 200 fungal operational taxonomic units and breathing zone air samples were predominantly composed of Botrytis cinerea, a cannabis plant pathogen. B. cinerea, commonly known as gray mold within the industry, has been previously associated with hypersensitivity pneumonitis. This work elucidates new occupational hazards related to cannabis production and the evolving occupational safety and health landscape of an emerging industry, provides a summary of cannabis-related HHEs, and discusses critical lessons learned from these previous HHEs.

Practice Patterns and Training Needs Among Physicians Certifying Patients for Medical Marijuana in Florida

BACKGROUND

Little is known about the clinical training or practice experiences among physicians who certify patients for medical marijuana. The objective of this study was to determine information sources, factors influencing recommendations, clinical practices in patient assessment, communications, and recommendations, and priority areas for additional training among physicians who certify patients for medical marijuana.

METHODS

A cross-sectional state-wide anonymous survey of registered medical marijuana physicians in Florida between June and October 2020 was administered. Numerical responses were quantified using counts and percentages. The frequencies for "often" and "always" responses were aggregated when appropriate.

RESULTS

Among 116 respondents, the mean (standard deviation) age was 57 (12) years old, and 70% were male. The most frequently used information sources were research articles (n = 102, 95%), followed by online sources (n = 99, 93%), and discussions with other providers and dispensary staff (n = 84, 90%). Safety concerns were most influential in patient recommendations (n = 39, 39%), followed by specific conditions (n = 30, 30%) and patient preferences (n = 26, 30%). Ninety-three physicians (92%) reported they "often" or "always" perform a patient physical exam. Eighty-four (77%) physicians provided specific administration route recommendations. Half (n = 56) "often" or "always" provided specific recommendations for Δ-9-tetrahydrocannabinol: cannabidiol ratios, while 69 (62%) "often" or "always" provided specific dose recommendations. Online learning/training modules were the most preferred future training mode, with 88 (84%) physicians "likely" or "very likely" to participate. The top 3 desired topics for future training were marijuana-drug interactions (n = 84, 72%), management of specific medical conditions or symptoms (n = 83, 72%), and strategies to reduce opioids or other drugs use (n = 78, 67%).

CONCLUSIONS

This survey of over 100 medical marijuana physicians indicates that their clinical practices rely on a blend of research and anecdotal information sources. While physicians report clinical factors as influential during patient recommendation, patient assessment practices and treatment regimen recommendations vary substantially and rely on experimental approaches. More research is needed to inform evidence-based practice and training, especially considering details on drug interactions, risk-benefit of treatment for specific clinical conditions, and strategies to reduce opioid use.

The Attitudes and Beliefs of Family Physicians Regarding the Use of Medical Cannabis, Knowledge of Side Effects, and Barriers to Use: A Comparison Between Residents and Specialists

BACKGROUND

Israel has a regulated system with clearly defined indications for treatment with medical cannabis.

STUDY QUESTION

The main question was whether family physicians in southern Israel face barriers/knowledge gaps in prescribing cannabis for medical indications. The secondary question was whether there was a difference between residents and specialists in family medicine.

STUDY DESIGN

A questionnaire-based cross-sectional study.

MEASURES AND OUTCOMES

Attitudes of the participating physicians on the use of medical cannabis; comparison of attitudes of specialists in family medicine and residents on the use of medical cannabis.

RESULTS

One hundred and fifty-two family physicians participated in the study including 48 residents. More than 78% supported the use of medical cannabis and about 63% supported it's legalization. About 84% of the physicians believed that medical cannabis helped cancer patients and 82% believed it helped in the chronic pain. Only 28.3% believed that family physicians should recommend the use of medical cannabis. The physicians were well aware of the psychiatric (82%) and the neurological (78%) adverse effects of medical cannabis. Most (68%) were not willing to prescribe medical cannabis. No socio-demographic characteristic was associated with willingness to prescribe cannabis. About 95% of the physicians believed that the main barrier to recommending treatment was its potential for abuse, 66% percent-the danger that it would leak to the general public. About 60% of the specialists were not prepared to undergoing training in the prescription of medical cannabis compared with 31% of the residents (P = 0.004).

CONCLUSIONS

Family physicians are concerned about recommending medical cannabis. It is encouraging that residents are motivated to undergo training to prescribe medical cannabis. There remain medical indications and adverse effects that family physicians are less aware of. Further studies should focus on effective ways to improve the level of physicians' knowledge on the issue.

Attitudes and knowledge about cannabis and cannabis-based therapies among US neurologists, nurses, and pharmacists

Use of cannabinoid therapies is on the rise in the United States, but responses of healthcare professionals and their knowledge of these therapies have been mixed. More information is needed about factors associated with healthcare professionals' attitudes and knowledge about medical cannabis. We conducted an online survey of US-based neurologists, nurse practitioners (NPs)/nurses, and pharmacists in August-September of 2018 (n = 451). We constructed perceived knowledge and attitudes scales and a knowledge index from multiple items and assessed state cannabis laws, participant's sociodemographics, workplace type and policies, and patient population. We used ordinary least-squares regression to examine associations among study variables. Over 80% of participants supported use and legalization of medical cannabis, especially cannabidiol (CBD) for epilepsy and when prescribed by a medical provider, but 40-50% (depending on item) felt unfamiliar with cannabinoid pharmacology and clinical applications. A total of 43% favored legal recreational cannabis. Pharmacists scored higher on the knowledge test than neurologists and NPs/nurses, but NPs/nurses had more favorable attitudes than neurologists and higher perceived knowledge than pharmacists. Both knowledge indicators predicted attitudes. State cannabis access and favorable workplace policies were associated with higher knowledge and more favorable attitudes. Healthcare professionals see potential in cannabis therapies but report significant knowledge gaps. Professional cannabinoid education is needed to address growing patient and provider demand for knowledge about cannabinoid therapies.

Comparison of Male and Female Patients in Louisiana Medical Marijuana Dispensaries

Relatively little is known in terms of patient demographics, indications, previous cannabis use, or the forms and dosages of medical marijuana (MM) dispensed for patients at MM dispensaries. Even less is known in terms of how male and female patients may differ in each of these aspects. The goal of the current study was to examine each of these variables using a retrospective analysis of deidentified patient data from MM dispensaries in Louisiana. Deidentified data were analyzed from web-based pharmacist-patient consultations at MM dispensaries throughout Louisiana. Data were collected during the first 6 months following the initiation of the MM dispensing program in Louisiana. A total of 1195 MM patients (598 male/597 female) were included in the analyses. The average age of the sample was 51.9 years (±14.8) and it was composed primarily of white patients (86.7%). Males and females were nearly identical in terms of average age, race, previous cannabis use, indication profile, and MM recommendations. Differences between males and females were observed in terms of opioid use, history of psychosis, presence of more than one indication, and the duration of previous cannabis use. Our data indicate that, in MM dispensaries of the Deep South state, there are numerous similarities-and some potentially important differences-between male and female MM patients. The importance of these differences, and the importance of continued data collection/analysis, for improving MM dispensing are discussed.

Knowledge, Practices, and Attitudes of Washington State Health Care Professionals Regarding Medical Cannabis

Introduction: Health care providers in Washington State practice in a unique environment where both medical and recreational cannabis use are legal. Five types of health care providers can authorize medical cannabis. State-certified medical cannabis consultants may advise patients in a cannabis retail store regarding use and consumption. Washington State's health care professionals' perspectives about medical cannabis can inform policy-makers nationwide who are navigating challenges posed by legalization of medical and recreational cannabis. Materials and Methods: A cross-sectional mixed-mode survey using a 26-item questionnaire was administered to a random sample of actively licensed health care professionals legally permitted to provide medical cannabis authorizations in Washington State. We describe participant demographics and summarize responses to survey questions. We report comparisons across provider types using Fisher's exact tests with a level of significance of p<0.01. Results: Among the 1440 health care professionals invited to participate in the study, 310 respondents met eligibility criteria (response rate 24%). Only 57 respondents (18.4%) indicated having ever issued a medical cannabis authorization. Among them, 6, all naturopaths, had provided more than 500. Over half (58%) reported that they did not feel they had the knowledge and skills necessary to provide authorizations. Depending on the condition, 29-93% of respondents correctly identified conditions that qualified a patient to receive a medical cannabis authorization. Very few knew that employers are not required to provide accommodations for medical cannabis. Health care professionals (64.8%) served as the most frequent source of information regarding cannabis risks and benefits. Over half (62%) strongly or somewhat agreed that the Drug Enforcement Agency should reschedule cannabis to make it legal at the federal level. Conclusion: A wide range of knowledge was exhibited within our sample of health care professionals regarding qualifying conditions for medical cannabis. As more states adopt comprehensive medical cannabis laws, health care professionals must be prepared to provide information to patients regarding the effects, risks, and benefits of cannabis. Standardized education could ensure that health care professionals are prepared to responsibly promote the use of cannabis when indicated for medically appropriate symptoms and conditions. A rational approach to medical cannabis is needed to assure that unforeseen consequences are mitigated.

Ohio physician attitudes toward medical Cannabis and Ohio's medical marijuana program

Background

Ohio’s medical cannabis program is one of three states that require physicians to become certified to recommend medical cannabis to their patients. The current study examines the attitudes of Ohio physicians toward medical cannabis and Ohio’s program to ascertain how likely physicians are to participate in Ohio’s program.

Methods

Physicians were invited to complete an internet survey that asked them about their concerns regarding medical marijuana, Ohio’s program, their likelihood of recommending medical cannabis, and becoming certified within the state. Ordinal and logistic regressions were used to understand the physicians’ likelihood of recommending cannabis, of becoming certified to recommend cannabis, and their attitude toward Ohio’s program.

Results

In total, 11,665 physicians licensed to practice in Ohio were contacted by email, and 344 responses were received for a response rate of 2.9%. Only 42 physicians reported being certified or had plans to become certified to recommend marijuana, and 62% were unlikely to recommend marijuana to their patients. Overall, the belief that medical cannabis should be legal had the greatest association with the likelihood of recommending cannabis (OR = .37, 95% CI = .24–.54), of becoming certified (OR = .21, 95% CI = .10–.38), and believing that Ohio’s program is too strict (OR = .39, 95% CI = .30–.51). However, the study sample precludes generalizing the results beyond this study. The 2.9% response rate could indicate a bias toward physicians who have strong opinions about the legality of medical cannabis.

Conclusion

The results show that many physicians have concerns about medical cannabis and Ohio’s program, and many physicians may not participate in the program. This could be a problem for patients who would like to use cannabis for medical reasons; therefore, these patients, may need to utilize one physician for cannabis and another for regular care. Physicians will likely be caring for patients who are using cannabis regardless of their own beliefs about it. The lack of training regarding cannabis in healthcare, along with requiring “certified recommenders” to have training could result in a fractured healthcare system.

Moving beyond perceived riskiness: Marijuana-related beliefs and marijuana use in adolescents

Background: Perceived riskiness of marijuana in adolescents has been trending downward in the context of increasing legality and availability. Low perceived riskiness has been associated with marijuana use though evidence is lacking on associations among use and more specific claims about marijuana's safety and benefit, improved understanding of which could guide clinical interventions to reduce use. Methods: We analyzed cross-sectional survey data collected from 502 adolescents aged 14-18 years recruited from an urban adolescent primary care clinic. Self-report questionnaires were administered via tablet computer. Use of marijuana was assessed with a brief validated screening tool, and agreement with each of five statements about marijuana's riskiness and health properties were reported using a four-point Likert scale. We conducted multivariable logistic regressions to determine the association between perceived riskiness and other marijuana-related beliefs and past-year marijuana use. Results: In total, 149 adolescents reported past-year marijuana use (29.7%). High overall perceived risk was associated with lower rates of past-year use (AOR 0.27, 95%CI: 0.15-0.48). Agreement with positive health beliefs that "marijuana can help teenagers focus in school" and that "marijuana is safe because it's natural" were associated with past-year marijuana use (respectively, AOR 5.50, 95%CI: 3.06-9.88 and AOR 6.61, 95%CI: 3.59-12.19) while agreement with negative health beliefs that "marijuana can affect youth even after they don't feel high anymore" and that "marijuana can be addictive" were both associated with lower rates of use (AOR 0.56, 95%CI: 0.31-0.99, and AOR 0.30, 95%CI: 0.16-0.56, respectively), adjusting for sociodemographic factors and use of other substances. Conclusions: Marijuana use varied in association with beliefs about its beneficial and harmful health properties. Clinical interventions that target specific marijuana-related health beliefs including unfounded claims of benefit may provide robust talking points for centering provider guidance and public health messaging.

Surveys of pharmacy students and pharmacy educators regarding medical marijuana

INTRODUCTION

In this study, a cohort of Ohio pharmacy students were surveyed about knowledge and attitudes regarding medical marijuana (MMJ). Pharmacy educators in legalized states were asked how MMJ education was incorporated into pharmacy curricula.

METHODS

Pharmacy students from six colleges were emailed surveys. Pharmacy educators from 79 colleges in states with legal MMJ programs were emailed regarding curricular content covering MMJ.

RESULTS

A total of 319 student respondents received scores between 50 and 60% on knowledge-based questions. Students favored legalization of medical, but not recreational marijuana; they are not confident in ability to counsel; they believe little education on MMJ is provided in pharmacy school; and feel that more education is needed on MMJ. Students supporting MMJ were more likely to support recreational use of marijuana (p < 0.001), and education about MMJ (p < 0.001). Students in advanced years were less willing to dispense medical marijuana (p < 0.01), and less likely to support pharmacist availability for counseling (p < 0.05). Sixty-two percent of colleges who responded to the survey in legalized states provided education on MMJ to pharmacy students. Sixty-four percent of colleges responding who provided MMJ education offered a required course; 84.6% educated on indications and misuse/abuse; 92.3% on side effects, and adverse drug reactions; 53.8% on drug interactions.

CONCLUSION

Ohio pharmacy student knowledge regarding medical marijuana is low. Students believe pharmacists should be available for counseling on MMJ; they feel unprepared to dispense MMJ, and would like more education on MMJ. Some colleges of pharmacy in the US report providing MMJ education; extent is unknown.

Medical Cannabis Use in Glioma Patients Treated at a Comprehensive Cancer Center in Florida

Background: Glioma is a devastating primary tumor of the central nervous system with difficult-to-manage symptoms. Cannabis products have been postulated to potentially benefit glioma patients. Recent state legalization allowed investigators an opportunity to study glioma patients' adoption of medical marijuana (MM). Objective: Our goals were to: (1) determine the prevalence of marijuana use, both through physician recommendation and self-medication, and (2) evaluate its perceived risks and benefits in glioma patients. Design: Self-report data were collected and descriptive analyses were conducted. Setting/Subjects: Participants were adult, English-speaking patients undergoing treatment for primary non-recurrent malignant glioma in neuro-oncology clinics at an NCI-designated Comprehensive Cancer Center. Measurements: The survey on MM was adapted from previous research and included questions on knowledge and attitudes toward MM; use, frequency, type, and sourcing of MM; and reasons for use of MM and perceived symptom relief among users. Results: A total of 73 patients were surveyed. The majority of participants were aware that MM was legal in the state, and most reported learning of this through the media. Over 70% of participants reported having considered using MM, and a third reported using marijuana products after their diagnosis. Most received recommendations from friends/family rather than a medical provider, and only half of the users had obtained a physician's recommendation. Users generally reported benefits. Conclusions: With the increasing national conversation that accompanies legalization, glioma patients are pursuing marijuana for the treatment for their symptoms. More research and education is needed to bring health care providers into the conversation.

Women's perspectives about cannabis use during pregnancy and the postpartum period: An integrative review

Cannabis is the most commonly used illicit drug among general and pregnant populations. Despite recommendations to abstain from cannabis use, its use is increasing during the perinatal period. In this integrative review, we aim to understand women's perspectives about the health aspects of perinatal cannabis use. The following databases were searched: MEDLINE, PsycInfo, EMBASE, and CINAHL. We included quantitative and qualitative studies with a primary focus on perinatal cannabis use. The methodological quality of the included studies was appraised using appropriate checklists. Extracted data were integrated into a single data matrix and iteratively compared across studies to summarize and synthesize the data. Full text of 33 citations was retrieved and reviewed of which 6 studies met the inclusion criteria. Women who continued to use cannabis during pregnancy often perceived no general or pregnancy-specific risk compared to nonusers. The uncertainty regarding adverse perinatal consequences, its perceived therapeutic effects, and lower costs of cannabis compared to that of cigarettes contributed to cannabis use. A lack of communication with health care providers regarding the health aspects of cannabis was evident. Women perceived this lack of counseling as an indication that adverse outcomes associated with cannabis use are not significant. Women's perceptions of health risks associated with cannabis use are important factors in the decision-making process regarding use or cessation, particularly as legal concerns are fading away. A discussion about health concerns surrounding cannabis use may influence women's perceptions of risk and help them to make informed choices.

Patients' and clinicians' perspectives of co-use of cannabis and opioids for chronic non-cancer pain management in primary care

BACKGROUND

The prevalence of opioid-associated morbidity and mortality underscores the need for research on non-opioid treatments for chronic non-cancer pain (CNCP). Pain is the most common medical condition for which patients request medical cannabis. Limited research indicates that patients are interested in cannabis as a potential addition to or replacement for opioid medication. This analysis reports on CNCP patient and clinician perceptions about the co-use of cannabis and opioids for CNCP management.

METHODS

We interviewed 23 clinicians and 46 CNCP patients, using semi-structured interview guides, from six safety-net clinics across the San Francisco Bay Area, and 5 key stakeholders involved in CNCP management. We used a modified grounded theory approach to code and analyze transcripts.

RESULTS

CNCP patients described potential benefits of co-use of cannabis and opioids for pain management and concerns about dosing and addictive potential. Patients reported seeking cannabis when unable to obtain prescription opioids. Clinicians stated that their patients reported cannabis being helpful in managing pain symptoms. Clinicians expressed concerns about the potential exacerbation of mental health issues resulting from cannabis use.

CONCLUSION

Clinicians are hampered by a lack of clinically relevant information about cannabis use, efficacy and side-effects. Currently no guidelines exist for clinicians to address opioid and cannabis co-use, or to discuss the risk and benefits of cannabis for CNCP management, including side effects. Cannabis and opioid co-use was commonly reported by patients in our sample, yet rarely addressed during clinical CNCP care. Further research is needed on the risks and benefits of cannabis and opioid co-use.