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Gabarin A, Yarmolinsky L, Budovsky A, Khalfin B, Ben-Shabat S. Cannabis as a Source of Approved Drugs: A New Look at an Old Problem. Molecules 2023; 28:7686. [PMID: 38067416 PMCID: PMC10707504 DOI: 10.3390/molecules28237686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 12/18/2023] Open
Abstract
Cannabis plants have been used in medicine since ancient times. They are well known for their anti-diabetic, anti-inflammatory, neuroprotective, anti-cancer, anti-oxidative, anti-microbial, anti-viral, and anti-fungal activities. A growing body of evidence indicates that targeting the endocannabinoid system and various other receptors with cannabinoid compounds holds great promise for addressing multiple medical conditions. There are two distinct avenues in the development of cannabinoid-based drugs. The first involves creating treatments directly based on the components of the cannabis plant. The second involves a singular molecule strategy, in which specific phytocannabinoids or newly discovered cannabinoids with therapeutic promise are pinpointed and synthesized for future pharmaceutical development and validation. Although the therapeutic potential of cannabis is enormous, few cannabis-related approved drugs exist, and this avenue warrants further investigation. With this in mind, we review here the medicinal properties of cannabis, its phytochemicals, approved drugs of natural and synthetic origin, pitfalls on the way to the widespread clinical use of cannabis, and additional applications of cannabis-related products.
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Affiliation(s)
- Adi Gabarin
- The Department of Clinical Biochemistry & Pharmacology, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva 84105, Israel; (A.G.); (L.Y.); (B.K.)
| | - Ludmila Yarmolinsky
- The Department of Clinical Biochemistry & Pharmacology, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva 84105, Israel; (A.G.); (L.Y.); (B.K.)
| | - Arie Budovsky
- Research and Development Authority, Barzilai University Medical Center, Ashkelon 7830604, Israel;
| | - Boris Khalfin
- The Department of Clinical Biochemistry & Pharmacology, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva 84105, Israel; (A.G.); (L.Y.); (B.K.)
| | - Shimon Ben-Shabat
- The Department of Clinical Biochemistry & Pharmacology, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva 84105, Israel; (A.G.); (L.Y.); (B.K.)
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Damisa J, Petohazi A, Jalil H, Richardson M. Is Cannabis Effective in the Treatment of Chronic Back Pain? Cureus 2023; 15:e43220. [PMID: 37692601 PMCID: PMC10490377 DOI: 10.7759/cureus.43220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Cannabis is commonly recognized as a recreational substance. It has been explored for its potential therapeutic applications in addressing various conditions, such as depression, anxiety, sleep disorders, neurological disorders, and chronic low back pain, which affect a significant portion of the population. In the United Kingdom, cannabis has been recognized and licensed for medical use since November 2018, with about 12 National Health Service prescriptions in circulation largely due to patient pressure, with support from media campaigns for its use when there was growing evidence of its use in intractable epilepsy. Cannabis is beginning to gain traction as an alternative or even a complementary drug to opiates with some pre-clinical studies showing opiate-sparing effects. Despite references to its therapeutic use, cannabis as a therapeutic drug has been controversial due to the negative perception of its use as a recreational drug. As a result, there have been challenges in changing the perception of healthcare authorities and clinicians on the use of cannabis as a therapeutic tool for pain relief. The stigma associated with cannabis could be responsible for the paucity of randomized controlled trials on the efficacy of medical cannabis, further decreasing the credibility of the few trials conducted.
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Affiliation(s)
- Josiah Damisa
- Orthopedic Surgery, Royal Preston Hospital, Preston, GBR
| | | | - Hassan Jalil
- Orthopedic Surgery, Royal Preston Hospital, Preston, GBR
| | - Michelle Richardson
- Orthopedic Surgery, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, GBR
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HaGani N, Sznitman S, Dor M, Bar-Sela G, Oren D, Margolis-Dorfman L, Goor-Aryeh I, Green MS. Attitudes Toward the Use of Medical Cannabis and the Perceived Efficacy, Side-effects and Risks: A Survey of Patients, Nurses and Physicians. J Psychoactive Drugs 2022; 54:393-402. [PMID: 34893011 DOI: 10.1080/02791072.2021.2009598] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Gaps between physician and patient perceptions may lead to misunderstandings and mismanage of treatment. There are sparse data about the differences in opinions toward medical cannabis (MC) between patients and health professionals. The aim of this study was to examine the attitudes toward MC, its perceived efficacy, side effects and risk of dependency, among patients, nurses and physicians. A cross-sectional study of samples of 430 patients, 65 nurses and 65 physicians in two large medical centers in Israel. Questionnaires were administered on attitudes, perceived efficacy, side-effects and perceived risks of dependency. Compared with nurses and physicians, patients who were using MC had the most positive attitudes toward MC (p < .001). Younger age, high school education, being Jewish and ever using MC, were associated with more positive attitudes toward MC among patients (p < .001). Among nurses and physicians, having an oncology specialty predicted more positive attitudes toward MC. Physicians had a less positive attitude toward MC compared to nurses (p < .01). Our study provides evidence that physicians are less positive in their views toward MC compared to nurses and patients. More information and awareness to MC may reduce the gap in perceptions between physicians and patients.
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Affiliation(s)
- Neta HaGani
- School of Public Heath, University of Haifa, Haifa, Israel.,Rambam Medical Center, Haifa, Israel
| | | | - Michael Dor
- Department of Health Systems Management, Ariel University, Ari'el, Israel
| | - Gil Bar-Sela
- Oncology and Hematology Division, Emek Medical Center, Afula, Israel.,Faculty of Medicine, Technion, Haifa, Israel
| | - Dana Oren
- Pain Medicine Institute, Sheba Medical Center, Ramat Gan, Israel
| | | | - Itay Goor-Aryeh
- Pain Medicine Institute, Sheba Medical Center, Ramat Gan, Israel
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Qatanani A, Umar M, Padela AI. Bioethical insights from the Fiqh Council of North America's recent ruling on medical cannabis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103360. [PMID: 34252785 DOI: 10.1016/j.drugpo.2021.103360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/17/2021] [Accepted: 06/21/2021] [Indexed: 10/20/2022]
Abstract
There is growing momentum to legalize medical cannabis across the United States. Positive public attitudes and permissive policies are based on growing anecdotal experiences and medical evidence that enumerate the health benefits of cannabis. Against this backdrop, Muslim stakeholders are (re)-evaluating their stance on the issue for Muslim patients who may benefit from such novel treatments, Muslim physicians who could incorporate the provision of cannabis into practices, and Muslim entrepreneurs who may seek to engage with the pharmaceutical and business aspects of the growing industry. Given this renewed interest, the Fiqh Council of North America (FCNA), a deliberative body comprised of Islamic jurists and medical consultants, examined the medical as well as religious evidence surrounding medical cannabis in order to furnish Muslim Americans with religious guidance. In 2018, they resolved that, while the use of intoxicating substances is proscribed by Islamic law, medical cannabis was permissible for Muslims to use with the following stipulations: Non-psychoactive preparations of cannabis are permitted to treat illnesses for which therapeutic effects of cannabis are certain, and psychoactive preparations are contingently permissible in cases of dire necessity. In this paper we first discuss the deliberative process and ethico-legal rationale brought to bear in furnishing the ruling, and then proceed to critically examine its conceptual gaps, practical limitations, and future implications. Clarifying the nuances around the religious permissibility of medical cannabis is important for Muslim patients and providers whose attitudes and behaviors may be informed by the ruling, as well for stakeholder groups within pharmaceutical and health policy circles who aim to address the needs of the global Muslim community that may stand to benefit from advances in medical cannabis research and therapeutics.
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Affiliation(s)
- Anas Qatanani
- Drexel College of Medicine, Philadelphia, PA, United States; Initiative on Islam and Medicine, Medical College of Wisconsin, Wauwatosa, WI, United States.
| | - Mustafa Umar
- California Islamic University, Fullerton, CA, United States; Fiqh Council of North America, IL, United States
| | - Aasim I Padela
- Initiative on Islam and Medicine, Medical College of Wisconsin, Wauwatosa, WI, United States
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O’Rourke R, Lima ML, Jetten J. Healthcare professionals and medical cannabis: a scoping review informed by the theoretical domains framework. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-021-01624-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Filetti M, Trapani D, Cortellini A, Cofini V, Necozione S, Pinato DJ, Porzio G, Marchetti P, Giusti R. Knowledge and attitudes of Italian medical oncologists and palliative care physicians toward medical use of cannabis in cancer care: a national survey. Support Care Cancer 2021; 29:7845-7854. [PMID: 34176017 DOI: 10.1007/s00520-021-06383-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/21/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE Despite advances in supportive care, cancer-related symptoms tend to be persistent regardless of cancer type, stage of disease, or treatment received. There is an increasing prescription for complementary and alternative medicines, such as medical cannabis (MC). Knowledge and attitudes of Italian medical oncologists and palliative care physicians toward medical cannabis in cancer care remain unknown. METHODS We conducted a cross-sectional study to investigate the knowledge and attitude toward MC prescription among cancer care professionals in Italy. All invited participants received an email with the electronic questionnaire accessible through a direct link. RESULTS Among the 2616 members who received the invitation, 475 replied to the questionnaire and were considered for the survey analysis. The most prescribed formulations among those available in Italy were cannabis FM2. The most frequent clinical indications for the use of MC were pain, gastrointestinal, and mood disorders. Only 9 responders reported MC-related side effects like anxiety insomnia and muscle spasms. The question regarding the normative references for MC prescription and use in Italy had conflicting results: only 14% indicated the exact legislative reference. CONCLUSION Our study highlights a significant discrepancy between personal attitudes, prescription levels, and actual knowledge on MC. This represent a critical issue that should be systemically faced, building educational programs and national guidelines that sublimate personal physicians' beliefs and predispositions, resulting in a robust science-based MC practice. Only through coordinated interventions on science and health policy of MC, there will be success of safety and efficacy, ensuring the best knowledge for the best outcomes.
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Affiliation(s)
- Marco Filetti
- Medical Oncology Unit, Sapienza University of Rome, Via di Grottarossa, 1035-1039, Rome, Italy
| | - Dario Trapani
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
| | - Alessio Cortellini
- Department of Biotechnology and Applied Clinical Science, University of L'Aquila, L'Aquila, Italy.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Vincenza Cofini
- Department of Clinical Medicine Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Stefano Necozione
- Department of Clinical Medicine Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - David James Pinato
- Department of Surgery and Cancer, Imperial College London, London, UK.,Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Giampiero Porzio
- Department of Biotechnology and Applied Clinical Science, University of L'Aquila, L'Aquila, Italy
| | - Paolo Marchetti
- Medical Oncology Unit, Sapienza University of Rome, Via di Grottarossa, 1035-1039, Rome, Italy.,Department of Clinical and Molecular Medicine, Sapienza University of Rome, Roma, Lazio, Italy
| | - Raffaele Giusti
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Sant'Andrea, Via di Grottarossa, 1035-39 00189, Rome, Italy.
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Ng JY, Gilotra K, Usman S, Chang Y, Busse JW. Attitudes toward medical cannabis among family physicians practising in Ontario, Canada: a qualitative research study. CMAJ Open 2021; 9:E342-E348. [PMID: 33849983 PMCID: PMC8084545 DOI: 10.9778/cmajo.20200187] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Medical cannabis has been legally available in Canada since 2001, but its benefits and harms remain uncertain. We explored attitudes toward medical cannabis among family physicians practising in Ontario. METHODS Between January and October 2019, we conducted a qualitative study of Ontario family physicians using semistructured telephone interviews. We applied thematic analysis to interview transcripts and identified representative quotes. RESULTS Eleven physicians agreed to be interviewed, and 3 themes regarding medical cannabis emerged: reluctance to authorize use, concern over harms and lack of practical knowledge. Participants raised concerns about the limited evidence for, and their lack of education regarding, the therapeutic use of cannabis, particularly the harms associated with neurocognitive development, exacerbation of mental illness and drug interactions in older adults. Some participants thought medical cannabis was overly accessible and questioned their role following legalization of recreational cannabis. INTERPRETATION Despite the increasing availability of medical cannabis, family physicians expressed reluctance to authorize its use because of lack of knowledge and concerns regarding harms. Family physicians may benefit from guidance and education that address concerns they have surrounding medical cannabis.
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Affiliation(s)
- Jeremy Y Ng
- Departments of Health Research Methods, Evidence and Impact (Ng, Gilotra, Usman, Chang, Busse) and Anesthesia (Busse), Faculty of Health Sciences, McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse); The Michael G. DeGroote Centre for Medicinal Cannabis Research (Busse), McMaster University, Hamilton, Ont
| | - Kevin Gilotra
- Departments of Health Research Methods, Evidence and Impact (Ng, Gilotra, Usman, Chang, Busse) and Anesthesia (Busse), Faculty of Health Sciences, McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse); The Michael G. DeGroote Centre for Medicinal Cannabis Research (Busse), McMaster University, Hamilton, Ont
| | - Sana Usman
- Departments of Health Research Methods, Evidence and Impact (Ng, Gilotra, Usman, Chang, Busse) and Anesthesia (Busse), Faculty of Health Sciences, McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse); The Michael G. DeGroote Centre for Medicinal Cannabis Research (Busse), McMaster University, Hamilton, Ont
| | - Yaping Chang
- Departments of Health Research Methods, Evidence and Impact (Ng, Gilotra, Usman, Chang, Busse) and Anesthesia (Busse), Faculty of Health Sciences, McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse); The Michael G. DeGroote Centre for Medicinal Cannabis Research (Busse), McMaster University, Hamilton, Ont
| | - Jason W Busse
- Departments of Health Research Methods, Evidence and Impact (Ng, Gilotra, Usman, Chang, Busse) and Anesthesia (Busse), Faculty of Health Sciences, McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse); The Michael G. DeGroote Centre for Medicinal Cannabis Research (Busse), McMaster University, Hamilton, Ont.
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Greenwald MK, Sarvepalli SS, Cohn JA, Lundahl LH. Demand curve analysis of marijuana use among persons living with HIV. Drug Alcohol Depend 2021; 220:108524. [PMID: 33453502 PMCID: PMC7889735 DOI: 10.1016/j.drugalcdep.2021.108524] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/23/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite medicalization and legalization of marijuana use, factors influencing demand for marijuana among persons living with HIV (PLWH) are incompletely understood. This knowledge gap undermines effective clinical management and policies. This study used demand curve simulation methods to address these issues. METHODS Marijuana-using PLWH (N = 119) completed experimental tasks to simulate amount of marijuana purchasing/use across different costs (money or time), and likelihood of reselling marijuana or marijuana therapeutic-use registration card in relation to profits. Additional simulations assessed purchasing of marijuana relative to other drug and non-drug goods. RESULTS Simulated marijuana use decreased as money and time costs increased. Consumption was greater for participants with more severe Cannabis Use Disorder (CUD) and anxiety, intermediate pain levels, and past 90-day opioid use. Whereas few participants chose to sell their registration card, marijuana resale (diversion) steeply increased with profit. Likelihood of seeking marijuana therapeutic-use certification decreased in relation to registration card money cost, having to visit more physicians to get a signature, and delay to receiving the card, and increased with duration of certification. Participants who reported recent opioid use were more likely to seek certification. Consumption of several commodities assessed was independent of marijuana. CONCLUSIONS Simulated marijuana use was related to participants' clinical profile (CUD, anxiety and pain symptoms, recent opioid use), and unrelated to purchasing other goods. Likelihood of seeking marijuana therapeutic-use registration was affected by several types of costs and recent opioid use. Participants were unlikely to divert registration cards. We discuss clinical and policy implications of these findings.
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Affiliation(s)
- Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, USA; School of Medicine, Department of Internal Medicine Wayne State University, Detroit, MI 48201, USA.
| | - Siri S Sarvepalli
- School of Medicine, Department of Internal Medicine Wayne State University, Detroit, MI 48201, USA
| | - Jonathan A Cohn
- School of Medicine, Department of Internal Medicine Wayne State University, Detroit, MI 48201, USA; Department of Internal Medicine Wayne State University, Detroit, MI 48201, USA
| | - Leslie H Lundahl
- Department of Psychiatry and Behavioral Neurosciences, USA; School of Medicine, Department of Internal Medicine Wayne State University, Detroit, MI 48201, USA
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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. Am J Ther 2020; 29:e400-e409. [PMID: 33416237 DOI: 10.1097/mjt.0000000000001236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Kogan L, Schoenfeld-Tacher R, Hellyer P, Rishniw M. US Veterinarians' Knowledge, Experience, and Perception Regarding the Use of Cannabidiol for Canine Medical Conditions. Front Vet Sci 2019; 5:338. [PMID: 30687726 PMCID: PMC6338022 DOI: 10.3389/fvets.2018.00338] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/17/2018] [Indexed: 01/03/2023] Open
Abstract
Due to the myriad of laws concerning cannabis, there is little empirical research regarding the veterinary use of cannabidiol (CBD). This study used the Veterinary Information Network (VIN) to gauge US veterinarians' knowledge level, views and experiences related to the use of cannabinoids in the medical treatment of dogs. Participants (n = 2130) completed an anonymous, online survey. Results were analyzed based on legal status of recreational marijuana in the participants' state of practice, and year of graduation from veterinary school. Participants felt comfortable in their knowledge of the differences between Δ9-tetrahydrocannabinol (THC) and marijuana, as well as the toxic effects of marijuana in dogs. Most veterinarians (61.5%) felt comfortable discussing the use of CBD with their colleagues, but only 45.5% felt comfortable discussing this topic with clients. No differences were found based on state of practice, but recent graduates were less comfortable discussing the topic. Veterinarians and clients in states with legalized recreational marijuana were more likely to talk about the use of CBD products to treat canine ailments than those in other states. Overall, CBD was most frequently discussed as a potential treatment for pain management, anxiety and seizures. Veterinarians practicing in states with legalized recreational marijuana were more likely to advise their clients and recommend the use of CBD, while there was no difference in the likelihood of prescribing CBD products. Recent veterinary graduates were less likely to recommend or prescribe CBD. The most commonly used CBD formulations were oil/extract and edibles. These were most helpful in providing analgesia for chronic and acute pain, relieving anxiety and decreasing seizure frequency/severity. The most commonly reported side-effect was sedation. Participants felt their state veterinary associations and veterinary boards did not provide sufficient guidance for them to practice within applicable laws. Recent graduates and those practicing in states with legalized recreational marijuana were more likely to agree that research regarding the use of CBD in dogs is needed. These same groups also felt that marijuana and CBD should not remain classified as Schedule I drugs. Most participants agreed that both marijuana and CBD products offer benefits for humans and expressed support for use of CBD products for animals.
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Affiliation(s)
- Lori Kogan
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Science, Colorado State University, Fort Collins, CO, United States
| | - Regina Schoenfeld-Tacher
- Department of Molecular and Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Peter Hellyer
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Science, Colorado State University, Fort Collins, CO, United States
| | - Mark Rishniw
- Veterinary Information Network, Davis, CA, United States
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