Training and Practices of Cannabis Dispensary Staff

State Requirements for Non-Medical US Cannabis Retail Personnel

In September 2023, we examined requirements for budtenders working in nonmedical dispensaries in the 20 states with active non-medical cannabis markets. Two coders extracted data from each state's licensing board and/or governmental websites. The age requirement for budtenders was ≥21 years old ( n = 17) or ≥18 ( n = 3). Most states ( n = 16) required background checks; 10 specified felony convictions preventing employment, 5 allowed the Department to determine eligibility, and 2 allowed petitions upon denial. Twelve states required fingerprinting. There were application fees ($25-$300) in 13 states. Structured training was required in 7 states, while 5 states required employee training. Given the diverse budtender requirements, the evaluation of budtender standards is essential to assess the impacts of training on regulatory compliance and consumer education, and of application costs and conviction-based employment restrictions on social equity. This must inform the development of effective regulations and enforcement protocols, as well as and how to promote equity in cannabis regulations.

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.

Dispensary personnel's views and experiences regarding oncologic cannabis and the counsel they offer adults with cancer

BACKGROUND

A minority of oncologists feel qualified to advise adults with cancer on issues pertaining to medicinal cannabis. Adults with cancer frequently access medicinal cannabis information from non-medical sources such as cannabis dispensaries. We explored dispensary personnel's views and experiences regarding oncologic cannabis and the counsel they extend individuals with cancer.

METHODS

Snowball sampling in this qualitative study facilitated recruitment across 13 states (N = 26). Semi-structured phone interviews ceased with thematic saturation. A multi-stage thematic analysis combined inductive and deductive codes.

RESULTS

Of the 26 dispensary personnel interviewed, 54% identified as female and 19% as non-white. Median age was 40 years. A consensus emerged among participants concerning the botanical's efficacy for cancer-related symptoms; less so regarding its antineoplastic potential. Principles for serving those with cancer included provision of client-centered, symptom-based, and trial-and-error approaches. Non-inhalation modes of administration were generally recommended. No consensus was reached as to whether delta-9-tetrahydrocannabinal (THC)- or cannabidiol-predominant products were preferable in this population. Challenges in oncologic advising included successfully identifying individuals with cancer at the dispensary counter, financial toxicity, the special treatment required for the THC-naïve, and operating in the absence of standardized guidelines.

CONCLUSIONS

These informed assertions suggest that members of the oncologic community should grapple with the extent to which they feel comfortable with both the nature and degree of counsel adults with cancer receive through dispensaries.

Cannabis use among cancer survivors in 22 states: Results from the Behavioral Risk Factor Surveillance System, 2020

BACKGROUND

This study identified factors associated with recent cannabis use and cannabis use for medical purposes among cancer survivors relative to individuals without a history of cancer.

METHODS

Data from the Behavioral Risk Factor Surveillance System were analyzed for the 22 states completing the optional cannabis module in 2020. Weighted multiple logistic regression was performed to explore variables associated with past 30-day cannabis use and cannabis use for medical purposes, stratified by history of cancer. Covariates included state-level cannabis policy, sociodemographic characteristics, health status indicators, and substance use.

RESULTS

Cannabis use was lower among cancer survivors compared to individuals with no history of cancer (7.57% vs. 10.83%). However, a higher proportion of cancer survivors reported use for medical purposes (82.23% vs. 62.58%). After adjusting for state-level policy, biological sex, age, educational attainment, self-reported race/ethnicity, home ownership, mental health status and physical health status, current smoking (odds ratio [OR], 5.14 vs. 3.74) and binge drinking (OR, 2.71 vs. 2.69) were associated with cannabis use in both groups. Characteristics associated with medical cannabis use varied for the two groups; however, daily use (20-30 days; OR, 1.72 vs. 2.43) was associated with cannabis use for medical purposes in both groups after adjusting for other variables in the model.

CONCLUSIONS

A high proportion of individuals report cannabis use for medical purposes with higher rates among cancer survivors. Findings support the urgent need for ongoing cannabis research to better understand and inform its use for medical purposes, as well as the development of high-quality standardized education materials and clinical practice guidelines.

Cannabis dispensary staff approaches to counseling on potential contraindications to cannabis use: insights from a national self-report survey

BACKGROUND

Legal cannabis is available in more than half of the United States. Health care professionals (HCPs) rarely give recommendations on dosing or safety of cannabis due to limits imposed by policy and lack of knowledge. Customer-facing cannabis dispensary staff, including clinicians (pharmacists, nurses, physician's assistants), communicate these recommendations in the absence of HCP recommendations. Little is known about how dispensary staff approach individuals with complex medical and psychiatric comorbidities. Using responses from a national survey, we describe how cannabis dispensary staff counsel customers with medical and psychiatric comorbidities on cannabis use and examine whether state-specific cannabis policy is associated with advice given to customers.

METHODS

National, cross-sectional online survey study from February 13, 2020 to October 2, 2020 of dispensary staff at dispensaries that sell delta-9-tetrahydrocannabinol containing products. Measures include responses to survey questions about how they approach customers with medical and psychiatric comorbidities; state medicalization score (scale 0-100; higher score indicates more similarity to regulation of traditional pharmacies); legalized adult-use cannabis (yes/no). We conducted multiple mixed effects multivariable logistic regression analyses to understand relationships between state medicalization and dispensary employees' perspectives.

RESULTS

Of 434 eligible respondents, most were budtenders (40%) or managers (32%), and a minority were clinicians (18%). State medicalization score was not associated with responses to most survey questions. It was associated with increased odds of encouraging customers with medical comorbidities to inform their traditional HCP of cannabis use (Odds ratio [OR]=1.2, 95% confidence interval [CI] 1.0-1.4, p=0.03) and reduced odds of recommending cannabis for individuals with cannabis use disorder (CUD) (OR=0.8, 95% CI 0.7-1.0, p=0.04). Working in a state with legalized adult-use cannabis was associated with recommending traditional health care instead of cannabis in those with serious mental illness (OR 2.2, 95% CI 1.1-4.7, p=0.04). Less than half of respondents believed they had encountered CUD (49%), and over a quarter did not believe cannabis is addictive (26%).

CONCLUSIONS

When managing cannabis dosing and safety in customers with medical and psychiatric comorbidity, dispensary staff preferred involving individuals' traditional HCPs. Dispensary staff were skeptical of cannabis being addictive. While state regulations of dispensaries may impact the products individuals have access to, they were not associated with recommendations that dispensary staff gave to customers. Alternative explanations for dispensary recommendations may include regional or store-level variation not captured in this analysis.

Cannabis for morning sickness: areas for intervention to decrease cannabis consumption during pregnancy

BACKGROUND

Cannabis use during pregnancy is increasing, with 19-22% of patients testing positive at delivery in Colorado and California. Patients report using cannabis to alleviate their nausea and vomiting, anxiety, and pain. However, preclinical and clinical data highlight harmful effects to offspring physiology and behavior following fetal cannabis exposure. This narrative review identifies potential areas for intervention to decrease cannabis consumption during pregnancy.

METHODS

A combination of keywords, including "cannabis", "cannabis", "weed", "pregnancy", "morning sickness", "child protective services", and "budtender" were searched in databases such as PubMed and Google Scholar, as well as in social media forums, governmental webpages, and other publicly available sources.

RESULTS

The literature search identified several areas for intervention to reduce cannabis use during pregnancy, including physician and pharmacist training, engagement with pregnant patients, regulation of dispensary workers, and the role of child protective services.

DISCUSSION

This comprehensive review identifies multiple areas for improvement to benefit pregnant patients. Recommendations are independent and can be implemented simultaneously by the identified groups. Limitations of this research includes the relatively limited availability of data focused specifically on cannabis consumption during pregnancy and the complexity of the sociopolitical field of substance use during pregnancy.

CONCLUSIONS

Cannabis consumption during pregnancy is increasing and causes harm to the developing fetus. To educate pregnant patients about these risks, we must address the gaps in education from multiple contact points.

An examination of cannabis-related information typically asked by consumers at retail cannabis locations: A Canadian survey of budtenders and managers

Background

Since cannabis has been legalized in Canada for medicinal and recreational use, there has been an increased demand on pharmacists for cannabis counselling. The aim of the study was to examine typical questions posed by consumers to managers and budtenders working at licensed recreational cannabis stores in Canada and to assess how often consumers seek unlicensed medical advice to treat various conditions using cannabis.

Methods

An online survey was synthesized, consisting of 22 questions capturing demographics and Likert scale responses to survey questions, and was distributed online across Canada from January to June 2021.

Results

There were 211 survey respondents: 91 budtenders and 120 managers. A total of 87.7% (n = 185) of respondents indicated that they receive questions related to cannabis use for medical purposes and/or perceived medical benefit, with the same number indicating that they have been told by a customer that their physician sent them to obtain a cannabis-containing product for medical purposes. The most common cannabis component asked about in an average day was THC (42% of responses).

Conclusion

An alarming proportion of budtenders and managers in Canada report that they are fielding medical cannabis questions. This situation has the potential to put individuals at risk for drug-drug interactions and drug-disease interactions and to increase unnecessary hospitalizations due to adverse effects.

Physicians' Attitudes and Practices Regarding Cannabis and Recommending Medical Cannabis Use

Introduction: Medical cannabis users tend not to trust or rely on health care providers regarding cannabis advice. Previous surveys of physicians have focused on favorability toward medical cannabis. The current study assesses how physicians interact with patients regarding cannabis in their day-to-day practice, and whether and how they address important topics such as use patterns and substituting cannabis for medications. We predicted that physicians would generally perceive cannabis dispensary staff and caretakers as not competent in addressing patient health needs and would not be likely to use their recommendations. Methods: Physicians in a university-affiliated health system completed an anonymous online survey. The survey assessed physicians' cannabis related education experiences, perceptions of their knowledge of and competence regarding medical cannabis, and the content of cannabis related discussions with patients. We also examined perceptions of the sources of influence on patients regarding cannabis and physicians' attitudes toward medical cannabis dispensary staff and medical cannabis caregivers (MCCs). Results: A few physicians (10%) had ever signed a medical cannabis authorization form for their patients, consistent with their perceptions of low knowledge and competence in this area. Discussions on cannabis primarily focus on risks (63%) rather than dosage (6%) and harm reduction (25%). Physicians see their influence on patients as weak compared with other information sources and have generally unfavorable attitudes toward medical cannabis dispensary staff and MCCs. Conclusion: Greater integration of medical cannabis knowledge is needed at all levels of medical and clinical education to address the potential harm to patients if they receive no guidance. Continued research is needed to provide a strong scientific basis for developing treatment guidelines and standardized medical education for medical cannabis use.

Do We Have Structure, Process and Outcomes to Support Cannabis as Supportive Therapy in Cancer?

Cannabis is becoming more popular and more available in the United States. It has been approved for use by multiple states for various conditions and several states now allow recreational cannabis. We explore the structure of cannabis distribution, the process of acquisition, outcomes, and the safety of cannabis in the United States.

Using Social Media Data to Investigate Public Perceptions of Cannabis as a Medicine: Narrative Review

BACKGROUND

The use and acceptance of medicinal cannabis is on the rise across the globe. To support the interests of public health, evidence relating to its use, effects, and safety is required to match this community demand. Web-based user-generated data are often used by researchers and public health organizations for the investigation of consumer perceptions, market forces, population behaviors, and for pharmacoepidemiology.

OBJECTIVE

In this review, we aimed to summarize the findings of studies that have used user-generated text as a data source to study medicinal cannabis or the use of cannabis as medicine. Our objectives were to categorize the insights provided by social media research on cannabis as medicine and describe the role of social media for consumers using medicinal cannabis.

METHODS

The inclusion criteria for this review were primary research studies and reviews that reported on the analysis of web-based user-generated content on cannabis as medicine. The MEDLINE, Scopus, Web of Science, and Embase databases were searched from January 1974 to April 2022.

RESULTS

We examined 42 studies published in English and found that consumers value their ability to exchange experiences on the web and tend to rely on web-based information sources. Cannabis discussions have portrayed the substance as a safe and natural medicine to help with many health conditions including cancer, sleep disorders, chronic pain, opioid use disorders, headaches, asthma, bowel disease, anxiety, depression, and posttraumatic stress disorder. These discussions provide a rich resource for researchers to investigate medicinal cannabis-related consumer sentiment and experiences, including the opportunity to monitor cannabis effects and adverse events, given the anecdotal and often biased nature of the information is properly accounted for.

CONCLUSIONS

The extensive web-based presence of the cannabis industry coupled with the conversational nature of social media discourse results in rich but potentially biased information that is often not well-supported by scientific evidence. This review summarizes what social media is saying about the medicinal use of cannabis and discusses the challenges faced by health governance agencies and professionals to make use of web-based resources to both learn from medicinal cannabis users and provide factual, timely, and reliable evidence-based health information to consumers.

Consumer Experiences with Delta-8-THC: Medical Use, Pharmaceutical Substitution, and Comparisons with Delta-9-THC

Introduction: Cannabis products containing delta-8-THC became widely available in most of the United States in late 2020 and rapidly became a significant source of revenue for hemp processing companies, especially in states where use of delta-9-THC remains illegal or requires professional authorization for medical use. Scientific research on the use of delta-8-THC is scarce, previous clinical studies included a combined total of 14 participants, leading some state governments to prohibit it until its properties and effects are better understood. Methods: Researchers developed an online survey for delta-8-THC consumers addressing a broad range of issues regarding delta-8-THC, including use for the treatment of health and medical conditions. Previous survey studies on the medical use of cannabis and cannabis products informed survey components. Results: Patterns of delta-8-THC use had both similarities with and differences from the use of delta-9-THC cannabis and products. Administration methods were primarily edibles (64%) and vaping concentrates (48%). About half of the participants (51%) used delta-8-THC to treat a range of health and medical conditions, primarily anxiety or panic attacks (69%), stress (52%), depression or bipolar disorder (46%), and chronic pain (41%). Participants compared delta-8-THC very favorably with both delta-9-THC and pharmaceutical drugs and reported substantial levels of substitution for both. Most participants did not inform their primary care provider of their delta-8-THC use (78%) and were not confident of their primary care provider's ability to integrate medical cannabis into their treatment (70%). Knowledge of effective dosages was low, and participants' knowledge of delta-8-THC was primarily from the Internet and their own experiences. Conclusion: Harm reduction is a central component of public health. Although the legal environment is becoming more restrictive for delta-8-THC in comparison to delta-9-THC, results suggest that delta-8-THC may be equally effective for desired purposes of cannabis use and lower in undesirable or adverse effects. All policies and practices should be informed by empirical evidence. Considerable research will be needed to systematically verify the patterns reported by participants, and collaborations among academic researchers, government, and the cannabis industry may be valuable in developing the knowledge base for delta-8-THC and other cannabinoids.

Differences in cannabis use characteristics, routines, and reasons for use among individuals with and without a medical cannabis card

As recreational and medical cannabis use increases in the U.S., the proliferation of novel cannabis products is expected to continue. Understanding cannabis product preferences and use patterns may inform public health and policy decisions. This study investigated similarities and differences in cannabis use patterns, product preferences, and beliefs about cannabis' subjective effects and therapeutic benefits among individuals with and without a medical cannabis card (MCC). Participants with an MCC completed individual interviews (N = 25; 40% male). Participants without an MCC completed focus groups (N = 31; 6-7 participants/group; 72% male). All sessions followed a semistructured agenda. Participants were queried about their use routines, reasons for using cannabis, and perceptions and experiences of subjective cannabis effects. Thematic analysis of coded transcripts revealed that MCC participants had structured, daily cannabis use routines whereas non-MCC participants' use routines were less structured. Product information including strain and cannabinoid composition were important to MCC participants whereas non-MCC participants primarily evaluated quality based on perceptual (e.g., olfactory) cues. Regardless of MCC status, participants reported misconceptions about cannabis' therapeutic benefits and agreed that the two primary cannabis strains-Indica and Sativa-produced primarily sedative and stimulant effects, respectively. Results have clinical, public health, and policy implications surrounding cannabis recommendation guidelines and ways providers can relay accurate information to patients seeking medical cannabis. Future research assessing demographic and geographic differences in cannabis product preferences and beliefs about medical cannabis use is warranted. Further, quantitative research is needed to evaluate whether cannabis' therapeutic value differs across products. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Backgrounds and Trainings in Cannabis Therapeutics of Dispensary Personnel

PURPOSE

A growing body of scientific research indicates that oncology teams tend to offer individuals with cancer little clinical advice regarding medicinal cannabis (MC) and that individuals with cancer instead turn to cannabis dispensaries for MC guidance. Our objective was to investigate dispensary personnel's backgrounds and trainings in MC advising.

METHODS

The study design was semistructured interviews across 13 states with cannabis dispensary personnel in managerial or client-facing positions. Of 38 recruited, 26 (68%) completed interview. The primary outcome was training in MC advising. Researchers targeted thematic saturation and adhered to Consolidated Criteria for Reporting Qualitative Research.

RESULTS

Of 26 participants, 54% were female, with an average age of 40 (range: 22-64) years. Half worked in client-facing roles; half worked in managerial ones. Study participants endorsed passionate commitment to their profession, often motivated by personal experience with MC therapeutics. Cannabis dispensaries often privileged sales skills over cannabis therapeutics knowledge when hiring, resulting in uneven baseline levels of cannabis therapeutics expertise among staff. Most participants reported workplace cannabis therapeutics training to be unstandardized and weak. They described dispensary personnel as resourceful in pursuing cannabis knowledge, self-financing learning in off-hours, sampling dispensary products, and exchanging knowledge. Nearly half the participants called for quality, standardized cannabis therapeutics training for dispensary personnel.

CONCLUSION

The many oncology teams who defer to dispensary personnel regarding MC advising rely on a workforce who views themselves as unevenly trained. Further research should include a national survey of cannabis dispensary personnel to learn whether these findings hold true in a larger sample. If so, the oncology community must determine the best approach to clinically advising individuals with cancer about MC.

Use patterns, beliefs, experiences, and behavioral economic demand of indica and sativa cannabis: A cross-sectional survey of cannabis users

Cannabis products available for retail purchase are often marketed based on purported plant species (e.g., "indica" or "sativa"). The cannabis industry frequently claims that indica versus sativa cannabis elicits unique effects and/or is useful for different therapeutic indications. Few studies have evaluated use patterns, beliefs, subjective experiences, and situations in which individuals use indica versus sativa. A convenience sample of cannabis users (n = 179) was surveyed via Amazon Mechanical Turk (mTurk). Participants were asked about their prior use of, subjective experiences with, and opinions on indica versus sativa cannabis and completed hypothetical purchasing tasks for both cannabis subtypes. Participants reported a greater preference to use indica in the evening and sativa in the morning and afternoon. Participants were more likely to perceive feeling "sleepy/tired" or "relaxed" after using indica and "alert," "energized," and "motivated" after using sativa. Respondents were more likely to endorse wanting to use indica if they were going to sleep soon but more likely to use sativa at a party. Hypothetical purchasing patterns (i.e., grams of cannabis purchased as a function of escalating price) did not differ between indica and sativa, suggesting that demand was similar. Taken together, cannabis users retrospectively report feeling different effects from indica and sativa; however, demand generally did not differ between cannabis subtypes, suggesting situational factors could influence whether someone uses indica or sativa. Placebo-controlled, blinded studies are needed to characterize the pharmacodynamics and chemical composition of indica and sativa cannabis and to determine whether user expectancies contribute to differences in perceived indica/sativa effects. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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.

"It's so Natural It Goes Hand in Hand": A Qualitative Study of Maternal Perceptions of Cannabis Use during Pregnancy

As the market continues to embrace marijuana as a holistic product, perceptions about its uses are increasingly contradictory to public health recommendations. The purpose of this research was to qualitatively analyze the perceived risks and benefits of cannabis use during pregnancy via in-depth semi-structured interviews conducted with nine women. This research is intended to inform patient-provider interactions regarding cannabis use in prenatal clinical settings.

Cannabis legalization and driving under the influence of cannabis in a national U.S. Sample

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A national survey sampled current cannabis users.

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Users in medical cannabis states were less likely to report driving high.

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Users in recreational states were less likely to report driving high.

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Likelihood of driving high varied by frequency of cannabis use.

The relationship between cannabis legalization and traffic safety remains unclear. Physiological measures of cannabis impairment remain imperfect. This analysis used self-report data to examine the relationship between cannabis legalization and driving under the influence of cannabis (DUIC)1.

Using a cross-sectional national sample (2016–2017) of 1,249 past–30-day cannabis users, we regressed self-reported DUIC (driving within three hours of “getting high”) on cannabis legalization (recreational and medical (recreational), medical only (medical), or no legal cannabis), adjusting for demographics, days of use (past 30 days), days of use*legal status, calibration weights, and geographic clustering.

The risk of DUIC in recreational (risk ratio [RR] = 0.41, 95% confidence interval (CI):0.23–0.72) and medical (RR = 0.39, 95% CI:0.20–0.79) states was lower than in states without legal cannabis, with one exception. Among frequent cannabis users (≥20 days per month), there was a significantly lower risk of DUIC for those living in recreational states (RR = 0.70, 95% CI: 0.49–0.99), but not for those living in medical states (RR = 0.87, 95% CI: 0.60–1.24), compared to users living in states without legal cannabis.

The risk of self-reported DUIC was lower in recreational and medical cannabis states compared to states without legal cannabis. The only exception was for frequent users in medical states, for whom there was no difference in risk compared to frequent users living in states without legal cannabis.

Healthcare professionals' and budtenders' perceptions of perinatal cannabis use

Background: While national guidelines state that cannabis should not be consumed during pregnancy, cannabis use during pregnancy continues to increase. Pregnant individuals have reported using healthcare professionals and budtenders (i.e., cannabis store retailers) as resources for information on cannabis use during pregnancy and postpartum.Objectives: To determine healthcare professionals' and budtenders' perceptions of risks and benefits of perinatal cannabis use.Method: A qualitative study, using semi-structured, open-ended questions, was conducted with ten healthcare professionals (predominantly nurses; 100% women) and ten budtenders (70% women) in a state where cannabis use is legal for adults 21 years of age and older. Data were interpreted using a qualitative description methodology to identify themes. Themes were generated from participant responses (implicit and explicit). We analyzed data separately and sequentially and present linked themes across samples. Data saturation, rigor, and trustworthiness were discussed and agreed upon by the analytic team.Results: Six themes arose from the healthcare professional and budtender data: 1) Perinatal customers and patients perceive cannabis to be medicinal, 2) Supporting perinatal people who use cannabis, 3) Spectrum of perceived impacts of perinatal cannabis use, 4) Comparison to use of other substances during pregnancy, 5) Perceived limited knowledge and training about cannabis regulation and product safety, and 6) Current trends of purchase and use.Conclusion: Participants reported that perinatal patients/customers perceived cannabis to be medicinal, and highlighted non-judgmental/harm reduction strategies for engaging patients/customers. Training is needed for healthcare professionals and budtenders to assist with patient/customer discussions about perinatal cannabis use.

Cannabidiol Product Dosing and Decision-Making in a National Survey of Individuals with Fibromyalgia

Many people with fibromyalgia use cannabidiol (CBD) products despite limited rigorous evidence of benefit. In the current study, we conducted a secondary analysis of a cross-sectional survey of N = 878 people with fibromyalgia to investigate naturalistic decision making around CBD product choices, use patterns, and dosing. We subgrouped participants based on use of high-THC cannabis (HTC) in the past year (yes/no) as previous studies have shown that HTC use influences CBD use patterns. The study population was largely female (93.6%), white (91.5%) and 55.5 years old on average. Participants typically purchased CBD products online or at dispensaries, with purchasing driven by personal research (63%) rather than endorsement from medical professionals (16%). Overall, tinctures and topicals were the most common administration routes endorsed. However, participants in the past-year HTC group used inhalation routes far more frequently than those who did not (39.8% vs 7.1%). Among participants using CBD tinctures or edibles, the average dose per session was 16 mg and 24 to 27 mg per day, although approximately one-third of participants did not know what dose of CBD they used. Participants using both inhalation and non-inhalation administration routes reported greater symptom relief than those using non-inhalation routes alone. However, there was no consistent relationship between CBD dose and reported effects, possibly due to expectancy effects around CBD products or interindividual variability. Our granular investigation reveals variability of CBD product dosing practices for fibromyalgia, and how past-year HTC use influences CBD product use. Future clinical trials should investigate the potential benefits of low-dose (<50mg) botanical CBD products. PERSPECTIVE: This article shows that past-year HTC use strongly influences how people with fibromyalgia choose and use CBD products. Participants typically used <50 mg/d of CBD, and there was no relationship between higher CBD dose and reported therapeutic benefit. Future clinical trials should investigate therapeutic benefits of low dose CBD.

Description of collaborative, fee-for-service, office-based, pharmacist-directed medical cannabis therapy management service for patients with chronic pain

BACKGROUND

Treatment with medical cannabis (MC) in the United States tends to be patient-driven in nature despite evidence that suggests that patients have remarkably poor knowledge on the medical use of this treatment modality.

OBJECTIVE

To develop and pilot a collaborative, fee-for-service (FFS), office-based, pharmacist-directed MC therapy management (MCTM) service for patients suffering chronic pain.

PRACTICE DESCRIPTION

A collaborative, FFS, office-based, pharmacist-directed MCTM service where patients are seen after a physician deems them suitable for treatment with MC. The pharmacist designs the initial treatment regimen by selecting a formulation, dose, route, and frequency of administration and then manages ongoing therapy by making regimen changes based on the patient's response, adverse effects, and financial concerns.

PRACTICE INNOVATION

The creation of a specialized service where a registered MC pharmacist is positioned in a collaborating provider's office and sees patients face-to-face for the provision of MCTM services.

EVALUATION METHODS

Patient retention, revenue generated, and ability to replicate the service were evaluated. Patient satisfaction was assessed by collecting subjective feedback on the service.

RESULTS

The pilot site that developed the service has seen 133 patients from 2016 to 2021 and has retained 89% of patients after 5 years of quarterly appointments. Patients appear willing to pay out of pocket for the service, and the revenue generated covers the pharmacist's and collaborating physician's time as well as additional overhead. The service has been replicated at 2 additional sites, and patient feedback has been positive.

CONCLUSIONS

MCTM is another useful pharmacist service that patients are willing to pay for. MCTM services decrease the collaborating provider's workload while still allowing them to offer their patients personalized treatment with MC. In our experience, the service retains patients, generates enough revenue to cover costs, can be replicated, and is well received by patients.

Medical Cannabis for Headache Pain: a Primer for Clinicians

PURPOSE OF REVIEW

Public acceptance of Cannabis sativa L. (cannabis) as a therapeutic option grows despite lags in both research and clinician familiarity. Cannabis-whether as a medical, recreational, or illicit substance-is and has been commonly used by patients. With ongoing decriminalization efforts, decreased perception of harms, and increased use of cannabis in the treatment of symptoms and disease, it is critical for clinicians to understand the rationale for specific therapies and their medical and practical implications for patients. In view of the opioid crisis, overall patient dissatisfaction, and lack of adherence to current chronic pain and headache therapies, this review provides up-to-date knowledge on cannabis as a potential treatment option for headache pain.

RECENT FINDINGS

Research into the use of cannabinoids for disease treatment have led to FDA-approved drugs for seizures, nausea, and vomiting caused by cancer chemotherapy; and for decreased appetite and weight loss in people with HIV/AIDS. For a wide variety of conditions and symptoms (including chronic pain), cannabis has gained increasing acceptance in society. The effects of cannabidiol (CBD) and tetrahydrocannabinol (THC) in pain pathways have been significantly elucidated. An increasing number of retrospective studies have shown a decrease in pain scores after administration of cannabinoids, as well as long-term benefits such as reduced opiate use. Yet, there is no FDA-approved cannabis product for headache or other chronic pain disorders. More is being done to determine who is likely to benefit from cannabis as well as to understand the long-term effects and limitations of the treatment. Cannabis can refer to a number of products derived from the plant Cannabis sativa L. Relatively well-tolerated, these products come in different configurations, types, and delivery forms. Specific formulations of the plant have been shown to be an effective treatment modality for chronic pain, including headache. It is important for clinicians to know which product is being discussed as well as the harms, benefits, contraindications, interactions, and unknowns in order to provide the best counsel for patients.

Analysis of State Cannabis Laws and Dispensary Staff Recommendations to Adults Purchasing Medical Cannabis

IMPORTANCE

Over the last decade, cannabis has become more accessible through the proliferation of dispensaries in states that have legalized its use. Most patients using cannabis for medical purposes report getting advice from dispensaries, yet there has been little exploration of frontline dispensary staff practices.

OBJECTIVE

To describe the practices of frontline dispensary workers who interact with customers purchasing cannabis for medical purposes and assess whether dispensary practices are associated with medicalization of state cannabis laws (degree to which they resemble regulation of prescription or over-the-counter drugs) and statewide adult use.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide cross-sectional survey study was conducted from February 13, 2020, to October 2, 2020, using an online survey tool. Potential respondents were eligible if they reported working in a dispensary that sells tetrahydrocannabinol-containing products and interacting with customers about cannabis purchases.

MAIN OUTCOMES AND MEASURES

Participant responses to questions about formulating customer recommendations and talking to customers about risks.

RESULTS

The 434 survey responses from 351 unique dispensaries were most often completed by individuals who identified as budtenders (40%), managers (32%), and pharmacists (13%). Most respondents reported basing customer recommendations on the customer's medical condition (74%), the experiences of other customers (70%), the customer's prior experience with cannabis (67%), and the respondent's personal experience (63%); fewer respondents relied on clinician input (40%), cost (45%), or inventory (12%). Most respondents routinely advised customers about safe storage and common adverse effects, but few counseled customers about cannabis use disorder, withdrawal, motor vehicle collision risk, or psychotic reactions. A higher state medicalization score was significantly associated with using employer training (odds ratio, 1.41; 95% CI, 1.18-1.67) and physician or clinician input (odds ratio, 1.23; 95% CI, 1.05-1.43) as a basis for recommendation. Medicalization score was not associated with counseling about cannabis risks.

CONCLUSIONS AND RELEVANCE

This survey study provides insight into how frontline dispensary staff base cannabis recommendations and counsel about risks. The findings may have utility for clinicians to counsel patients who purchase cannabis, customers who want to be prepared for a dispensary visit, and policy makers whose decisions affect cannabis laws.

Assessing the Retail Environments of Licensed and Unlicensed Cannabis Dispensaries: Adapting the Marijuana Retail Surveillance Tool to Inform Cannabis Regulation in Los Angeles County

CONTEXT

After statewide legalization of recreational cannabis in California, the Los Angeles (LA) County Board of Supervisors requested a health equity impact assessment to inform its decisions on whether and how to regulate cannabis dispensaries in unincorporated areas of LA County.

OBJECTIVE

As part of this assessment, the LA County Department of Public Health compared the retail environments of licensed and unlicensed cannabis dispensaries in different parts of the county, using the Marijuana Retail Surveillance Tool (MRST), a validated instrument piloted in Colorado and Washington.

DESIGN

Two waves of observational surveys were conducted, one comparing licensed and unlicensed dispensaries within and near unincorporated areas of LA County and another comparing licensed dispensaries across LA County in areas with varying levels of health advantage according to a neighborhood index measuring social determinants of health.

MAIN OUTCOME MEASURES

Dispensaries were compared on measures of product types, promotional activities, security measures, regulatory compliance, and neighborhood context.

RESULTS

Unlicensed dispensaries were more likely than licensed dispensaries to sell products in packaging designed to be attractive to children (71.8% vs 10.8%, P < .001) and in non-child-resistant packaging (98.9% vs 15.6%, P < .001) and were more likely allow on-site consumption (60.9% vs 0%, P < .001). Licensed dispensaries showed high compliance with regulations, regardless of whether they were in areas of high or low health advantage.

CONCLUSIONS

The study points to the importance of efforts to eliminate illicit businesses as part of an overall strategy for regulating cannabis. It also demonstrates that the MRST is a flexible tool for regulatory surveillance and for continuing to study the relationships between cannabis retail environments and potential risks to public health.

A randomized trial of medical cannabis in patients with stage IV cancers to assess feasibility, dose requirements, impact on pain and opioid use, safety, and overall patient satisfaction

PURPOSE

The prevalence of medical cannabis (MC) use in patients with cancer is growing, but questions about safety, efficacy, and dosing remain. Conducting randomized, controlled trials (RCTs) using state-sponsored MC programs is novel and could provide data needed to guide patients and providers.

METHODS

A pilot RCT of patients with stage IV cancer requiring opioids was conducted. Thirty patients were randomized 1:1 to early cannabis (EC, n = 15) versus delayed start cannabis (DC, n = 15). The EC group obtained 3 months (3 M) of MC through a state program at no charge, while the DC group received standard oncology care without MC for the first 3 M. Patients met with licensed pharmacists at one of two MC dispensaries to determine a suggested MC dosing, formulation, and route. Patients completed surveys on pain levels, opioid/MC use, side effects, and overall satisfaction with the study.

RESULTS

Interest in the study was high as 36% of patients who met eligibility criteria ultimately enrolled. The estimated mean daily THC and CBD allotments at 3 M were 34 mg and 17 mg, respectively. A higher proportion of EC patients achieved a reduction in opioid use and improved pain control. No serious safety issues were reported, and patients reported high satisfaction.

CONCLUSION

Conducting RCTs using a state cannabis program is feasible. The addition of MC to standard oncology care was well-tolerated and may lead to improved pain control and lower opioid requirements. Conducting larger RCTs with MC in state-sponsored programs may guide oncology providers on how to safely and effectively incorporate MC for interested patients.

A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019

In 2017, a National Academies of Sciences, Engineering, and Medicine (NASEM) report comprehensively evaluated the body of evidence regarding cannabis health effects through the year 2016. The objectives of this study are to identify and map the most recently (2016-2019) published literature across approved conditions for medical cannabis and to evaluate the quality of identified recent systematic reviews, published following the NASEM report. Following the literature search from 5 databases and consultation with experts, 11 conditions were identified for evidence compilation and evaluation: amyotrophic lateral sclerosis, autism, cancer, chronic noncancer pain, Crohn's disease, epilepsy, glaucoma, human immunodeficiency virus/AIDS, multiple sclerosis (MS), Parkinson's disease, and posttraumatic stress disorder. A total of 198 studies were included after screening for condition-specific relevance and after imposing the following exclusion criteria: preclinical focus, non-English language, abstracts only, editorials/commentary, case studies/series, and non-U.S. study setting. Data extracted from studies included: study design type, outcome definition, intervention definition, sample size, study setting, and reported effect size. Few completed randomized controlled trials (RCTs) were identified. Studies classified as systematic reviews were graded using the Assessing the Methodological Quality of Systematic Reviews-2 tool to evaluate the quality of evidence. Few high-quality systematic reviews were available for most conditions, with the exceptions of MS (9 of 9 graded moderate/high quality; evidence for 2/9 indicating cannabis improved outcomes; evidence for 7/9 indicating cannabis inconclusive), epilepsy (3 of 4 graded moderate/high quality; 3 indicating cannabis improved outcomes; 1 indicating cannabis inconclusive), and chronic noncancer pain (12 of 13 graded moderate/high quality; evidence for 7/13 indicating cannabis improved outcomes; evidence from 6/7 indicating cannabis inconclusive). Among RCTs, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). The body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions, and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions.

The model of care at a leading medical cannabis clinic in Canada

Medical cannabis access has been legalized in more than 30 countries worldwide and popularity among patients is increasing rapidly. Cannabinoid-based treatments have been shown to be beneficial for several symptoms such as chemotherapy-induced nausea and vomiting, spasticity, chronic pain, intractable seizures and insomnia, yet high-quality clinical trials are still limited. As millions of patients now have legal access to medical cannabis, little information is available about the development of best clinical practices and an effective medical cannabis clinic model. A medical cannabis clinic is an innovative and emergent practice model that may be necessary to bridge the gap between patient and healthcare provider interest and existing barriers to the prescription of medical cannabis treatments, such as limited medical education, lack of high-quality clinical research and challenging or evolving regulatory frameworks. In this paper, we describe the model of care and organization of a dedicated medical cannabis clinic operating in Quebec, Canada since 2014. We share the principles of medical cannabis practice, including the structure of its medical and support team, clinic organisation and procedure guidelines. Key clinic statistics and patient demographics are shared with year by year comparison. Operating since 2014, the clinic has endured a rapidly changing regulatory landscape in Canada, overcoming numerous challenges including medical and social stigma, limited funding, resources and institutional support combined with a high demand for services. To support medical cannabis leaders globally, an important knowledge-sharing is required. The clinic has expanded to a network of four clinic sites across Quebec and offers continuing education and preceptorships to health care providers and trainees as well as research services to both academic and industry partners. The description of the clinic offers guidance on medical cannabis treatment and care and discusses possible solutions to associated challenges. The clinic model of care can be adapted to different healthcare settings and regulatory frameworks; it may assist physicians and health care providers in the development of medical cannabis clinics or the implementation of best practices as medical cannabis access continues to evolve.

The use of an integrated opioid and medical marijuana prescription drug monitoring program

OBJECTIVES

To (1) identify the reasons for which pharmacists in Connecticut use the CPMRS when dispensing opioid medications and medical marijuana products, (2) determine pharmacists' perceived value of the CPMRS when dispensing opioids or medical marijuana, and (3) compare practices and the perceived value of the CPMRS among community-based pharmacists (CBPs) and medical marijuana dispensary pharmacists (MMDPs).

METHODS

An online survey was administered from May 2019 to June 2019 to CBPs (n = 178) and MMDPs (n = 12). The survey included items about background, use, and attitudes about current and future use of the CPMRS.

RESULTS

Both pharmacist groups indicated that opioid use information was the most useful aspect of the CPMRS. Ninety percent of both groups checked patients' use of opioids using the CPMRS, and 81.2% of the MMDPs compared with 38.4% of the CBPs indicated that they checked for patients' use of medical marijuana. A greater percentage of MMDPs than CBPs felt that access to the marijuana use information was useful and needed for counseling. Several pharmacists recommended improvements in marijuana use information in the CPMRS and greater efficiencies for users of the system.

CONCLUSION

Access to both marijuana and opioid use information can allow pharmacists to make specific recommendations on the basis of potential drug interactions and dose adjustments. The results from the present study highlight how integrated systems of opioid and marijuana dispensing information can be further enhanced by resolving existing pharmacy barriers involving technology, workflow, and need for systems with more detailed marijuana product information.

Targeting the CB2 receptor and other endocannabinoid elements to delay disease progression in amyotrophic lateral sclerosis

Cannabinoids form a singular group of plant-derived compounds, endogenous lipids and synthetic derivatives with multiple therapeutic effects exerted by targeting different elements of the endocannabinoid system. One of their therapeutic applications is the preservation of neuronal integrity exerted by attenuating the multiple neurotoxic events that kill neurons in neurodegenerative disorders. In this review, we will address the potential of cannabinoids as neuroprotective agents in amyotrophic lateral sclerosis (ALS), a devastating neurodegenerative disorder characterized by muscle denervation, atrophy and paralysis, and progressive deterioration in upper and/or lower motor neurons. The emphasis will be paid on the cannabinoid type 2 (CB₂ ) receptor, whose activation limits glial reactivity, but the potential of additional endocannabinoid-related targets will be also addressed. The evidence accumulated so far at the preclinical level supports the need to soon move towards the patients and initiate clinical trials to confirm the potential of cannabinoid-based medicines as disease modifiers in ALS. LINKED ARTICLES: This article is part of a themed issue on Neurochemistry in Japan. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.6/issuetoc.

Sex differences in driving under the influence of cannabis: The role of medical and recreational cannabis use

BACKGROUND

Existing evidence suggest that cannabis may impair driving and is the most prevalent drug identified in drivers. Males exhibit an excess risk for driving under the influence of drugs or alcohol compared to females. We assessed sex differences in the association between the reason for cannabis use (medical, recreational, or both) and driving under the influence of cannabis (DUIC).

METHODS

A sample of 17,405 past 12-month cannabis users (18 + years old) were analyzed from the 2016-17 National Survey on Drug Use and Health. Multivariable logistic regression was used to assess the interaction of sex and reason for cannabis use on DUIC using predicted probabilities.

RESULTS

Among cannabis users in the sample, 88.1% used for recreational reasons, 7.8% used for medical reasons, and 4.1% used for medical and recreational reasons. The probability of DUIC was as low as 20% among female medical only users, and as high as 40% among male combined medical and recreational users. Females showed more similar probabilities of DUIC across reasons of use (range 20% to 25%s) than males (range 28% to 40%). The difference in the probability of DUIC between combined medical and recreational users and recreational only users was significantly greater among males than among females (Δ 0.1, p < 0.05).

CONCLUSIONS

The observed effects of sex and reasons for cannabis use on DUIC suggests a need for targeted educational interventions, particularly among males reporting combined medical and recreational marijuana use.

Perceptions of Marijuana Use for Glaucoma from Patients, Cannabis Retailers, and Glaucoma Specialists

PURPOSE

As marijuana's popularity continues to grow, patients with glaucoma will encounter conflicting opinions on marijuana's role in glaucoma therapy. This study seeks to define the differing perceptions among glaucoma specialists, medical marijuana dispensaries, and glaucoma patients in a state with legalized marijuana.

DESIGN

Cross-sectional study.

PARTICIPANTS

Medical marijuana dispensaries in Colorado, members of the American Glaucoma Society (AGS), and patients with glaucoma at the University of Colorado glaucoma clinic.

METHODS

First, medical marijuana dispensary employees were surveyed using a mystery call approach and a brief phone script. Dispensary employees were questioned as to whether marijuana was recommended and whether marijuana was safe and effective. Second, a self-administered survey was distributed to AGS members to determine the history of recommending marijuana and influencing factors for or against this recommendation. Third, the self-administered glaucoma patient survey assessed demographics, history of glaucoma, knowledge and rate of marijuana use, and perceptions of marijuana use. All surveys were conducted from October 2018 to March 2019.

MAIN OUTCOME MEASURES

The proportion of medical marijuana dispensaries and glaucoma specialists recommending marijuana for the treatment of glaucoma, and the proportion of patients with glaucoma using marijuana as a treatment for glaucoma.

RESULTS

A total of 203 of the 300 medical marijuana dispensaries called were successfully contacted (68%). Of these, 103 respondents (51%) recommended marijuana products for the treatment of glaucoma. The remaining 100 (49%) deferred making a recommendation or were unsure. Of the 1308 AGS members, 290 (22%) responded to the survey. Twenty-two respondents (7.6%) reported that they had recommended marijuana for the treatment of glaucoma, with the majority of these (86.4%) having done so infrequently. Among the 231 respondents with glaucoma, most (58.9%) had heard about the possible use of marijuana for glaucoma, but only 2.6% had used marijuana as a treatment for glaucoma.

CONCLUSIONS

Few glaucoma specialists have recommended marijuana as a treatment for glaucoma, and an even smaller percentage of patients report its use as a treatment for their glaucoma. In contrast, many marijuana dispensary employees endorse its use. As legal access and public acceptance of marijuana escalate, physicians should be aware of these perceptions when educating patients.

Association of Depression With Past-Month Cannabis Use Among US Adults Aged 20 to 59 Years, 2005 to 2016

IMPORTANCE

Despite studies showing that repeated cannabis use may worsen depressive symptoms, the popular media increasingly presents cannabis as beneficial to mental health, and many members of the public view cannabis as beneficial for depression. Therefore, cannabis use among individuals with depression may be becoming more prevalent.

OBJECTIVE

To examine the association of depression with past-month cannabis use among US adults and the time trends for this association from 2005 to 2016.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study used data from 16 216 adults aged 20 to 59 years who were surveyed by the National Health and Nutrition Examination Survey, a national, annual, cross-sectional survey in the United States, between 2005 and 2016. Data analysis was conducted from January to February 2020.

EXPOSURES

Survey year and depression, as indicated by a score of at least 10 on the Patient Health Questionnaire-9.

MAIN OUTCOMES AND MEASURES

Any past-month cannabis use (ie, ≥1 use in the past 30 days) and daily or near-daily past-month cannabis use (ie, ≥20 uses in the past 30 days). Logistic regression was used to examine time trends in the prevalence of cannabis use, depression, and the association between cannabis use and depression from 2005 to 2016.

RESULTS

The final analysis included 16 216 adults, of whom 7768 (weighted percentage, 48.9%) were men, 6809 (weighted percentage, 66.4%) were non-Hispanic White participants, and 9494 (weighted percentage, 65.6%) had at least some college education. They had a weighted mean age of 39.12 (95% CI, 38.23-39.40) years. Individuals with depression had 1.90 (95% CI, 1.62-2.24) times the odds of any past-month cannabis use and 2.29 (95% CI, 1.80-2.92) times the odds of daily or near-daily cannabis use compared with those without depression. The association between cannabis use and depression increased significantly from 2005 to 2016. The odds ratio for depression and any past-month cannabis use increased from 1.46 (95% CI, 1.07-1.99) in 2005 to 2006 to 2.30 (95% CI, 1.82-2.91) in 2015 to 2016. The odds ratio for depression and daily or near-daily past-month cannabis use increased from 1.37 (95% CI, 0.81-2.32) in 2005 to 2006 to 3.16 (95% CI, 2.23-4.48) in 2015 to 2016.

CONCLUSIONS AND RELEVANCE

The findings of this study indicate that individuals with depression are at increasing risk of cannabis use, with a particularly strong increase in daily or near-daily cannabis use. Clinicians should be aware of these trends and the evidence that cannabis does not treat depression effectively when discussing cannabis use with patients.

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.

Perceived Importance of Factors in Cannabis Purchase Decisions: A Best-worst Scaling Experiment

BACKGROUND

Consumers' access to cannabis has been considerably expanded in US states where recreational cannabis was legalized and commercialized. However, little is known about the important factors influencing consumers' purchase decisions in cannabis retail dispensaries. This study examined cannabis users' perceptions of the relative importance of policy-relevant factors when they made cannabis purchase decisions.

METHODS

An online survey was administered to 817 adult cannabis users in seven states in the US (California, Colorado, Maine, Massachusetts, Nevada, Oregon, and Washington) that had approved cannabis commercialization by the time of interview in January 2018. Twenty policy-relevant cannabis attributes were evaluated, including those pertaining to product characteristics, quality, package characteristics, price and free sample, store characteristics, and restrictions on use. A best-worst scaling experiment was employed, which asked respondents to select the most and the least important attributes in a choice scenario. Each respondent answered 10 choice scenarios, each including a random combination of four attributes out of the 20. The relative importance of each attribute was evaluated using hierarchical Bayesian estimation of mixed logit models.

RESULTS

Overall, 'quality', 'strain type', 'price', 'THC' (tetrahydrocannabinol) and 'pesticide' were the top five important attributes affecting cannabis users' willingness to buy cannabis in a dispensary. These five attributes jointly accounted for approximately half of the total importance. In subsample analysis, both recreational and dual-purpose users attached higher importance to 'quality', 'THC', and 'price', whereas medical users tended to think 'CBD' (cannabidiol) and 'pesticide' were more important. All cannabis users perceived 'package' to be the least important attribute. Gender had no major differences in perceptions.

CONCLUSIONS

Cannabis users in general perceived product characteristics, quality, and price to be important factors in their willingness to buy cannabis in dispensaries. There were heterogeneities in the perceptions by cannabis use purposes. The findings might deserve consideration in cannabis policy design.

Attitudes about cannabis mediate the relationship between cannabis knowledge and use in active adult athletes

BACKGROUND

Little is known about how cannabis knowledge and attitudes impact cannabis use behavior.

OBJECTIVE

To test the knowledge-attitudes-behavior paradigm in active adult athletes.

DESIGN

The Athlete Pain, Exercise, and Cannabis Experience (PEACE) Survey, a cross-sectional survey study, used social media and email blasts to recruit participants and SurveyGizmo to collect data.

PARTICIPANTS

Self-defined active adult athletes (n = 1161).

MAIN MEASURES

Knowledge about cannabis was evaluated with four questions. Attitudes toward cannabis was evaluated with 11 questions. The attitudes questions were used in a TwoStep Cluster analysis in SPSS to assign group membership by attitudes. Chi-square was used to determine if there were differences in cluster membership by demographic factors and if knowledge about cannabis differed by cluster membership. Regression analysis was performed to determine if cannabis attitudes mediated the relationship between cannabis knowledge and cannabis use.

KEY RESULTS

A three-cluster solution was the best fit to the data. The clusters were named Conservative (n = 374, 32.2%), Unsure (n = 533, 45.9%), and Liberal (n = 254, 21.9). There was a significant difference among the clusters for all 11 attitudes items (all p < 0.001). Attitude cluster membership was significantly different by age (p < 0.001), primary sport (p < 0.05), and knowledge about cannabis (p < 0.001). Athletes in the liberal cluster answered the knowledge questions correctly most often. Attitudes mediated the relationship between cannabis knowledge and cannabis use [Never (32.4%), Past (41.6%), Current (26.0%)] with athletes in the liberal cluster showing more knowledge and greater likelihood to be a current cannabis user (p < 0.001). Among current cannabis users there were differential patterns of cannabis use depending on their attitudes and knowledge; liberal athletes tended to co-use THC and CBD and used cannabis longer. (p < 0.001).

CONCLUSIONS

Cannabis education needs to consider attitudes about cannabis, especially among those who might benefit from medical cannabis.

A Balanced Approach for Cannabidiol Use in Chronic Pain

Cannabidiol (CBD), the major non-psychoactive constituent of Cannabis sativa L., has gained traction as a potential treatment for intractable chronic pain in many conditions. Clinical evidence suggests that CBD provides therapeutic benefit in certain forms of epilepsy and imparts analgesia in certain conditions, and improves quality of life. CBD continues to be Schedule I or V on the list of controlled substances of the Drug Enforcement Agency of the United States. However, preparations labeled CBD are available publicly in stores and on the streets. However, use of CBD does not always resolve pain. CBD purchased freely entails the risk of adulteration by potentially hazardous chemicals. As well, CBD use by pregnant women is rising and poses a major health-hazard for future generations. In this mini-review, we present balanced and unbiased pre-clinical and clinical findings for the beneficial effects of CBD treatment on chronic pain and its deleterious effects on prenatal development.

Indications and administration practices amongst medical cannabis healthcare providers: a cross-sectional survey

BACKGROUND

The medical use of cannabis has been legislatively restricted for decades in the US and abroad. In recent years, changing local and national policies have given rise to a community of healthcare providers who may be recommending the medical use of cannabis without the benefit of formal clinical practice guidelines or sufficient training and education. In addition, a citizen science movement has emerged whereby unlicensed and untrained individuals are acting as healthcare provider proxies, offering cannabis-specific clinical care to "patients". This study sought to characterize the clinical practice characteristics of these provider groups.

METHODS

An anonymous, online survey was designed to describe levels of cannabis-specific education, practice characteristics, indications for medical use, dose, administration forms and adverse effects related to cannabis use. The questionnaire was disseminated via professional medical cannabis associations and by word-of-mouth. It was accessed between June 31-December 31, 2018. A self-selecting sample of respondents (n = 171) completed the survey.

RESULTS

Formal education or training in the medical use of cannabis was significantly more common among licensed respondents than unlicensed respondents (95.5% vs 76.9% respectively, OR, 6.3, 95% CI, 1.2-32.3, p = 0.03). The vast majority (n = 74, 83.15%) of licensed respondents reported having recommended cannabis as an adjunct to an existing prescription drug. Almost two-thirds (n = 64, 71.9%) reported having recommended it as a substitute. When delta-9-tetrahydrocannabinol (THC) is the principal therapeutic constituent of interest, vaporization is the most common method of administration recommended (n = 94 responses, 71.4% of respondents). In contrast, when cannabidiol (CBD) is the principal therapeutic constituent of interest, oral administration (sublingual or oromucosal absorption) is the most common method (n = 70 responses, 71.4% of respondents).

CONCLUSIONS

Individuals who recommend the medical use of cannabis appear to be self-generating a community standard of practice in the absence of formal clinical guidelines on dosing, interactions and other characteristics. Reducing barriers to clinical research on cannabis products is needed, not only to better understand their risks and benefits, but also to augment the evidence-base for informing clinical practice.

Priming primary care providers to engage in evidence-based discussions about cannabis with patients

Cannabis use has become increasingly common in the U.S. in recent years, with legalization for medical and recreational purposes expanding to more states. With this increase in use and access, providers should be prepared to have more conversations with patients about use. This review provides an overview of cannabis terminology, pharmacology, benefits, harms, and risk mitigation strategies to help providers engage in these discussions with their patients. Current evidence for the medical use of cannabis, cannabis-related diagnoses including cannabis use disorder (CUD) and withdrawal syndromes, and the co-use of opioids and cannabis are discussed. It is crucial that providers have the tools and information they need to deliver consistent, evidence-based assessment, treatment, prevention and harm-reduction, and we offer practical guidance in these areas.

Characterization of mental health in cannabis dispensary users, using structured clinical interviews and standardized assessment instruments

BACKGROUND

Cannabis is commonly used for its medical properties. In particular, cannabis is purported to have beneficial effects on a wide range of neuropsychiatric conditions. Studies assessing mental health in cannabis dispensary users typically evaluate symptoms using self-report check lists, which provide limited information about symptom severity, and whether subjects meet criteria for a psychiatric diagnosis. There is, therefore, a need for studies which assess mental health in dispensary users with standardized and well validated scientific instruments, such as those used in clinical drug trials.

METHODS

One hundred medical cannabis users were recruited from a community dispensary. All subjects completed a structured clinical interview with the Mini-International Neuropsychiatric Interview (MINI). Subjects also completed the Perceived Stress Scale-10, PROMIS Fatigue Scale, PROMIS Sleep Disturbance Scale, Beck Depression Inventory, the Patient Health Questionnaire-15 and the Brief Pain Inventory. Details about cannabis use were also recorded.

RESULTS

Lifetime prevalence of mental illness in this cohort was high, and a large proportion of subjects endorsed psychological symptoms. The proportion of subjects who met criteria for classification of a current psychiatric disorder was low for mood disorders, but high for anxiety disorders and substance abuse/dependence. Cannabis use differed between the main psychiatric conditions.

CONCLUSIONS

The present results indicate that rates of mental illness may be high in medical cannabis dispensary users. Use of structured clinical assessments combined with standardized symptom severity questionnaires provide a feasible way to provide a more rigorous and detailed evaluation of conditions and symptoms in this population.

Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use

OBJECTIVE

To characterize recommendations given to pregnant women by Colorado cannabis dispensaries regarding use of cannabis products for nausea during the first trimester of pregnancy.

METHODS

This was a statewide cross-sectional study in which advice about cannabis product use was requested using a mystery caller approach. The caller stated she was 8 weeks pregnant and experiencing morning sickness. Dispensaries were randomly selected from the Colorado Department of Revenue Enforcement Division website. The primary outcome was the proportion of marijuana dispensaries that recommended a cannabis product for use during pregnancy. We hypothesized that 50% of dispensaries would recommend use. A sample size of 400 was targeted to yield a two-sided 95% CI width of 10%. Secondary outcomes included the proportion endorsing cannabis use as safe during pregnancy, specific product recommendations, and encouraging discussion with a health care provider. Recommendations were compared by licensure type (medical, retail, or both) and location (rural vs urban).

RESULTS

Of the 400 dispensaries contacted, 37% were licensed for medical sale (n=148), 28% for retail (n=111), and 35% for both (n=141). The majority, 69% (277/400), recommended treatment of morning sickness with cannabis products (95% CI 64-74%). Frequency of recommendations differed by license type (medical 83.1%, retail 60.4%, both 61.7%, P<.001). Recommendations for use were similar for dispensary location (urban 71% vs nonurban 63%, P=.18). The majority (65%) based their recommendation for use in pregnancy on personal opinion and 36% stated cannabis use is safe in pregnancy. Ultimately, 81.5% of dispensaries recommended discussion with a health care provider; however, only 31.8% made this recommendation without prompting.

CONCLUSION

Nearly 70% of Colorado cannabis dispensaries contacted recommended cannabis products to treat nausea in the first trimester. Few dispensaries encouraged discussion with a health care provider without prompting. As cannabis legalization expands, policy and education efforts should involve dispensaries.

Frequently asked questions about dabbing concentrates in online cannabis community discussion forums

BACKGROUND

"Dabbing" involves vaporizing a "dab" of cannabis concentrate on a heated "nail," passing the vapour through a water-pipe rig or portable pen device, and inhaling the vapour. While some cannabis industry media claims that this process is cleaner, safer, and more effective for getting high, medical and public health sources raise concerns about residual solvents and pesticides, unexpectedly intense effects, and rapid increases in tolerance. The aim of this study is to characterize the content of questions about dabbing posed in cannabis and dabbing-specific forums on the Reddit social media platform, as well as comment responses to these questions.

METHODS

We conducted a content analysis of one year (2017) of information-seeking user-generated posts to three Reddit online cannabis community discussion forums ("subreddits") that contained the terms "dab" and "question." We also examined post engagement and the types and sentiment of information exchanged in the comment responses.

RESULTS

Across 193 dabbing question posts, the most frequently asked question content was about types and logistical use of devices and related equipment (38%) and comparisons of cannabis products (32%), followed by questions about the step-by-step process of getting high (18%), legal issues (17%), and health concerns (13%). Nearly every post had a response (98%), with a median 5 comments per post and few negative (i.e. hostile, condescending, or trolling) comments (4%). Source of advice or information was stated in about a quarter (26%) of comment responses, with the overwhelming majority of this information (89%) coming from disclosures of personal experience vs. web or commercial sources.

CONCLUSION

People seeking advice online about dabbing inquired most often about logistics of use, but less often about health, tolerance, and legal risks. These findings may be used to inform public health efforts and health practitioner education as cannabis becomes increasingly legal and accessible.

Marijuana use among patients with epilepsy at a tertiary care center

The expansion of medical and recreational marijuana legalization facilitates patient access to cannabis, and many patients with epilepsy pursue marijuana as a treatment for seizures. We administered a nine-item survey on marijuana use to patients seen in an epilepsy clinic over a 9 month period at a tertiary care center in Oregon where recreational use was legalized in 2015. The majority of respondents (n = 39) reported cannabis use for the purpose of treating epilepsy (87.2%, n = 34), and strongly agreed (53.8%, n = 21) or agreed (28.2%, n = 11) that cannabis use improved seizure control. The most commonly selected cannabis strains were high cannabidiol (CBD) (30.8%, n = 12) or multiple types (30.8%, n = 12), with administration methods of smoking (66.7%, n = 26), edibles (48.7%, n = 19), and concentrates (43.6%, n = 17). More participants reported using marijuana with primarily CBD than primarily tetrahydrocannabinol (THC) or equal CBD:THC content, and very few women reported using marijuana with primarily THC compared with men (10% of female versus 47% of male respondents). Only 2 of 39 participants were able to give an exact dosage used in milligrams. Medical and recreational dispensaries were the most common cannabis sources, followed by homegrown and friends/family members. Although pharmaceutical CBD extract is now Food and Drug Administration (FDA)-approved for certain epilepsy types, access remains limited. Further research is needed to understand recreational cannabis use among patients with epilepsy while clinical research for pharmaceutical cannabis products continues.

Navigating Blind in the Green Rush: Clinical Considerations and Harm Reduction Practices for Cannabis

Background

The United States has recently experienced extensive changes in state policy regarding the use of cannabis for recreational and medicinal purposes. Despite its rapidly increasing accessibility and social acceptance, there is a striking dearth of research on cannabis as a treatment for medical and psychological conditions. Research on cannabis is difficult to conduct as it is classified as a schedule I drug with high potential for abuse and currently no accepted medical use in treatment. As a result, no standard dosing procedures exist and the lack of conclusive scientific evidence has left clinical providers without evidence-based guidelines about if, when, and how to guide clients on using cannabis safely.

Objective

To (1) provide critical psychoeducational information about cannabis and cannabis problems to guide client-provider conversations about cannabis use and (2) describe common clinical concerns around cannabis use, highlight special considerations for vulnerable populations, and review harm reduction techniques and practical resources that may help clinicians and their clients navigate safer cannabis use.

Conclusion

The removal of regulatory barriers would enable researchers to address key public health questions about the potential therapeutic and adverse effects of cannabis use. Additionally, funds for research, clinician education, and public health education initiatives are necessary to reduce risk around cannabis use in the United States.

A cross-sectional examination of choice and behavior of veterans with access to free medicinal cannabis

Background: With a rise in public pressure to increase veteran access to medicinal cannabis, free cannabis collectives for military veterans are proliferating across the US. Objectives: The aim of the current study was to document which cannabis formulations and routes of administration are chosen by veterans with increased access to cannabis, and to determine whether cannabis is being used as a substitute for other licit and illicit drugs. Method: The current study collected cross-sectional self-report data on cannabis use, cannabinoid constituent composition, primary indication of use, and substitution practices among a sample of 93 US military veterans (84.9% male) with access to free cannabis. Result: Most of the sample reported using cannabinoids as a substitute for either alcohol, tobacco, prescription medications, or illicit substances, reported that they use cannabis frequently (Modal frequency >4x/day, Modal quantity = 5 to 8 grams/week), and primarily select higher-risk cannabis formulations (i.e., high THC/low CBD, smoked). The majority of the sample reported that they use cannabis to self-treat multiple physical and mental health conditions/symptoms. Conclusions: Results of the current study suggest that military Veterans with reduced barriers to access cannabis could be making both helpful and harmful choices regarding their cannabis use. These findings suggest that more guidance on the selection of cannabis-based products in this population is warranted, particularly as barriers to medicinal cannabis access are reduced.

Medical Cannabis Use among Adults in the Southeastern United States

OBJECTIVES

To assess the self-reported reasons for medical cannabis use within the southeastern United States and compare recreational and medical cannabis users.

METHODS

This study was a cross-sectional survey administered in 2017 through Amazon's Mechanical Turk and enrolled 432 adult, regular cannabis users. Measures included demographics, cannabis use characteristics, and medical reasons for cannabis use.

RESULTS

Under half (47%) of respondents endorsed using cannabis for both medical and recreational reasons and 12% reported medical use only. The most commonly cited reasons for medical cannabis use were psychiatric and 60 unique medical conditions were listed. Recreational and medical users were similar on several measures of current use, but did vary in their use history, methods of use, and product knowledge.

CONCLUSIONS

Despite state laws and conclusive scientific evidence to support medical cannabis use for certain conditions, cannabis is still used frequently for a range of medical issues.

POLICY IMPLICATIONS

These data may assist healthcare providers in better understanding medical cannabis use in states with tightened restrictions and tailoring information to medical cannabis users about their specific conditions and prioritizing therapeutic options.