Irish general practitioner attitudes toward decriminalisation and medical use of cannabis: results from a national survey

Knowledge gap in a cross section of Irish general practitioners prescribing denosumab for osteoporosis

BACKGROUND

Denosumab is commonly used by general practitioners (GPs) in Ireland to treat osteoporosis though drug holidays are not recommended with rebound bone loss and risk of vertebral fractures if stopped. We aimed to investigate GP practice and knowledge regarding denosumab including use and reasons for use, therapy duration, blood monitoring and recommended vitamin D status/calcium intake on treatment, staff administering, methods of recall, delays in receiving injections, management of and awarenes of guidelines if stopped, reasons for stopping and concerns about same.

METHODS

GPs were contacted (n = 846) by email and invited to complete an online anonymous survey comprising 25 questions in January 2022. We collated responses and explored for differences between GP principals/trainers and GP trainees.

RESULTS

There were 146 responses. Sixty-seven percent were female and 50% were GP principal/trainers. Forty-three percent used denosumab as a first line therapy citing convenience in 32% of cases. Half (50%) envisaged therapy for 3-5 years and 15% lifelong use. A fifth (21%) had no concerns about it being stopped (11% trainors vs 31% trainees, P = 0.002). If stopped, 41% cited opting for a drug holiday with monitoring. Forty percent of GPs gave patients a reminder card for the next injection and 27% had an alert system.

CONCLUSION

We identified a knowledge gap in denosumab prescribing among a sample of Irish GPs. Findings suggest a need for education to increase awareness around denosumab use and to consider recall systems in GP practices as suggested elsewhere to ensure persistence with therapy.

Attitudes of Swiss psychiatrists towards cannabis regulation and medical use in psychiatry: a cross-sectional study

BACKGROUND

Changes in regulation for cannabis for nonmedical use (CNMU) are underway worldwide. Switzerland amended the law in 2021 allowing pilot trials evaluating regulative models for cannabis production and distribution. Simultaneously, cannabis for medical use (CMU) in psychiatry is a growing issue, asked for by patients and being discussed by medical professionals.

METHODS

From December 2021 to February 2022, we conducted an online survey of psychiatrists in Switzerland. The survey comprised questions on attitudes towards regulative models for CNMU and towards prescribing CMU for mental disorders.

RESULTS

We contacted 2010 psychiatrists in Switzerland. A total of 274 (14%) participated in the survey. Sixty-four percent agreed to a regulated legalization of CNMU, and 89% would welcome pilot trials in Switzerland assessing models for regulating CNMU with those from a French-speaking region being more skeptical. Forty-nine percent of psychiatrists agree that CMU might have a therapeutic effect in mental disorders, but 50% agree that there is not enough scientific evidence yet. Participants working in an inpatient setting or in a French-speaking region as well as those with a longer duration of practice were more skeptical on CMU for mental health.

CONCLUSIONS

Most surveyed Swiss psychiatrists favor the regulation of CNMU and the conduct of pilot trials. Despite little evidence and potential negative consequences, many participating Swiss psychiatrists agreed that cannabis could be efficacious in the treatment of some mental disorders advocating for more research in this topic.

The Quebec Cannabis Registry: Investigating the Safety and Effectiveness of Medical Cannabis

Objective: To investigate the safety and effectiveness of medical cannabis (MC) in the real-world clinical practice setting. Design: A 4-year prospective noncomparative registry of adult patients who initiated MC for a variety of indications. This paper reports on patients followed for up to 12 months, with interim visits at 3, 6, and 9 months after enrollment. Setting: Public or private outpatient clinics certified to authorize MC in the province of Quebec, Canada. Participants: Overall, 2991 adult (age ≥18 years) patients (mean age 51 years; 50.2% women) were enrolled between May 2015 and October 2018, with the last follow-up ending in May 2019. Interventions/Exposures: Cannabis products (dried, oil, or other) purchased from a Canadian licensed cannabis producer as authorized by physicians. Main Outcome Measures: The primary outcomes were self-reported pain severity, interference and relief (Brief Pain Inventory [BPI]), symptoms using the Revised Edmonton Symptom Assessment System (ESAS-r) and health-related quality of life dimensions (EQ-5D-5L) at baseline and each follow-up visit. The secondary outcomes were self-reported adverse events (AEs) and characteristics of cannabis treatment. Results: All patient-reported outcomes (BPI, ESAS-r, and EQ-5D-5L) showed a statistically significant improvement at 3 months (all p<0.01), which was maintained or further improved (for pain interference, tiredness, and well-being) over the remainder of the 12-month follow-up. Results also revealed clinically significant improvements in pain interference and tiredness, anxiety, and well-being from baseline. There were 79 AE reports (77 patients), 16 met the regulatory definition of seriousness, in which only 8 AEs were certainly or probably related to MC. Conclusions: MC directed by physicians appears to be safe and effective within 3 months of initiation for a variety of medical indications.

GP preferences for, access to, and use of evidence in clinical practice: a mixed-methods study

BACKGROUND

GPs aim to provide patient-centred care combining clinical evidence, clinical judgement, and patient priorities. Despite a recognition of the need to translate evidence to support patient care, barriers exist to the use of evidence in practice.

AIM

To ascertain the needs and preferences of GPs regarding evidence-based guidance to support patient care. The study also aimed to prioritise content and optimise structure and dissemination of future evidence-based guidance.

DESIGN & SETTING

This was a convergent parallel mixed-methods study in collaboration with the national GP professional body in the Republic of Ireland (Irish College of General Practitioners [ICGP]). Quantitative and qualitative findings were integrated at the interpretive level.

METHOD

A national GP survey was administered via the ICGP (December 2020) and seven GP focus groups were undertaken (April-May 2021).

RESULTS

Of 3496 GPs, a total of 509 responders (14.6%) completed the survey and 40 GP participants took part in focus groups. Prescribing updates, interpretation of test results, chronic disease management, and older person care were the preferred topics for future evidence-based guidance. GPs reported that they required rapid access to up-to-date and relevant evidence summaries online for use in clinical practice. Access to more comprehensive reviews for the purposes of continuing education and teaching was also a priority. Multimodal forms of dissemination were preferred to increase uptake of evidence in practice.

CONCLUSION

GPs indicated that rapid access to up-to-date, summarised evidence-based resources, available from their professional organisation, is preferred. Evidence should reflect the disease burden of the population and involve multifaceted dissemination approaches.

"It's a big added stress on top of being so ill": The challenges facing people prescribed cannabis in the UK

BACKGROUND

This paper reports on the first qualitative study to interview people prescribed cannabis in the UK. Cannabis is a class B controlled substance under the 1971 Misuse of Drugs (MoD) Act, but a 2018 change to UK regulations provided for the prescription of cannabis for medical purposes. Relatively few people have been able to access a prescription, despite this policy change. This paper examines their experiences.

METHODS

Qualitative, semi-structured interviews were conducted with 24 people with a prescription for cannabis, or their carers. Data was analysed using a reflextive thematic analysis approach. The findings are discussed using a zemiology (social harms) perspective which provides a language for critical reflection on the current cannabis policy context.

RESULTS

All participants reported that cannabis had significantly improved their mental and/or physical health, across a broad range of conditions. Many had been able to reduce their use of conventional medicines and reported that cannabis had relatively few side effects. Despite the potentially life-enhancing benefits of cannabis medicine, patients in the UK face multiple barriers to access. These include a lack of funding streams, bureaucratic supply problems, and a lack of training for doctors and police. Even for the few people able to obtain a prescription, the ongoing criminalisation of cannabis in the UK contributed to their experiences of stigmatisation. This often made it difficult and anxiety-inducing to take their medicine in public spaces.

CONCLUSION

The UK government's lack of implementation of medical cannabis legalisation, combined with their ongoing prohibition position, is producing multiple harms to people who need cannabis medicine. The policy context is perpetuating stigmatising attitudes to cannabis which, as we demonstrate, contribute to social harms. We make recommendations on equality of patient access, and highlight the importance of education and policy change as means of combatting stigma.

Medical and recreational cannabis: A cross-sectional survey assessing a sample of physicians' attitudes, knowledge and experience in a university hospital in Lebanon

CONTEXT

A law legalizing the farming of medical cannabis for the international market was passed in Lebanese parliament in April 2020. Thus, this makes Lebanon the first Arab country to legalize medical cannabis, a law which can hold potential public health consequences. The advocates of legalization of medical cannabis in society and in the media influence the public opinion. A community of Lebanese physicians was the first to be asked about this subject.

OBJECTIVE

This study aims to assess a sample of physicians' opinions, knowledge and experiences with medical and non-medical cannabis.

METHOD

All physicians of every speciality working at the Hôtel Dieu de France-Beirut hospital (450) received by email a 33-question-online survey in French between November 2020 and December 2020. The survey was designed based on similar studies published outside of Lebanon.

RESULTS

Eighty-five Lebanese physicians responded to the survey and 80% of them supported the decriminalization of medical cannabis in Lebanon. But only 16% reported knowing the indications of medical cannabis, and only 24% stated that they have adequate knowledge of its secondary effects. Eighty-eight percent of them felt that they might be more comfortable discussing the option of medical cannabis if they had formal education on the subject.

CONCLUSION

Even though the majority of the sample who participated in this study seemed to approve the use of medical cannabis, they lacked the knowledge and confidence to do it. Therefore, this study highlights the need of physician training in the subject of medical cannabis. Future well-conducted university studies will produce evidence-based-guidelines for medical cannabis indications and side effects.

Knowledge, experiences, and attitudes of Australian General Practitioners towards medicinal cannabis: a 2021-2022 survey

BACKGROUND

Medicinal cannabis (MC) products have been available on prescription in Australia for around six years. General practitioners (GPs) are at the forefront of MC prescribing and recent years have seen substantial increases in prescription numbers. This study examined the current knowledge, experiences, and attitudes of Australian GPs around MC. We also compared our findings to those of an earlier 2017 investigation.

METHOD

We conducted a cross-sectional study using a 42-item on-line questionnaire adapted from our earlier 2017 survey. The current survey was completed by GPs attending an on-line, multi-topic educational seminar. Australian GPs (n = 505) completed the survey between November 2021 and February 2022. Data were synthesised using descriptive statistics. MC 'prescribers' and 'non-prescribers' responses were compared using Pearson's χ2 tests.

RESULTS

While most GPs (85.3%) had received patient enquiries about MC during the last three months, only half (52.3%) felt comfortable discussing MC with patients. Around one fifth (21.8%) had prescribed a MC product. GPs strongly supported MC prescribing for palliative care, cancer pain, chemotherapy-induced nausea and vomiting, and epilepsy, more so than in our 2017 survey. Prescribing for mental health conditions (e.g., depression, anxiety) and insomnia received less support. Opioids, benzodiazepines, and chemotherapy drugs were rated as more hazardous than MC. GPs correctly endorsed concerns around Δ⁹-tetrahydrocannabinol-related driving impairment and drug-seeking behaviour. However, additional concerns endorsed around cannabidiol causing addiction and driving impairment do not agree with current evidence. Consistent with this, many GPs (66.9%) felt they had inadequate knowledge of MC.

CONCLUSION

Acceptance of MC as a treatment option has increased among Australian GPs since 2017. However, there is a clear need for improved training and education of GPs around cannabis-based medicines to provide increased numbers of skilled prescribers in the community.

Healthcare professionals' perspectives on the use of medicinal cannabis to manage chronic pain: A systematic search and narrative review

RATIONALE, AIMS, AND OBJECTIVES

Chronic pain is a global public health problem that negatively impacts individuals' quality of life and imposes a substantial economic burden on societies. The use of medicinal cannabis (MC) is often considered by patients to help manage chronic pain as an alternative or supplement to more conventional treatments, given enabling legalization in a number of countries. However, healthcare professionals involved in providing guidance for patients related to MC are often doing so in the absence of strong evidence and clinical guidelines. Therefore, it is crucial to understand their perspectives regarding the clinical use and relevance of MC for chronic pain. As little is known about attitudes of HCPs with regard to MC use for chronic pain specifically, the aim of this review was to identify and synthesize the published evidence on this topic.

METHODS

A systematic search was conducted across six databases: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, and PubMed from 2001 to March 26, 2021. Three authors independently performed the study selection and data extraction. Thematic analysis was undertaken to identify key themes.

RESULTS

A total of 26 studies were included, involving the United States, Israel, Canada, Australia, Ireland, and Norway, and the perspectives of physicians, nurses, and pharmacists. Seven key themes were identified: MC as a treatment option for chronic pain, and perceived indicated uses; willingness to prescribe MC; legal issues; low perceived knowledge and the need for education; comparative safety of MC versus opioids; addiction and abuse; and perceived adverse effects; CONCLUSION: To support best practice in the use of MC for chronic pain, healthcare professionals require education and training, as well as clinical guidelines that provide evidence-based information about efficacy, safety, and appropriate dosage of products for this indication. Until these gaps are addressed, healthcare professionals will be limited in their capacity to make treatment recommendations about MC for people/patients with chronic pain.

Magic Mushrooms - an exploratory look at how mental health professionals feel and think about Psilocybin

Psilocybin recently received breakthrough status by the FDA for its use in treatment of depression. We therefore investigated mental health professionals' (MHPs) opinions on Psilocybin (n = 155). Overall, attitudes were neutral but self-rated knowledge of Psilocybin was low. The term used in the survey, 'Psilocybin' or 'Magic Mushrooms', did not significantly affect their responses. Some variables (i.e., gender, attitudes towards medical cannabis, and personal history of psychedelic usage) were associated with ratings of Psilocybin. These results provide a baseline of MHPs' thoughts on Psilocybin and what should be considered in the future if it is FDA-approved.

Clinician Beliefs and Practices Related to Cannabis

Introduction: Medical cannabis (marijuana) use is legal in 33 U.S. states and the District of Columbia. Clinicians can play an important role in helping patients access and weigh potential benefits and risks of medicinal cannabis. Accordingly, this study aimed to assess clinician beliefs and practices related to cannabis. Methods: Data are from 1506 family practice doctors, internists, nurse practitioners, and oncologists who responded to the 2018 DocStyles, a web-based panel survey of clinicians. Questions assessed medicinal uses for and practices related to cannabis and assessed clinicians' knowledge of cannabis legality in their state. Logistic regression was used to assess multivariable correlates of asking about, assessing, and recommending cannabis. Results: Over two-thirds (68.9%) of clinicians surveyed believe that cannabis has medicinal uses and just over a quarter (26.6%) had ever recommended cannabis to a patient. Clinicians who believed cannabis had medicinal uses had 5.9 times the adjusted odds (95% confidence interval 3.9-8.9) of recommending cannabis to patients. Beliefs about conditions for medical cannabis use did not necessarily align with the current scientific evidence. Nearly two-thirds (60.0%) of clinicians surveyed incorrectly reported the legal status of cannabis in their state. Discussion: Findings suggest that while clinicians believe that cannabis has medicinal uses, they may not have a full understanding of the scientific evidence and may not accurately understand their state-based policies for cannabis legalization and use. Given that clinicians are responsible for recommending medicinal cannabis in most states that have legalized it, ongoing education about the health effects of cannabis is warranted.

Exploratory Factor Analysis of Medical Students’ Perceptions of Medical Cannabis Scale

Background

There are few published research articles investigating medical students’ perceptions of medical cannabis (MC), including their attitudes toward its efficacy and appropriateness in medicine, concerns for potential adverse effects, and their willingness to prescribe it to patients (in future practice). This research investigated the factor structure of a tool to assess medical students’ perceptions of MC for the purpose of curriculum enhancement.

Methods

Using a voluntary electronic survey, quantitative data were collected between January and March 2022 from 526 medical students enrolled in a large medical school in Florida, United States. A 32-item questionnaire developed by the researchers was used to investigate medical students’ perceptions of MC. The survey was anonymous and took about 10 minutes to complete. Bivariate correlation analyses were conducted prior to performing a principal component analysis with varimax rotation.

Results

Using principal component analysis with varimax rotation, three factors were identified with eigenvalues greater than 1.0 and a cumulative variance of 59.694%. These factors are perceived knowledge of MC, concern for possible adverse effects of MC (e.g., the potential for misuse/dependence), and attitudes toward MC (e.g., cannabis having an acceptable role in medicine, willingness (as a future physician) to help patients access MC, obtaining training about MC in school and residency training, the physician’s role as a prescriber, and efficacy and benefits of MC for certain health conditions).

Conclusions

The development of this kind of brief measure may be valuable for defining the future educational needs of medical students and other health professionals as well as a tool for future research.

Primary care physicians' attitudes and knowledge regarding medical cannabis and willingness to prescribe it: the Israeli experience

BACKGROUND

Use of medical cannabis (MC) in Israel has increased since its regulatory approval in 2016. Currently, more than 1% of Israeli adults are treated with MC; this requires primary care physicians (PCPs) to be familiar with this treatment option.

OBJECTIVES

We assessed the attitudes and knowledge of Israeli PCPs toward MC and evaluated their willingness to prescribe it for different medical conditions.

METHODS

A cross-sectional survey which was distributed to PCPs in Israel. Physicians were asked about their opinions, knowledge, and willingness to prescribe MC.

RESULTS

Two hundred and one PCPs answered the questionnaire. Their average age was 47 years (±11.2), 71% were specialists. 51% of the respondents thought that MC is an effective treatment. 63% replied that they had little knowledge and 75% indicated that they would like to deepen it. 61% of the respondents were willing to initiate an MC treatment for a dying patient, while less than 50% were willing to initiate MC treatment for various other conditions. Most respondents indicated that they were willing to renew a prescription for any approved medical condition. Willingness to prescribe MC increased for physicians who agreed that MC was effective (odds ratio [OR] 21.9, 95% confidence interval [CI] 2.40-200.85), for physicians who strongly agreed with the statement that they had sufficient knowledge (OR 5.0, 95% CI 1.58-15.83) and for residents compared with specialists (OR 4.0, 95% CI 1.52-10.73).

CONCLUSIONS

Our survey revealed PCPs' differing opinions and insufficient knowledge regarding treatment with MC. These findings suggest that continuing medical education regarding MC is needed.

To Treat or Not to Treat? Polish Physicians' Opinions about the Clinical Aspects of Cannabinoids-An Online Survey

Introduction: Medical cannabis’ importance in Poland increased dramatically following its legalization as the 12th country in Europe in 2017. However, no studies have been published to give insight into Polish physicians’ opinions about medical cannabis. Objectives: To investigate physician’s opinions about cannabinoids’ utility in clinical practice, concerns regarding their safety profile, and their clinical experience with cannabinoids. Methods: The survey using a self-developed tool was conducted online; participants were physicians with or without specialist training. Participation was voluntary. Physicians were recruited through personal networks, palliative care courses, and Medical Chambers. Results: From June to October 2020, we recruited 173 physicians from 15/16 voivodeships. The largest age group (43.9%; n = 76) was 30–39 year-olds. A similar proportion declared they never used cannabis and did not receive any training regarding cannabinoids (60% for both). Only 15 (8%) ever prescribed medical cannabis, although about 50% declared knowing suitable patients for such therapy, and 53.8% had at least one patient proactively asking for such treatment in the last 6 mo. The most common indication chosen was pain: chronic cancer-related (n = 128), chronic non-cancer (n = 77), and neuropathic (n = 60). Other commonly chosen conditions were alleviation of cancer treatment side-effects (n = 56) and cachexia (n = 57). The overall safety profile of THC was assessed as similar to most commonly used medications, including opioids; NSAIDs and benzodiazepines were, however, perceived as safer. Conclusions: Polish physicians favored the legalization of medical cannabis. However, it is of concern that a limited number have any experience with prescribing cannabis. The creation of clear guidelines to advise physicians in their routine practice and education about pain management and the risks related to the consumption of recreational cannabis for medical conditions are needed.

Clinician views on and ethics priorities for authorizing medical cannabis in the care of children and youth in Canada: a qualitative study

BACKGROUND

The use of cannabis for medical purposes by pediatric patients is expanding across Canada; however, supporting evidence, federal regulations and treatment guidelines are lacking. To understand factors affecting treatment decisions in this landscape, we sought to delineate clinician perspectives, ethics priorities and values for cannabis authorization.

METHODS

We sampled participants purposefully through Canadian Childhood Cannabinoid Clinical Trials listservs, which include the majority of pediatric oncologists and palliative care physicians practising in Canada, among many other pediatric physicians and clinicians. Inclusion criteria were being a practising clinician in Canada, involvement in the care of children and willingness to be interviewed regardless of stance on medical cannabis. In November and December 2020, we conducted semistructured interviews focusing on principles, values and priorities, including medical, professional, regulatory, evidentiary and social considerations, for authorizing medical cannabis to children. Interviews were recorded, transcribed and analyzed by means of deductive and inductive thematic methods.

RESULTS

We conducted 18 interviews with a diverse group of clinicians representing a range of specialties within pediatric care, including neurology, palliative care, oncology, family medicine and pharmacology. The interviews yielded 4 themes and 12 subthemes related to a priori (medical, professional, regulatory, evidentiary and social themes) and emergent themes. The 4 themes of access, relationships and relational autonomy (autonomy within relationships), medically appropriate use and research priorities were grounded in principles of harm reduction. Participants described problematic authorization procedures that negatively affect patient use. Principles associated with relational autonomy were highlighted as a feature of open clinical communication. Benefits of appropriate medical uses weighed positively over risks, even in the context of potential effects on neurodevelopment. Participants expressed that more research is essential to align medical cannabis with biomedical standards.

INTERPRETATION

Clinicians reported pursuing ethical use of medical cannabis for pediatric patients and prioritizing their safety under principles of harm reduction. There is a need for evidence about neurodevelopmental risks, support for research, treatment guidelines and greater knowledge about stakeholder perspectives to alleviate burdens related to use of medical cannabis for pediatric patients in Canada.

Implementation of medicinal cannabis in Australia: innovation or upheaval? Perspectives from physicians as key informants, a qualitative analysis

OBJECTIVE

We sought to explore physician perspectives on the prescribing of cannabinoids to patients to gain a deeper understanding of the issues faced by prescriber and public health advisors in the rollout of medicinal cannabis.

DESIGN

A thematic qualitative analysis of 21 in-depth interviews was undertaken to explore the narrative on the policy and practice of medicinal cannabis prescribing. The analysis used the Diffusion of Innovations (DoI) theoretical framework to model the conceptualisation of the rollout of medicinal cannabis in the Australian context.

SETTING

Informants from the states and territories of Victoria, New South Wales, Tasmania, Australian Capital Territory, and Queensland in Australia were invited to participate in interviews to explore the policy and practice of medicinal cannabis prescribing.

PARTICIPANTS

Participants included 21 prescribing and non-prescribing key informants working in the area of neurology, rheumatology, oncology, pain medicine, psychiatry, public health, and general practice.

RESULTS

There was an agreement among many informants that medicinal cannabis is, indeed, a pharmaceutical innovation. From the analysis of the informant interviews, the factors that facilitate the diffusion of medicinal cannabis into clincal practice include the adoption of appropriate regulation, the use of data to evaluate safety and efficacy, improved prescriber education, and the continuous monitoring of product quality and cost. Most informants asserted the widespread assimilation of medicinal cannabis into practice is impeded by a lack of health system antecedents that are required to facilitate safe, effective, and equitable access to medicinal cannabis as a therapeutic.

CONCLUSIONS

This research highlights the tensions that arise and the factors that influence the rollout of cannabis as an unregistered medicine. Addressing these factors is essential for the safe and effective prescribing in contemporary medical practice. The findings from this research provides important evidence on medicinal cannabis as a therapeutic, and also informs the rollout of potential novel therapeutics in the future.

Physicians' experiences, attitudes, and beliefs towards medical cannabis: a systematic literature review

Background

An increasing number of countries legalise the use of medical cannabis or allow it for a narrow range of medical conditions. Physicians, and often the patients’ general practitioner, play a major role in implementing this policy. Many of them, however, perceive a lack of evidence-based knowledge and are not confident with providing patients with medical cannabis. The objectives of this review are to synthesise findings about hospital physicians’ and GPs’ experiences, attitudes, and beliefs towards the use of medical cannabis with the purpose of identifying barriers and facilitators towards providing it to their patients.

Methods

Peer-reviewed articles addressing hospital physicians’ and GPs’ experiences, attitudes, and beliefs towards the use of medical cannabis were searched systematically in PubMed, Scopus, EMBASE, and the Cochrane Library.

Results

Twenty-one articles were included from five different countries in which the medical cannabis laws varied. The studied physicians experienced frequent inquiries about medical cannabis from their patients (49–95%), and between 10 and 95% of the physicians were willing to prescribe and/or provide it to the patients, depending on setting, specialty and experience among the physicians. This review found that physicians experienced in prescribing medical cannabis were more convinced of its benefits and less worried about adverse effects than non-experienced physicians. However, physicians specialized in addiction treatment and certain relevant indication areas seemed more sceptical compared to physicians in general. Nevertheless, physicians generally experienced a lack of knowledge of clinical effects including both beneficial and adverse effects.

Conclusion

This review indicates that GPs and hospital physicians from various specialties frequently experience patient demands for medical cannabis and to some degree show openness to using it, although there was a wide gap between studies in terms of willingness to provide. Hospital physicians and GPs’ experienced in prescribing are more convinced of effects and less worried of adverse effects. However, most physicians experience a lack of knowledge of beneficial effects, adverse effects and of how to advise patients, which may comprise barriers towards prescribing. More research, including larger studies with cohort designs and qualitative studies, is needed to further examine facilitators and barriers to physicians’ prescribing practices.

A systematic review of medical students' and professionals' attitudes and knowledge regarding medical cannabis

Background

Recently, the renewed global interest in cannabis’ therapeutic properties has resulted in shifting attitudes and legislative policies worldwide. The aim of this systematic review is to explore the existing literature on medical professionals’ and students’ attitudes and knowledge regarding medicinal cannabis (MC) to assess any relevant and significant trends.

Methods

This systematic review was conducted in accordance with PRISMA guidelines. Using PubMed and Google Scholar, a literature search was performed to identify studies pertaining to healthcare professionals’ and medical students’ knowledge and attitudes regarding MC. There were no search limits on the year of publication; however, studies without primary data (e.g., abstracts, systematic reviews, meta-analyses) and non-English language papers were excluded. Studies were coded according to the following research questions: (1) Do respondents believe that cannabis should be legalized (for medicinal and/or recreational purposes)? (2) Are respondents confident in their level of knowledge regarding cannabis’ clinical applications? (3) Are respondents convinced of cannabis’ therapeutic potential? 4) What current gaps in knowledge exist, and how can the medical community become better informed about cannabis’ therapeutic uses? and (5) Are there significant differences between the knowledge and opinions of healthcare students versus healthcare professionals with respect to any of the aforementioned queries? Chi-square tests were used to assess differences between medical students and medical professionals, and Pearson’s bivariate correlations were used to analyze associations between survey responses and year of publication—as a proxy measurement to assess change over time.

Results

Out of the 741 items retrieved, 40 studies published between 1971 and 2019 were included in the final analyses. In an evaluation of 21 qualified studies (8016 respondents), 49.9% of all respondents favored legalization (SD = 25.7, range: 16–97%). A correlational analysis between the percentage of survey respondents who support MC legalization and year of publication suggests that both medical students’ and professionals’ support for MC legalization has increased from 1991 to 2019 (r(19) = .44, p = .045). Moreover, medical professionals favor the legalization of MC at a significantly higher rate than students (52% vs. 42%, respectively; χ² (1, N = 9019) = 50.72 p < .001). Also, respondents consistently report a strong desire for more education about MC and a substantial concern regarding MC’s potential to cause dependence and addiction. Pearson’s correlations between year of publication and survey responses for both of these queried variables suggest minimal changes within the last decade (2011–2019 for addiction and dependence, 2012-2019 for additional education; r(13) = − .10, p = .713 and r(12) = − .12, p = .678, respectively).

Conclusion

The finding that both medical students’ and professionals’ acceptance of MC has significantly increased in recent decades—in conjunction with their consistent, strong desire for more educational material—suggests that the medical community should prioritize the development of MC educational programs. MC is far more likely to succeed as a safe and viable therapy if the medical professionals who administer it are well-trained and confident regarding its clinical effects. Limitations include a lack of covariate-based analyses and the exclusion of studies published after the literature search was performed (June 2019). Future research should analyze studies published post-2019 to draw temporal comparisons and should investigate the effect of numerous covariates (e.g., gender, religiosity, prior cannabis use) as newer studies gather data on these factors [PROSPERO Registration: CRD42020204382].

Polish Physicians' Perspectives on Medical Cannabis Policy and Educational Needs: Results of An Online Survey

(1) Background: In November 2017, medical cannabis was legalized in Poland. Until now, there have been no studies conducted to examine the perspectives of Polish physicians about their preferences regarding medical cannabis legal status and educational needs. (2) Methods: The survey was a self-developed online questionnaire with 57 participants. Participation was voluntary. The link was shared through a personal network of medical doctors, regional medical chambers, and with doctors attending palliative care courses organized by our research group. Results: Between June and October 2020, 173 HCPs from Poland completed the survey. More than half of the study participants never received any education on medical cannabis (60.1%); 71.1% declared their knowledge was insufficient to counsel patients about medical cannabis use. The majority claimed that they would like to be able to answer patient questions (92.4%); 93.1% declared a need to create clear guidelines for using cannabinoids in clinical practice. Furthermore, 71.7% believed that medicines containing cannabinoids and 52.0% that herbal cannabis should be reimbursed (3). Conclusion: Most medical doctors do not feel prepared for patient counseling. They could benefit from targeted educational interventions. We have also identified physicians’ preferences that might inspire the stakeholders involved who are critical for shaping policies regarding cannabis-based therapeutics.

Cannabis and its therapeutic value in the ageing population: Attitudes of health-care providers

OBJECTIVE(S)

To explore the attitudes of health-care providers and the perceived barriers and facilitators regarding the use of cannabis-containing medicines (CCMs) in older patients.

METHODS

Semi-structured interviews with eleven health-care providers in rural New South Wales (NSW). A thematic analysis was performed.

RESULTS

Themes and recommendations include attitudes towards CCMs for therapeutic purposes, their perceived uses, side effects, barriers to use and prescription (stigma, regulation, access and driving), difficulties encountered with the Special Access Scheme (SAS) and the need for ongoing research and education. An ecological framework demonstrated the complex interactions between patients and health-care providers and their social, community and political environment.

CONCLUSION

Providers' attitudes towards CCM use in older patients are generally positive; however, there is a need for further high-quality evidence on efficacy and safety, alongside improved CCM education and training, to reduce barriers to their implementation. Barriers to prescription and access continue to evolve on personal, organisational and systemic levels.

Knowledge, attitudes, and prescribing patterns of cannabis and cannabinoid-containing medicines among European healthcare workers: a systematic literature review

BACKGROUND

Since the introduction of the National Medical Cannabis Programme in The Netherlands, many other countries in Europe have made medical cannabis (MC) and cannabis-based medicines (CBMs) available. However, each of them has implemented a unique legal framework and reimbursement strategy for these products. Therefore, it is vital to study healthcare professionals' knowledge level (HCP) and HCPs in-training regarding both medical uses and indications and understand their safety concerns and potential barriers for MC use in clinical practice.

METHODS

A comprehensive, systematic literature review was performed using PubMed/MEDLINE, EMBASE, and Google Scholar databases, as well as PsychINFO. Grey literature was also included. Due to the high diversity in the questionnaires used in the studies, a narrative synthesis was performed.

RESULTS

From 6995 studies retrieved, ten studies, all of them being quantitative survey-based studies, were included in the review. In most studies, the majority of participants were in favor of MC and CBMs use for medical reasons. Other common findings were: the necessity to provide additional training regarding medical applications of cannabinoids, lack of awareness about the legal status of and regulations regarding MC among both certified physicians, as well as prospective doctors and students of other medicals sciences (e.g., nursing, pharmacy).

CONCLUSIONS

For most European countries, we could not identify any studies evaluating HCPs' knowledge and attitudes towards medicinal cannabis. Therefore, similar investigations are highly encouraged. Available evidence demonstrates a need to provide medical training to the HCPs in Europe regarding medical applications of cannabinoids.

Attitudes and knowledge about medical cannabis among Israeli and American nursing students

BACKGROUND

Although medical cannabis regulations are emerging in many places around the world, a contentious conundrum remains within the medical establishment regarding the appropriate part that cannabis may have in the provision of health care. Nurses have an indispensable role in the care management of patients, and given the consideration of cannabis as a possible treatment, they are warranted to be aware of its medical properties, as well as to be able to adequately answer patient queries. Nevertheless, very little is currently known about nurses' perceptions related to medical cannabis.

OBJECTIVE

To assess attitudes, beliefs and knowledge about medical cannabis among nursing students.

METHODS

Cross-sectional study in two universities: Rutgers University (RU) in New Jersey and Ben Gurion University of the Negev (BGU) in Israel. In addition to demographic data, the survey instrument included questions about attitudes, beliefs, knowledge, and training.

RESULTS

Overall, 387 students participated, mainly females (87.8%). The vast majority from both sub-groups stated they would recommend cannabis to their patients if allowed to do so (91.2%), and were in agreement that medical cannabis is associated with significant benefits for physical (93.5%) and mental (87.8%) health. Compared to the BGU sub-group, more students from RU stated that they feel prepared to answer patient questions about medical cannabis (19.5% vs. 33.5%, respectively; χ² = 9.74, p < 0.01). While the majority of respondents stated they have not received any formal education related to medical cannabis, they expressed endorsement for such training and education.

CONCLUSIONS

In light of the expanding number of patients who use medical cannabis, this study highlights the importance of incorporating medical cannabis education for nurses in academic and clinical curricula.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

STUDY QUESTION

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

STUDY DESIGN

A questionnaire-based cross-sectional study.

MEASURES AND OUTCOMES

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

RESULTS

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

CONCLUSIONS

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

The effect of attitudes, subjective norms and stigma on health-care providers' intention to recommend medicinal cannabis to patients

AIM

The aim of this study was to explore the effect of health-care providers' attitudes towards the medical use of cannabis, subjective norms and perceived stigma towards medicinal cannabis users on health-care providers' intention to recommend medicinal cannabis for patients with qualifying conditions.

METHODS

A cross-sectional correlational study included 221 health-care providers (mean age, 42.2 ± 11.2; 74.2% women and 76.5% nurses) who completed a questionnaire examining theory-based variables and stigma towards medicinal cannabis users.

RESULTS

More positive attitudes towards the medical use of cannabis were associated with lower stigma towards medicinal cannabis users, which, in turn, was associated with a higher intention of recommending medicinal cannabis for patients with qualifying conditions. The relationship between attitudes towards the medical use of cannabis and the intention to recommend medicinal cannabis varies according to subjective norms.

CONCLUSIONS

Among nurses and physicians, stigma towards medicinal cannabis users mediated the relationship between attitudes towards the medical use of cannabis and the intention to recommend medicinal cannabis for patients with qualifying conditions, whereas subjective norms moderated this relationship. Effective treatment with medicinal cannabis might be compromised by health-care providers' negative attitudes, stigma and subjective norms.

Health professional beliefs, knowledge, and concerns surrounding medicinal cannabis - A systematic review

BACKGROUND

The number of jurisdictions allowing access to medicinal cannabis has been steadily increasing since the state of California introduced legislation in 1996. Although there is a high degree of legislative heterogeneity across jurisdictions, the involvement of a health professional is common among all. This places health professionals at the forefront of therapy, yet no systematic review of literature has offered insight into the beliefs, knowledge, and concerns of health professionals regarding medicinal cannabis.

METHODS

Using a predetermined study protocol, PubMed, EMBASE, PsycINFO, CINAHL, and Scopus databases were searched for studies indexed up to the 1st August 2018. Pre-defined inclusion and exclusion criteria were applied uniformly. Screening for relevancy, full-text review, data extraction, and risk of bias were completed by two independent investigators. Risk of bias was assessed using CASP criteria (qualitative) and a modified domain-based risk assessment tool (quantitative).

RESULTS

Of the 15,775 studies retrieved, 106 underwent full-text review and of these, 26 were included. The overall risk of bias was considered low across all included studies. The general impression was that health professionals supported the use of medicinal cannabis in practice; however, there was a unanimous lack of self-perceived knowledge surrounding all aspects of medicinal cannabis. Health professionals also voiced concern regarding direct patient harms and indirect societal harms.

CONCLUSION

This systematic review has offered a lens through which to view the existing literature surrounding the beliefs, knowledge, and concerns of health professionals regarding medicinal cannabis. These results are limited, however, by the implicit common-sense models of behaviour utilised by the included studies. Before strategies can be developed and implemented to change health professional behaviour, a more thorough understanding of the factors that underpin the delivery of medicinal cannabis is necessary.

Is policy 'liberalization' associated with higher odds of adolescent cannabis use? A re-analysis of data from 38 countries

BACKGROUND

Policy makers worldwide face the choice of whether to reform cannabis policy from the 'full prohibition' model. A paper by Shi et al. (2015) suggested that such 'liberalization' is significantly associated with higher odds of adolescent cannabis use.

AIM

To test the validity and reliability of Shi et al's conclusion that the HBSC data show an association between policy 'liberalization' and increased likelihood of adolescent cannabis use.

METHODS

Replication and re-analysis of the same pooled data from three waves of the Health Behaviour in School-aged Children (HBSC) survey (2001/2, 2005/6 and 2009/10). This replicates - as far as possible - the coding and analytical strategy of the Shi et al article. The re-analysis makes some improvements by: excluding a variable ('number of siblings') for which many cases have missing data; including available data from the theoretically relevant case of Sweden for the latter two waves of the HBSC survey, which Shi et al omit; and including random slopes for gender between countries as well as random intercepts for countries in the mixed effects model, as the predictive effect of gender on cannabis use varies across countries.

RESULTS

Shi et al's verbal summary of their findings is not supported by detailed interpretation of their own numerical results. Without making the suggested amendments, it is possible to find a statistically significant association between policy 'liberalization' and higher odds of some measures of adolescent cannabis use. But when these improvements are made, this association becomes statistically non-significant.

CONCLUSION

Using a larger and more theoretically relevant sample of the HBSC respondents and an improved statistical model shows that the HBSC data do not reveal a statistically significant association between policy 'liberalization' and higher odds of adolescent cannabis use.

Personal experience and attitudes of pain medicine specialists in Israel regarding the medical use of cannabis for chronic pain

Introduction

The scientific study of the role of cannabis in pain medicine still lags far behind the growing use driven by public approval. Accumulated clinical experience is therefore an important source of knowledge. However, no study to date has targeted physicians who actually use cannabis in their daily practice.

Methods

Registered, active, board-certified pain specialists in Israel (n=79) were asked to complete a Web-based survey. The survey was developed using the Qualtrics Online Survey Software. Questions were formulated as multiple-choice questions, and these addressed three areas of interest: 1) doctors’ personal experience; 2) the role of cannabis in pain medicine; and 3) cannabis medicalization and legalization.

Results

Sixty-four percent of all practicing pain specialists in Israel responded. Almost all prescribe cannabis. Among them, 63% find cannabis moderately to highly effective, 56% have encountered mild or no side effects, and only 5% perceive it as significantly harmful. Common indications are neuropathic pain (65%), oncological pain (50%), arthralgias (25%), and any intractable pain (29%). Leading contraindications are schizophrenia (76%), pregnancy/breastfeeding (65%), and age <18 years (59%). Only 12% rated cannabis as more hazardous than opiates. On a personal note, 45% prefer cannabis for themselves or a family member. Lastly, 54% would like to see cannabis legalized in Israel.

Conclusion

In this survey, pain clinicians experienced in prescribing cannabis over prolonged periods view it as an effective and relatively safe treatment for chronic pain, based on their own experience. Their responses suggest a possible change of paradigm from using cannabis as the last resort.

Knowledge and attitudes of Australian general practitioners towards medicinal cannabis: a cross-sectional survey

OBJECTIVES

To examine the knowledge and attitudes of Australian general practitioners (GP) towards medicinal cannabis, including patient demand, GP perceptions of therapeutic effects and potential harms, perceived knowledge and willingness to prescribe.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey completed by 640 GPs (response rate=37%) attending multiple-topic educational seminars in five major Australian cities between August and November 2017.

MAIN OUTCOME MEASURES

Number of patients enquiring about medicinal cannabis, perceived knowledge of GPs, conditions where GPs perceived it to be beneficial, willingness to prescribe, preferred models of access, perceived adverse effects and safety relative to other prescription drugs.

RESULTS

The majority of GPs (61.5%) reported one or more patient enquiries about medicinal cannabis in the last three months. Most felt that their own knowledge was inadequate and only 28.8% felt comfortable discussing medicinal cannabis with patients. Over half (56.5%) supported availability on prescription, with the preferred access model involving trained GPs prescribing independently of specialists. Support for use of medicinal cannabis was condition-specific, with strong support for use in cancer pain, palliative care and epilepsy, and much lower support for use in depression and anxiety.

CONCLUSIONS

The majority of GPs are supportive or neutral with regards to medicinal cannabis use. Our results highlight the need for improved training of GPs around medicinal cannabis, and the discrepancy between GP-preferred models of access and the current specialist-led models.

Decriminalization of drug use

PURPOSE OF REVIEW

To review the literature on decriminalization of drug use from 2016 to 2017 and suggest the way forward.

RECENT FINDINGS

The systematic review of the literature on decriminalization resulted in seven articles that discuss decriminalization as compared with 57 published articles on legalization. Decriminalization of drug use did not have an effect on the age of onset of drug use and the prices of drugs did not decrease after the implementation of drug decriminalization. Policy-based studies on decriminalization suggest shifting from criminal sanctions to a public health approach, which was endorsed by the United Nations (UN) that viewed drug addiction as a preventable and treatable health disorder. One study preferred decriminalization only for cannabis and cautioned against regulating cannabis like alcohol. Another study indicated that general medical practitioners in Ireland did not favour the decriminalization of cannabis.

SUMMARY

Scientific evidence supporting drug addiction as a health disorder and the endorsement by the UN strengthen the case for decriminalization. However, studies reporting on the positive outcomes of decriminalization remain scarce. The evidence needs to be more widespread in order to support the case for decriminalization. Furthermore, the endorsement by the UN needs to be acted upon by individual member states.

Attitudes of Irish patients with chronic pain towards medicinal cannabis

BACKGROUND

Medicinal cannabis use is topical in the media in Ireland. A recent Health Products Regulatory Authority review, however, has recommended against its use for patients with chronic pain. This is despite evidence for its effectiveness in this patient's cohort and the inadequate pain management of these patients.

AIM

The aim of this study was to evaluate the attitudes of Irish patients with chronic pain towards medicinal cannabis.

METHODS

After institutional ethics committee approval, a 12-item questionnaire (excluding demographics) was randomly assigned to patients attending a chronic pain clinic (University Hospital Limerick). The questionnaire was designed to incorporate patient's attitudes on a variety of medicinal cannabis related topics.

RESULTS

Ninety-six adult patients were surveyed. 88.54% agreed that cannabis should be legalised for chronic pain medicinal purposes. 80.21% believed it would have health benefits for them and 73.96% agreed it would be socially acceptable to use cannabis for this purpose. 33.33% perceived cannabis to be addictive while 68.75% would be willing to try it if prescribed by a medical professional.

CONCLUSIONS

The study highlights the attitudes of chronic pain patients in Ireland towards medicinal cannabis. It shows their desire to have medical cannabis legalised for chronic pain and that they view it as a reasonable pain management option.

Availability and approval of cannabis-based medicines for chronic pain management and palliative/supportive care in Europe: A survey of the status in the chapters of the European Pain Federation

BACKGROUND

There is considerable public and political interest in the use of cannabis products for medical purposes.

METHODS

The task force of the European Pain Federation (EFIC) conducted a survey with its national chapters representatives on the status of approval of all types of cannabis-based medicines, the covering of costs and the availability of a position paper of a national medical association on the use of medical cannabis for chronic pain and for symptom control in palliative/supportive care.

RESULTS

Thirty-one out of 37 contacted councillors responded. Plant-derived tetrahydrocannabinol/cannabidiol (THC/CBD) oromucosal spray is approved for spasticity in multiple sclerosis refractory to conventional treatment in 21 EFIC chapters. Plant-derived THC (dronabinol) is approved for some palliative care conditions in four EFIC chapters. Synthetic THC analogue (nabilone) is approved for chemotherapy-associated nausea and vomiting refractory to conventional treatment in four EFIC chapters'. Eight EFIC chapters' countries have an exceptional and six chapters an expanded access programme for medical cannabis. German and Israeli pain societies recommend the use of cannabis-based medicines as third-line drug therapies for chronic pain within a multicomponent approach. Conversely, the German medical association and a team of finish experts and officials do not recommend the prescription of medical cannabis due to the lack of high-quality evidence of efficacy and the potential harms.

CONCLUSIONS

There are marked differences between the countries represented in EFIC in the approval and availability of cannabis-based products for medical use. EFIC countries are encouraged to collaborate with the European Medicines Agency to publish a common document on cannabis-based medicines.

SIGNIFICANCE

There are striking differences between European countries in the availability of plant-derived and synthetic cannabinoids and of medical cannabis for pain management and for symptom control in palliative care and in the covering of costs by health insurance companies or state social security systems.