In 2018, Denmark’s government approved the initiation of a medical cannabis access scheme that allows general practitioners (GPs) to prescribe cannabis-based medicinal products (CBMPs). Originally scheduled to run for four years, the scheme has now been extended to run until 31 December 2025. The pilot scheme allows patients to access medical cannabis for conditions in individuals that have not responded to other, more conventional therapies.
While doctors are able to prescribe CBMPs included in the pilot for any indication, the Danish Medicines Agency recommends that they should only be used for painful spasms caused by multiple sclerosis or spinal cord damage, nausea associated with chemotherapy, and neuropathic pain. Doctors are under no obligation to prescribe medical cannabis to their patients and those that do must accept full responsibility for the prescription of any CBMP, including determining the correct dose for each patient. This responsibility means that GPs are also held accountable if the prescribed medical cannabis product turned out to be harmful to the patient.
Despite the pilot scheme, many Danish GPs are concerned about the lack of sufficient evidence for the prescription of medical cannabis. Unfamiliarity and inexperience likely contribute to the discomfort of prescribing these medications and as a result, many GPs will not prescribe medical cannabis unless their peers agree. Figures show that while GPs and hospital physicians experience frequent inquiries about medical cannabis, far fewer report having prescribed these products.
A recent study aimed to explore the associations between GP experiences prescribing medical cannabis and practice and GP characteristics. The study also aimed to assess GPs’ knowledge and attitudes towards medical cannabis.
Design and Methods of the Study
In order to gather relevant information regarding the aims of this study, a database was created to collect data from all GPs in Denmark. This was achieved by combining two national registries: the Danish Patient Safety Authority’s online register of registered health professionals and the Danish Health Data Network. From this data, a sample of one-third of all Danish GPs was identified and sent an electronic survey.
The questions featured in the survey were developed following a systematic literature review uncovering central themes in relation to physicians’ attitudes and knowledge about medical cannabis and motives for prescribing, or not prescribing, CBMPs. The researchers also conducted interviews with nine strategically selected physicians in relevant specialties to further qualify the themes of the final survey. Five physicians completed a qualitative pilot test of the survey to test the relevance, acceptability, and feasibility of the questionnaire.
A total of 41 items were included in the final survey covering four domains: “experiences”, “knowledge”, “attitudes”, and “GP and practice characteristics”. A total of 1,112 postal invitations to participate in the survey were sent to the GP sample, and 427 responded to the questionnaire.
Results of the Study
One part of the survey focused on physicians’ experiences with the prescription of medical cannabis and CBMPs. In this part, participants were asked whether they had been approached by patients interested in medical cannabis and whether they had ever prescribed it – and if so, for what indications. Questions concerning knowledge related to prescription behaviour and overall knowledge about indications, dosage, side effects, and more. Each participant was also asked about their overall attitude towards medical cannabis, including evidence, legislation, and patient safety.
Of the 427 respondents, only 37 GPs (8.7%) reported that they had prescribed medical cannabis to one or more patients. All GPs who prescribed medical cannabis did so for indications listed in the guidelines for the national test scheme. Interestingly, almost half of the GPs who reported prescribing CBMPs had a negative attitude towards medical cannabis (45.9%; n = 17), compared with 11 prescribers (29.7%) who were neither negative nor positive, and 8 prescribers (21.6%) who were positive towards it.
Of all respondents, 83 GPs (20%) claimed to have quite some knowledge of medical cannabis and its use. This means that four out of five had low or no knowledge of medical cannabis. Among GPs who had prescribed medical cannabis, more than half (56.8%; n = 21) reported having quite some knowledge of medical cannabis. In comparison, 15 of the medical cannabis prescribers (40.5%) had less or no knowledge of medical cannabis at all. Nonetheless, most of the GPs stating to have quite some knowledge of medical cannabis also had a negative attitude towards medical cannabis (60.3%; n =50).
The incidence of prescribing medical cannabis appeared to be higher among male GPs and GPs working in a singlehanded practice setting. Being male was also significantly associated with a positive attitude towards the use of medical cannabis, and the odds of having a positive attitude was more than five times higher when one perceived themself to have quite some knowledge of medical cannabis.
Interpreting these Findings
The data collected in this study indicate that knowledge of medical cannabis among prescribers in Denmark remains low, with the vast majority of respondents reporting having little to no knowledge of CBMPs. However, GPs who perceived themselves to have quite some knowledge of medical cannabis were more likely to have a positive attitude towards CBMPs. This finding is supported by past evidence which shows that physicians who are more experienced in prescribing medical cannabis are more convinced of its benefits and less worried about potential adverse events when compared with physicians without such experience.
The researchers suggest that the negative attitude demonstrated by most GPs towards medical cannabis may be due to their responsibility under Danish law, which makes them liable in the case of negative outcomes. It is also likely that the low prescription rate of medical cannabis, demonstrated by these data, is partially due to a perceived lack of training among GPs. A recent systematic review that investigated physicians’ experiences, attitudes, and beliefs in medical cannabis found that a general lack of knowledge of clinical effects, both beneficial and adverse, affected their decision to prescribe.
Conclusion
The findings of this study demonstrate an overall association between GPs’ prescribing patterns of medical cannabis and their attitudes and knowledge of the products. The authors of this study recommend that future studies should collect similar data across other countries with differing medical cannabis policies to establish whether prescribing patterns differ. They also suggest that future studies “investigate the influence of patient-reported effects and side effects on the GPs’ prescription patterns, as this might also play a role in their decision to prescribe.”
