Emergency Medicine Physicians Would Prefer to Use Cannabis instead of Opioids for First-Line Treatment if Provided Evidence

What are the Perceived Barriers Impacting the Cannabis Prescribing Practices of Healthcare Providers?

In recent years, access to medical cannabis has opened up to patients around the world in a growing number of jurisdictions. Medical cannabis has now been legalised to varying extents throughout significant portions of Europe, the Americas, Australia, New Zealand, and Asia – including in the UK, where cannabis was rescheduled to Schedule II of the Misuse of Drugs Act in November 2018. 

One of the most liberal nations with respect to medical cannabis policy is Canada, where, in 2001, the Marihuana Medical Access Regulations established a legal supply of cannabis-based products for medicinal uses. This was later replaced by the Access to Cannabis for Medical Purposes Regulations (ACMPR). In October 2018, the Canadian government introduced The Cannabis Act, legalising adult-use cannabis. Current data shows, however, that over 20 years since the introduction of the original legislation, some Canadian patients are still encountering difficulties in finding a healthcare provider who authorises their access to medical cannabis products. 

One study found that barriers affecting Canadian patients’ access to legal medical cannabis included difficulties finding their preferred products, the cost of products, and difficulties using the legal system – including finding a healthcare provider to authorise access. As a result, some figures suggest that patients are turning to the recreational market to meet their needs. 

The barriers that affect healthcare providers in authorising medical cannabis remain unclear. The authors of a recent study, therefore, note the importance of understanding healthcare providers’ knowledge and comfort level in medical cannabis in order to inform policies that will improve appropriate patient access.

Design and Methods of the Study

To better understand the barriers affecting healthcare providers’ ability and willingness to authorise medical cannabis prescriptions, the researchers aimed to answer two questions: (I) healthcare providers’ knowledge of, comfort in, and practice of cannabis for medical and recreational purposes; (II) healthcare providers’ opinions on various topics related to cannabis for medical and recreational purposes; (III) how the COVID-19 pandemic may have affected their cannabis prescribing practices. 

To determine the answers to these questions, an anonymous survey was electronically administered to healthcare professionals. The survey was set out in four parts. Part I of the survey collected demographic information, including age, sex, role, years in practice, location, etc; Part II evaluated participant knowledge, comfort, and practice of medical cannabis; Parts III and IV collected information on practice, knowledge, and comfort in recreational cannabis use as well as the impact of the COVID-19 pandemic in cannabis practice.

Results

Of the organisations contacted, 24 (26%) agreed to circulate the survey either to all members or to members within their institutions. However, some may have circulated it without confirmation and it is unknown how many potential respondents received the survey. It is, therefore, not possible to calculate a true response rate. Nonetheless, a total of 117 participants accessed the survey; 47 participants were excluded from the analysis. A final sample of 70 healthcare professionals was included in the analysis.

Medical Cannabis Prescribing

Of the final sample, 16 (23%) neither recommend nor prescribe medical cannabis; 14 (20%) recommend medical cannabis when indicated but refer patients to a person/clinic with expertise in medical cannabis for prescriptions; 25 (36%) recommend and prescribe medical cannabis themselves. Fifteen participants (21%) chose not to answer the question.

The strongest barrier reported by respondents who do not recommend medical cannabis was the lack of sufficient scientific evidence to support its use to treat the indications of their patients. This was followed by fear of interactions with other medications and reservations regarding signing a medical declaration to certify patients in a medical cannabis program. 

For healthcare professionals who do not prescribe medical cannabis, the strongest barrier was not knowing which dose of cannabis to prescribe, followed by a lack of sufficient scientific evidence to support its use to treat the indications of their patients, as well as not having prescribing privileges, and not knowing which cannabis formulation or method of administration to choose. 

Furthermore, 14 respondents reported that they do recommend medical cannabis and refer patients to a person/clinic with expertise. These respondents most often recommended cannabis for ‘other pain’ and neuropathic pain, followed by nausea/vomiting and nociceptive pain. HCPs who prescribe medical cannabis themselves, most often prescribed for neuropathic pain, as well as other pain, nausea/vomiting, insomnia, and loss of appetite.

Knowledge and Comfort

The vast majority (over 94%) of all respondents did not receive any training in cannabinoid-based medicines in professional school, but 10% did receive practical training outside of medical school or residency programs, and 53% received other training, including workshops and conferences. Most respondents (57%) reported receiving more questions from patients regarding medical cannabis since recreational cannabis was legalised; however, 19 (27%) reported being unfamiliar with the requirements for patients to obtain medical cannabis in Canada.

Of the respondents who already prescribed/recommended medical cannabis (36%; n = 25), most felt, on average, comfortable with their level of knowledge on the topic. Furthermore, most of these respondents (53%) had sought out education on medical cannabis outside of their medical training. However, almost a quarter of respondents (23%) reported that they neither recommend nor prescribe medical cannabis – with a further one-fifth (21%) choosing not to answer the question. Previous studies have found that most trainees in Canada and the rest of the world have had only minimal exposure to medical cannabis-related topics in their curricula.

The Effect of the COVID-19 Pandemic

The researchers postulated that cannabis use may have increased over the pandemic, due to an increase in the number of people working from home, increased levels of isolation and mental health issues. The findings of other studies have supported this hypothesis; however, most respondents in this study reported no change in the frequency of prescriptions they made and questions they received regarding medical cannabis. The researchers note that this finding “makes sense, as most of the sample did not prescribe themselves.

Researcher Discussion and Conclusions

As most respondents reported a rise in the number of questions they received regarding cannabis, it is essential that healthcare providers be sufficiently knowledgeable to counsel patients – even if they do not support or promote the use of medical cannabis themselves. This may be achieved by introducing increased coverage of medical cannabis in medical training curricula. The researchers note that, since the majority of medical cannabis prescriptions/referrals indicated in this data were for cancer or terminal-illness-related symptoms and intractable pain, increased education “may ideally take place during training in fields such as family medicine, palliative care, and pain management.”

The lack of scientific evidence to support the use of medical cannabis for some indications was highlighted as a major barrier to healthcare providers recommending and prescribing medical cannabis. This finding emphasises the need for further high-quality clinical trials and evidence. This research should also aim to inform on educational material on dosages, routes of administration, and proper prescription, as lack of such information was also identified as a significant barrier to cannabis prescribing across all respondents.