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

Education, training, and perceptions of physician competency among medical cannabis patients in Israel

BACKGROUND

Medical cannabis use is expanding globally, yet knowledge gaps persist among both patients and healthcare professionals. This study aimed to examine age-related differences in medical cannabis use patterns, sources of education and training, and perceptions of physician competencies among medical cannabis patients in Israel.

METHODS

A cross-sectional survey of 233 Israeli medical cannabis patients assessed use patterns, education and training sources, and perceptions of physician competencies. Data were analyzed by age groups (18-33, 34-48, 49-64, 65 +) using descriptive statistics, chi-square tests, and ANOVA.

RESULTS

Use patterns differed significantly by age. Smoking was common among participants aged 18-33 (40 %) and 34-48 (37.8 %) but less common in the 49-64 group (16.7 %) and the 65 + group (10 %; p < .001). Conversely, ingestion-based methods were reported by 65.5 % of participants aged 65 + and by 72.2 % in the 49-64 group, but only by 45.9 % and 50 % in younger groups (p < .01). Among 57.6 % of participants who knew the THC/CBD concentration of their cannabis, mean THC concentration decreased with age (p < 0.05), while mean CBD concentration increased with age (p < 0.01). Most participants (89.8 %) received education on medical cannabis, primarily from physicians (74.7 %), but 35.4 % used internet sources, and 20.1 % reported peer networks.

CONCLUSION

This study identifies age-related differences in medical cannabis use patterns, information sources, and perceptions of physician competencies. Future research should explore how tailored patient education and clinician training can address these differences and improve guidance for medical cannabis use.

Healthcare Professionals' Perceptions About Medical Cannabis in Greece: A Qualitative Study

BACKGROUND

Medical cannabis continues to generate interest as a potential therapeutic option, yet its acceptance in clinical practice faces challenges, including regulatory barriers, social stigma, and gaps in scientific evidence.

METHODS

This study explores the perspectives of Greek medical doctors and pharmacists on medical cannabis-key stakeholders in its clinical application-through semi-structured interviews with 12 participants from each profession.

RESULTS

Medical doctors and pharmacists expressed a range of views on medical cannabis, with many acknowledging its potential while emphasizing the need for rigorous, disease-specific research. Medical doctors highlighted the lack of consistent clinical trials, concerns about drug interactions, and the fine line between medical use and misuse. Pharmacists echoed these concerns, citing regulatory inconsistencies and the need for standardized dosing. Both groups agreed that social stigma and misinformation hinder cannabis adoption, advocating for targeted education and transparent research communication. Participants indicated that regulatory barriers also pose challenges, with calls for harmonized policies and phased market entry approaches. Effective communication strategies, including digital outreach and clear messaging, were suggested to differentiate medical cannabis from recreational use and improve trust among healthcare providers and patients. Participants also highlighted the urgent need for collaboration between policymakers, researchers, and healthcare professionals to establish medical cannabis as a credible therapeutic option.

CONCLUSION

The insights gained provide actionable recommendations to bridge existing gaps and emphasize the need for a responsible, evidence-based approach to the acceptance of medical cannabis as a therapeutic option.

Medical Cannabis: Breaking Through the Grass Ceiling for Inpatient Care and Use

PURPOSE/OBJECTIVES

Medical cannabis is often prohibited for inpatient use. This disallows patients from using a substance they find beneficial, when other treatments have failed, for symptom relief including pain, nausea, insomnia, and mood. We found no other facilities with medical cannabis policies. Our team amended the medical cannabis policy to align with California state laws to facilitate inpatient use. Project aims were to (1) align the policy with state guidelines, (2) update workflow including eligibility algorithm with lockbox, and (3) improve patients' pain relief.

DESCRIPTION

A clinical nurse specialist spearheaded a cannabis interdisciplinary integration committee. A medical cannabis policy existed but did not meet recent legislative changes, prohibiting inpatient cannabis utilization. The committee revamped existing policy and created an eligibility algorithm, a medical administration record order, and a drug cross-referencing guide.

OUTCOME

Fifty patients were able to utilize cannabis during their inpatient stay over a 1-year period after medical cannabis policy implementation. Pain relief was the primary reason for cannabis usage, with 60% of surveyed patients reporting reducing opioids since starting cannabis.

CONCLUSION

Implementation of the revamped medical cannabis procedure to facilitate inpatient use was successful in implementation and patient outcomes. This can serve as a guiding framework for other institutions.

Perceived Risk of Medical Cannabis and Prescribed Cannabinoids for Chronic Pain: A Cross-Sectional Study Among Quebec Clinicians

Objective

An increase in medical cannabis and prescribed cannabinoids use for chronic pain management has been observed in Canada in the past years. This study aimed to: 1) Describe clinicians' perceived risk associated with the use of medical cannabis and prescribed cannabinoids for the management of chronic pain; and 2) Identify sociodemographic and professional factors associated with perceived risk of adverse effects.

Method

A web-based cross-sectional study was conducted in Quebec, Canada in 2022. A convenience sample of 207 clinicians was recruited (physicians/pharmacists/nurse practitioners). They were asked to rate the risk of adverse effects associated with medical cannabis (e.g., smoke, or oil) and prescribed cannabinoids (e.g., nabilone) on a scale of 0 to 10 (0: no risk, 10: very high risk), respectively. Multiple linear regression was performed to identify factors associated with perceived risk.

Results

Average perceived risk associated with medical cannabis and prescribed cannabinoids were 5.93 ± 2.08 (median:6/10) and 5.76 ± 1.81 (median:6/10). Factors associated with higher medical cannabis perceived risk were working in primary care (β = 1.38, p = .0034) or in another care setting (β = 1.21, p = .0368) as compared to a hospital setting. As for prescribed cannabinoids, being a pharmacist (β = 1.14, p = .0452), working in a primary care setting (β = 0.83, p = .0408) and reporting more continuing education about chronic pain (β = 0.02, p = .0416) were associated with higher perceived risk. No sex differences were found in terms of perceived risk.

Conclusions

Considering the clinician's experience provide insights on cannabis risk as these professionals are at the forefront of patient care when they encounter adverse effects.

"It frees your body from that pain thought": A mixed-methods exploration of patterns, contexts, and experiences of cannabis use for pain in rural communities

U.S. adults increasingly report using cannabis to manage chronic pain and rural areas have inadequate comprehensive pain management. Using mixed methods, we aimed to understand how and why some rural adults use cannabis for pain, including within the context of co-use with opioids. Participants (N = 14, Oklahoma) were rural-dwelling adults who used tobacco and ≥1 other substance, including cannabis and opioids, ≥3 days per week. Participants completed 14 days of ecological momentary assessment (EMA) regarding substance use and subsequent in-depth interviews discussing maps of their substance use reports. Half (7/14) described cannabis use for chronic pain, and most of these (85%) reported use on ≥75% of EMA days. The most frequently reported cannabis use motive was therapeutic/medicinal (90% of use reports). Most reports were of combusted cannabis (88% of use reports) at home (99% of use reports). Same-day use of cannabis and opioids was relatively common (45% of daily surveys), but seemingly not within close temporal proximity. Interview narratives characterized cannabis as modifying pain-adjacent factors (eg, thoughts), not eliminating pain itself. They recounted using a repertoire of substances to manage different pain dimensions (eg, intensity, quality) and balance perceived trade-offs of different substances. Participants described high medical cannabis access, low pain specialist access, and most physicians as unwilling to discuss cannabis for pain. The findings suggest that rural-dwelling patients could benefit from increased access to comprehensive pain management, having cannabis addressed within pain management provider discussions, and that risks and benefits of cannabis use for pain must be better established. PERSPECTIVE: This study used a geographically explicit EMA mixed method to gather rich, intensive pilot data on cannabis use and co-use for chronic pain in rural Oklahoma. It provides unique insights to inform future research on cannabis use among a vulnerable and understudied subgroup of adults with pain-rural residents.

Decriminalizing and Legalizing Cannabis for Clinical Benefits in Malaysia: Perspective Among Pharmacists (A Qualitative Study)

Cannabis, often criticized, has active compounds that indicate multiple medical benefits. However, before the potential decriminalization and legalization of medical cannabis, pharmacists play a crucial role in the decision-making for personalized therapy and evidence-based medicine. This study investigates pharmacists' perspectives on medical cannabis, covering medical use, societal impact, research, legality, and regulation. This study was conducted through semi-structured interviews with pharmacists from different sectors. Interviews were conducted with 16 pharmacists, with 4 from each sector: industry, academia, community, and hospital. There was a consensus on the need for streamlined research before potential decriminalization and legalization of cannabis, highlighting concerns about abuse and misuse despite its benefits. With that in mind, all participants agree that there is a need to update the current legislation and regulations to better control the use and distribution of medical cannabis. Several participants also called to attention that education plays an important role in the potential decriminalization of medical cannabis, with cannabis-related stigma being a potential deterrent for not only the public but also healthcare professionals. As medical cannabis is a new subject in Malaysia, this study could ignite further multidisciplinary human-related research with strict regulations which will ultimately result in evidence-based medicine.

Therapeutic Use of Cannabinoids in Critically Ill Patients: A Survey of Intensive Care Physicians in Germany

Background: In the course of the legalization of cannabis for therapeutic purposes in Germany, there has been growing interest in the medical use of cannabinoids. To date, the therapeutic potential of cannabinoids for the treatment of critically ill patients has not been explored. Objectives: This study aims to understand better whether and how frequently cannabinoids have been administered to critically ill patients in recent years. Study Design: Initially, a survey was conducted among physicians working in intensive care units (ICUs) at the Hannover Medical School. Subsequently, 653 physicians working in ICUs throughout Germany were surveyed. The frequency and regimen of cannabinoid therapy initiated by the participating physicians in the last 2 years at the time of the survey were characterized. Results: Eight out of 9 physicians at Hannover Medical School and 59 out of 653 physicians in ICUs in Germany participated. At Hannover Medical School, 6 out of 8 physicians and in ICUs in Germany, 16 out of 59 physicians had used cannabinoids in some patients (mainly 9-10) during the 2-year period studied, with dronabinol in doses between 1 and 20 mg being their cannabinoid of choice. Metabolic and psychological distress and medication savings, followed by pain and nausea/vomiting, were the most frequently cited indications for cannabinoid therapy. No relevant safety issues arrived. Lack of personal experience, limited evidence, and gaps in knowledge were the most commonly cited reservations about cannabinoid use. Conclusions: During a 2-year period, dronabinol is used in a few critically ill patients in ICUs. The main indications are to reduce metabolic and psychological distress and to save medication. The majority of participating physicians indicated that the use of cannabinoids in the context of critical care medicine needs further exploration.

Clinical Benefits and Safety of Medical Cannabis Products: A Narrative Review on Natural Extracts

Interest in medical cannabis and cannabis-based medicinal products (CBMPs) has increased greatly in recent years. Two cannabinoids are of principal importance; delta-9-tetrahydrocannabinol (∆9-THC), the primary psychoactive component, and also cannabidiol (CBD), considered non-intoxicating. Each has distinct mechanisms of action and different therapeutic potentials. CBMPs differ in their ∆9-THC and CBD components; predominantly ∆9-THC, balanced formulations with equivalent ∆9-THC and CBD elements, and CBD-predominant products. In this narrative review, we evaluate the published evidence for the clinical benefits of CBMPs and overall benefits in well-being. We also review the overall safety profile and discuss the potential for dependence with CBMPs. Evidence can be drawn from a wide range of randomized and other controlled studies and from observational real-world studies. Most data from observational registry studies are supportive of ∆9-THC-based products (∆9-THC-predominant or balanced CBMPs) in the management of chronic neuropathic pain. Balanced products are also effective in reducing spasticity in multiple sclerosis. Most CBMPs show benefit in providing symptomatic benefits in reducing anxiety, nausea, and in improving sleep, but the place of specific products is more subtle, and choice guided by specific circumstances. Symptomatic improvements are accompanied by improved quality of life and well-being. Safety data indicate that CBMPs are generally well tolerated in most patients without specific contraindications. The majority of adverse effects are non-serious, and transient; most are principally associated with ∆9-THC and are dose-dependent. In contrast to recreational cannabis use, there is little evidence from clinical studies that CBMPs have any potential for dependence.

Support for Expanding Access to Cannabis Among Physicians and Adults With Chronic Pain

This survey study reports opinions of patients with chronic pain and physicians who treat chronic pain on policies regarding access to cannabis for chronic pain management.

Cannabis use in Parkinson's disease: Patient access to medical cannabis and physician perspective on product safety

The rate of medical cannabis use has increased in parallel with the number of states legalizing its use. Parkinson's disease (PD) patients are of particular concern due to their higher cannabis use rate than in the general US population (25-40 % PD patient cannabis users vs. ∼18 % in the general population), as well as their susceptibility to environmental contaminants in cannabis, including pesticides, toxic elements, solvents, microbes, and mycotoxins. In order to address the complex nature of this industry, we examined the changes in PD-related qualifying conditions in the U.S. from 2019 to 2023. We also conducted an online survey to gain insight into the knowledge, risk perceptions, and opinions regarding medical cannabis and contamination issues from physicians who treated PD patients. The number of states including PD-related qualifying conditions increased over the past 5 years from 28 to 36 states. These conditions included PD (increasing from 14 to 16 states), muscle spasms (14 to 24), anxiety (1 to 5), and pain (17 to 35). State-by-state comparisons revealed high variability in the language used to describe the different qualifying conditions. Online surveys were sent out to 45 neurologists and movement disorder specialists who primarily treated PD patients. The response rate was 44 % from nine states (AZ, CA, FL, MA, MN, WI, PA, IL, and NM). When asked if they were aware of any contaminants in cannabis products, we found that 65 % of the physicians were unaware of any contaminants commonly found in cannabis and only 25 %, 15 %, and 15 % of them were aware of pesticide, toxic element, and solvent contaminants, respectively. In their free-text opinion response on the health impact of cannabis-borne contaminants, "long-term effect" (35 %) and "comorbidities and PD prognosis" (40 %) were identified as the two most common themes. These results point to the need for further regulatory deliberation regarding risks and susceptibility to cannabis contaminants. Additionally, education is needed to inform physicians on cannabis safety issues. Further research will identify the implementation strategies to reduce contaminant exposure and protect patient health.

Indirect effects of emotion regulation in the relationship between pain and cannabis use in adults 18-64 years

INTRODUCTION

Individuals with chronic pain often receive prescription opioid medication, and they may use cannabis to treat pain as well, although the risks of cannabis-opioid co-use are significant. This study aimed to investigate whether two transdiagnostic factors, emotion regulation and distress tolerance, had significant indirect effects in the relationship between pain and cannabis use in adults with chronic pain and an opioid prescription.

METHODS

Participants (n = 450; mean age = 38.6 ± 11.09) were recruited using Qualtrics panel service and were 75 % female and 79 % White, non-Hispanic. Participants completed a 30-minute self-report survey capturing three-month cannabis use, the Difficulties in Emotional Regulation Scale (DERS), and the Distress Tolerance Scale (DTS). The Graded Pain Scale (GCPS) assessed pain severity/intensity and disability. Analyses used the SPSS PROCESS macro, with both single (i.e., one transdiagnostic factor) and parallel indirect effects (i.e., both the DERS and DTS) examined.

RESULTS

There were statistically significant indirect effects for both the DERS and DTS in the relationship between pain intensity or disability and three-month cannabis use in single factor models. In the parallel indirect effect model, only the DERS was statistically significant (intensity indirect effect coefficient = 0.0195 % confidence interval [95 %CI] = 0.0065, 0.390; disability indirect effect coefficient = 0.0147, 95 %CI = 0.0055, 0.0274).

CONCLUSIONS

When examining parallel indirect effects, only emotional regulation and not distress tolerance mediated the relationship between chronic pain and cannabis use among those with an opioid prescription. Clinically, interventions aimed at improving emotional regulation in individuals with chronic pain can help limit cannabis and opioid co-use.

Medical students' attitudes and perceived competence regarding medical cannabis and its suggestibility

INTRODUCTION

The global trend of legalizing medical cannabis (MC) is on the rise. In Germany, physicians have prescribed MC at the expense of health insurers since 2017. However, the teaching on MC has been scant in medical training. This study investigates medical students' attitudes and perceived competence regarding MC and evaluates how varying materials (videos/articles) impact their opinions.

METHODS

Fourth-year medical students were invited to participate in the cross-sectional study. During an online session, students viewed a video featuring a patient with somatoform pain discussing her medical history, plus one of four randomly assigned MC-related materials (each an article and a video depicting a positive or negative perspective on MC). Students' opinions were measured at the beginning [T0] and the end of the course [T1] using a standardized questionnaire with a five-point Likert scale. We assessed the influence of the material on the students' opinions using paired-sample t-tests. One-way analysis of variance and Tukey post-hoc tests were conducted to compare the four groups. Pearson correlations assessed correlations.

RESULTS

150 students participated in the course, the response rate being 75.3% [T0] and 72.7% [T1]. At T0, students felt a little competent regarding MC therapy (M = 1.80 ± 0.82). At T1, students in groups 1 (positive video) and 3 (positive article) rated themselves as more capable in managing MC therapy [Formula: see text], and students in groups 3 (positive article) and 4 (negative article) felt more skilled in treating patients with chronic pain [Formula: see text]. Compared to the other groups, group 2 students (negative video) felt significantly less competent. They perceived cannabis as addictive, hazardous and unsuitable for medical prescription.

DISCUSSION

This study showed that medical students lack knowledge and perceived competence in MC therapy. Material influences their opinions in different ways, and they seek more training on MC. This underlines that integrating MC education into medical curricula is crucial to address this knowledge gap.

Medicinal use of cannabis: A qualitative study of the perspectives of doctors and pharmacists from six African countries

We conducted a qualitative study to examine the enablers and barriers influencing the implementation of medical cannabis from the perspectives of practicing doctors and pharmacists within the African context. Interviews were conducted to investigate medical professionals' perceptions and concerns regarding medicinal cannabis. Three major themes were identified: beliefs about consequences, optimism, and environmental resources and context. Depending on the context of use, medical professionals described cannabis as potentially useful as an adjunct medicine and yet problematic owing to knowledge and social barriers, particularly religion. Implementation strategies tailored to address structural and social concerns to providing optimal care are needed to ensure that medical professionals are well versed in policy and clinical aspects.

Experiences and Perceptions of Medical Cannabis among People Living with Chronic Pain and Community Pharmacists: A Qualitative Study in Canada

Background

The use of cannabis to treat chronic pain is under debate despite high expectations from patients. Qualitative data obtained by exploring both patients' and health professionals' perspectives are scarce.

Aims

This study aimed to understand the experiences and perceptions of people living with chronic pain and community pharmacists regarding the role of cannabis in chronic pain treatment in the Canadian context where both medical and recreational cannabis are legal.

Methods

We conducted 12 online focus groups (July 2020-February 2021) with 26 patients and 19 community pharmacists using semistructured discussion guides. All discussions were audio recorded and transcribed verbatim were analyzed using a reflexive thematic approach.

Results

We developed three themes related to patients' perspectives and three themes related to pharmacists' perspectives. Patients' perspectives included (1) cannabis as an alternative to other pain medications, (2) a new treatment with potential health-related risks, and (3) a therapy rather than a recreational drug. Pharmacists' perspectives included (1) challenges in monitoring drug interactions with cannabis in the context of scarce research data, (2) informing and treating patients self-medicating with cannabis amid its growing popularity, and (3) financial costs and legal constraints for patients.

Conclusions

This study highlights patients' and pharmacists' urgent need for reliable information regarding the benefits and risks of cannabis. Training tailored to pharmacists' needs and evidence-based information for patients should be developed to support pharmacists' practice, improve patients' experiences, and promote safe cannabis use.

Effects of U.S. State Medical Cannabis Laws on Treatment of Chronic Noncancer Pain

BACKGROUND

State medical cannabis laws may lead patients with chronic noncancer pain to substitute cannabis in place of prescription opioid or clinical guideline-concordant nonopioid prescription pain medications or procedures.

OBJECTIVE

To assess effects of state medical cannabis laws on receipt of prescription opioids, nonopioid prescription pain medications, and procedures for chronic noncancer pain.

DESIGN

Using data from 12 states that implemented medical cannabis laws and 17 comparison states, augmented synthetic control analyses estimated laws' effects on receipt of chronic noncancer pain treatment, relative to predicted treatment receipt in the absence of the law.

SETTING

United States, 2010 to 2022.

PARTICIPANTS

583 820 commercially insured adults with chronic noncancer pain.

MEASUREMENTS

Proportion of patients receiving any opioid prescription, nonopioid prescription pain medication, or procedure for chronic noncancer pain; volume of each treatment type; and mean days' supply and mean morphine milligram equivalents per day of prescribed opioids, per patient in a given month.

RESULTS

In a given month during the first 3 years of law implementation, medical cannabis laws led to an average difference of 0.05 percentage points (95% CI, -0.12 to 0.21 percentage points), 0.05 percentage points (CI, -0.13 to 0.23 percentage points), and -0.17 percentage points (CI, -0.42 to 0.08 percentage points) in the proportion of patients receiving any opioid prescription, any nonopioid prescription pain medication, or any chronic pain procedure, respectively, relative to what we predict would have happened in that month had the law not been implemented.

LIMITATIONS

This study used a strong nonexperimental design but relies on untestable assumptions involving parallel counterfactual trends. Statistical power is limited by the finite number of states. Results may not generalize to noncommercially insured populations.

CONCLUSION

This study did not identify important effects of medical cannabis laws on receipt of opioid or nonopioid pain treatment among patients with chronic noncancer pain.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse.

The evolving culture of medical cannabis in Canada for the management of chronic pain

Although used therapeutically for millennia, cannabis has been a prohibited substance worldwide for most of the 20th Century. With revision of prohibitive regulations in many jurisdictions during the past 2 decades, cannabis is increasingly available to patients as a potential treatment option for various symptoms. Pain relief, sleep promotion and alleviation of distress, depression and anxiety are the most common reasons for cannabis use. Canada has been at the forefront of medical cannabis (MC) legislation revisions to enable and facilitate access for therapeutic use. Although initially viewed with caution and stigma, attitudes to cannabis in general have changed. Medical cannabis is identified as the herbal plant product sourced from a grower/producer and is not at present a regulated pharmaceutical product. Medical cannabis use is currently prevalent in Canada but has bypassed the rigorous study required for usual drug approval. Although uptake has been enthusiastic by patients, the medical community has voiced cautions and concerns. Access to medical cannabis is fairly easy once an approval document is obtained from a healthcare professional, but without obligation for medical or pharmacy oversight. The greatest concern is a dearth of sound clinical evidence for effects and harms. Emerging concerns include prevalent patient self-management with information based on personal research, an abundance of on-line information which may not always be accurate, the emergence of designated "cannabis clinics," potential risks to society due to accidents, and high cost of the legal medical product leading to access via the recreational market. With cannabis now entrenched in Canadian healthcare, physicians must be sufficiently knowledgeable to provide guidance that is evidence-based and will ensure personal and societal harm reduction. Examination of the changing culture of medical cannabis in Canada will provide insight for countries that may be anticipating similar revisions of cannabis regulations to allow cannabis access for their patient population and learn from the issues created by recreational legalization.