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Health professionals wary of medicinal cannabis misuse and adverse effects

A Queensland University of Technology (QUT) analysis of studies gauging attitudes to medicinal cannabis has found that while health professionals are broadly supportive, they feel they lack clinical and legislative knowledge, and their greatest concerns are the psychiatric harm that may be caused to patients and misuse by recreational drug users.

Key points: 26 published studies conducted in Australia, the US, Canada, Ireland and internationally were analysed; these studies assessed the beliefs, knowledge and concerns about medicinal cannabis held by medical practitioners, nurses, pharmacists and allied health professionals; generally, health professionals supported clinical use of medicinal cannabis, however they said they lacked knowledge across all aspects, from pharmacology and dosing to legislation around access, distribution and supply; and their greatest concerns about the drug were patient harm, adverse drug interactions and whether cannabis would be obtained 'medicinally' as a legal guise for recreational use.

QUT pharmacy PhD researcher Kyle Gardiner led the analysis of the studies with principal supervisor Professor Lisa Nissen, head of QUT's faculty of health, School of Clinical Sciences.

Gardiner said with cannabis moving rapidly from a criminalised product to where it may be prescribed medicinally it was important to understand the views of the health sector. "In almost all international jurisdictions the involvement of at least one health professional is required for patients to acquire medicinal cannabis," he said. "So, clinicians are in the crosshairs and we need to understand their behaviours and engagement.

"It is important to know their attitudes and concerns about the delivery and use of medicinal cannabis, what knowledge they have, and where they are getting their information. However, these are a few pieces of a much larger picture. The picture we need to build is a more robust understanding of health professional behaviour. This is an important step in recognising and better informing strategies that change the way healthcare is delivered so that patients are not disadvantaged. This study is one part of putting together that picture relating to medicinal cannabis."

In Australia, several forms of imported medicinal cannabis are available, to be prescribed under certain conditions and used in clinical trials.

Gardiner said in the various studies examined, practitioners raised concerns around people growing cannabis for medicinal use, potential contamination, drug misuse, interactions with other drugs, and driving under the influence.

They were also concerned about psychiatric adverse effects, and in three of the studies medical practitioners believed "negative mental health outcomes were positively correlated with the use of medicinal cannabis."

However, Gardiner said it wasn't clear whether the views of all health professionals were based on peer-reviewed clinical evidence or something else. "Consistently across medicine, pharmacy and nursing, health professionals all said their knowledge of medicinal cannabis was poor," he said. "Many highlighted a need for further education and easy-to access information. Where they felt evidence-based resources were not accessible, their knowledge was generated from online learning, news and media, and patient experiences."

Gardiner said it wasn't surprising that in the more recently published studies, health professionals' views were more supportive of medicinal cannabis than those reported in older studies. "Support did vary between jurisdictions, but there was no obvious pattern relative to the laws and leniency or strictness around cannabis in those jurisdictions. There was also greater support from professionals who were in specialty medical fields rather than in general or community practice."

Gardiner said while broadly health professionals in the various studies expressed support for medicinal cannabis, this doesn't necessarily mean a willingness to deliver it. "There is a fundamental difference between being supportive of medicinal cannabis and being directly responsible for its delivery. More research is needed in this area."

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.

Kyle M Gardiner, Judith A Singleton, Janie Sheridan, Gregory J Kyle, Lisa M Nissen

[link url=""]Queensland University of Technology material[/link]
[link url=""]PLOS One abstract[/link]

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