Cannabis for the therapeutic purpose (CTP) played a significant role in conventional medicine towards the end of the 19th century, however, around the start of the 20th century, the use of cannabis for medicinal purposes gradually decreased. One major cause of this decrease was the 1961 United Nation convention on narcotic drugs, which classified cannabis as a Schedule I drug due to its psychoactive properties. Under the convention, cannabis was considered to have minimal therapeutic properties and was considered to pose a high risk of dependence and misuse (Kieft, Brouwer, Francke, & Delnoij, 2014; Ryan & Sharts-Hopko, 2017). Subsequently, generations of health care professionals (HCPs) were trained in a system where cannabis was considered a purely illicit substance, with no legitimate medical purpose (Ablin, Elkayam, & Fitzcharles, 2016).
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Nevertheless, regulatory changes, clinical trials, and pharmacological developments in the last two decades have led to the reintroduction of CTP as a viable treatment option in many countries (Zolotov, Vulfsons, & Sznitman, 2019). In recent years, there has been a shift in CTP-related policies around the world, which has resulted in more jurisdictions allowing cannabis legal access. In some countries with established cannabis programs, primary health care providers now believe that medical cannabis is a legitimate and safer medical therapy than illegal cannabis (Larsson, Sahlsten, Segesten, & Plos, 2011; Palace, & Daniel, 2018).
Conversely, HCPs in some countries without an established medical cannabis program have retained an extremely restrictive attitude towards medicinal cannabis use due to the past illegal status and psychoactive properties of the substance. Concerns have been raised that many HCPs are reluctant to discuss CTP use with their patients and patients are often hesitant to ask their HCPs about the safe and effective use of CTP (Carlini, Garrette, & Gregory, 2017). Even more problematic for CTP users is the potential for discrimination in health care settings. In such situations, individuals often do not receive appropriate treatment for their health conditions because they are viewed as drug abusers (Bottorff et al. 2013; Daly, Gibson, & Dewing, 2019). In this context, patient-physician consultations become focused on extraneous issues, such as addiction, rather than on the larger concerns of the underlying pathology of disease and the management of symptoms. This type of preoccupation fuels lingering beliefs that CTP use is manipulative and contrived and adds to the problems of both the individual and society (Cooke, Knight, & Miaskowski, 2019).
In this context, a burgeoning body of literature was searched to answer my research question: What factors prevent health care providers from providing quality care to CTP users in acute care settings? This review was guided by the following objectives: 1. To describe how HCPs feel about the use of CTP in clinical practice and to highlight their knowledge on CTP; 2. To determine what concerns exist for HCPs regarding the delivery of CTP; 3. To identify gaps in the literature in order to point out directions for future research.
A search of the cumulative index of nursing and allied health literature (CINHAL), PubMed, and Google Scholar was conducted to identify relevant keywords in titles, subject descriptors, and abstract. Searches included a combination of the following terms: “medical cannabis”, “medical marijuana”, “cannabis for therapeutic purpose and health care provider”, “medical cannabis and policies”, and “medical cannabis legislation”. This search resulted in thousands of articles, so to narrow the results I restricted the search to the following inclusion criteria: a) peer reviewed articles; b) CTP users and health care providers participants; c) studies included cannabis for medical purpose; d) studies in English; and e) studies set in any country. The exclusion criteria included the following: a) mixed samples of patient and health care providers, b) the study that included cannabis for recreational purposec) articles not written in English; d) articles that could not be accessed through the university libraries. The search included all searches completed between 2015–2020. Initially, the search identified a total of 385 records. Record screening was conducted based on title and abstract, which lead to the exclusion of 337 articles based on the exclusion criteria, and 48 full-text articles were assessed for eligibility. After the use of strict inclusion criteria, 15 articles have been included in this review.
Of the fifteen studies included in this review, five were conducted in the United States (U.S.) (Ananth et al., 2018; Bega, Simuni, Okun, Chen, & Schmidt, 2017; Braun et al., 2017; Carlini, Garrette, Gregory, 2017; Philpot, Ebbert, & Hurt, 2019), four were conducted in Canada (Balneaves, Alraja, Ziemianski, McCuaig, & Ware, 2018; Fitzcharles et al., 2014; Mitchell, Gould, Le Blanc, & Manuel, 2016; Ziemianski et al., 2015), three were conducted in Israel (Ablin et al., 2016; Ebert et al., 2015; Zolotova, Vulfsonsb, Zarhina, & Sznitmana, 2018), two were conducted in Australia (Isaac, Saini, & Chaar, 2016; Karanges, Suraev, Elias, Manocha, & McGregor, 2018), and one was conducted in Ireland (Crowley, Collins, Delargy, Laird, & Van Hout, 2017). Nine studies sampled physicians (Albin, 2016; Bega et al., 2017; Braun et al., 2017; Crowley et al., 2017; Ebert et al., 2015; Fitzcharles et al., 2014, Karanges et al., 2018; Ziemianski et al., 2015; Zolotova et al., 2018), two studies sampled pharmacists (Isaac, Saini, & Chaar, 2016; Mitchell et al., 2016), one study exclusively sampled Nurse Practitioners (NPs) (Balneaves et al., 2018), and other studies sampled a mixed cohort of allied HCPs (Ananth et al., 2018; Carlini et al., 2017; Philpot et al., 2019 ). The major themes that emerged during the literature search were knowledge, attitude, and beliefs of physicians, nurses, pharmacists, and other allied HCPs.
Knowledge, Attitude, and Beliefs of Physicians.
Of the nine studies investigating physicians’ perspectives, none presented results that outright rejected the clinical usefulness of CTP, and HCPs opinions were divided between those expressing some reservation and those endorsing great conviction about the medicinal value of cannabis. Five studies reported that most of the participants supported the clinical usefulness of CTP (Albin et al., 2016; Crowley et al., 2017; Ebert et al., 2015; Karanges et al., 2018; Ziemianski et al., 2015). Two other studies indicated that participants believed CTP to be a viable treatment option for various illnesses (Braun et al., 2017; Zolotova et al., 2018). In contrast, Fitzcharles et al. (2014) revealed that most of the HCPs involved in their study believed CTP to have a minimal role in their respective clinical fields. One study reported a high proportion of neutrality when respondents were asked whether CTP had any clinical benefit (Bega et al., 2017). However, regardless of physicians’ preconceived beliefs, they supported the use of CTP when all other treatment options failed or if treatment was to be used in the palliative field (Crowley et al., 2017; Mitchell et al., 2016). Notably, practicing in a state where CTP use was legal was significantly associated with actively recommending its use (Bega et al., 2017).
Concerning knowledge, five studies reported the self-perceived knowledge of the cannabinoid system and mechanism of action of cannabinoid molecules to be predominantly low on a five-point Liker scale (Albin et al., 2016; Ebert et al., 2015; Fitzcharles et al., 2014; Karanges et al., 2018; Ziemianski et al., 2015). Similarly, four of these studies also demonstrated that procedural knowledge, as well as the specifics of cultivation, prescribing, and distribution was very low among physicians (Albin et al., 2016; Fitzcharles et al., 2014; Karanges et al., 2018; Ziemianski et al., 2015). In regard to academic curriculum, two studies reported the desire for more information on CTP across undergraduate, graduate, and post-graduate curricula (Bega et al., 2017; Ebert et al., 2015). Additionally, physicians from Canada stated that they might feel more confident offering CTP if cannabis had been part of their formal education (Ziemianski et al., 2015). Throughout the studies, a lack of easy access to information regarding cannabis and a self-perceived lack of knowledge was cited as a significant barrier to the authorization of CTP (Karanges et al., 2018; Ziemianski et al., 2015).
In seven studies physicians reported several CTP-related concerns surrounding the potential for recreational cannabis misuse, reproductivity and contamination, the risk of drug to drug interactions, the potential physiological and psychiatric adverse effects, the risks of driving under the influence of CTP, the potential for diversion into illicit channels, and the risks associated with an uncontrolled supply of cannabis (Ablin et al., 2016; Bega et al., 2017; Braun et al., 2017; Crowley et al., 2017; Ebert et al., 2015; Karanges et al., 2018; Ziemianski et al., 2015). Two studies indicated that physicians viewed an increase in cannabis use as being positively related to negative mental health outcomes (Braun et al., 2017; Crowley et al., 2017).
Knowledge, Attitude, and Beliefs of Pharmacists.
Of all the studies examining the attitudes, beliefs, and knowledge regarding CTP, only one study conducted in Canada examined pharmacists’ beliefs. The study’s researchers reported that 55% of the pharmacists in Canadian hospitals considered CTP to be safe and effective (Mitchell et al., 2016). Two studies used self-reported surveys to examine the knowledge, attitudes, beliefs, and opinions of hospital pharmacists regarding CTP (Isaac et al., 2016; Mitchell et al., 2016). Overall, self-reported knowledge of pharmacists regarding CTP was very low. Mitchell et al. (2016) reported that only 17.2% of pharmacists felt they were knowledgeable about CTP, while 65% of pharmacists reported having no formal training related to pharmacology, pharmacodynamics, and pharmacokinetics related to medicinal cannabis, and 17.8% of respondents reported using self-directed learning by gathering information from online sources. Pharmacists acknowledged the importance of continued learning and training regarding information on CTP.
Additionally, participants in the studies identified safety as a major area of concern due to the lack of globally recognized standardized forms of medicinal cannabis. They also identified stigma as a major barrier that needs to be eradicated for CTP to be successfully rolled out (Isaac et al., 2016; Mitchell et al., 2016). Pharmacists expressed similar concerns as physicians concerning the potential for recreational misuse of medical cannabis, the risk of drug to drug interactions, the potential for contamination of products due to the lack of quality control, and the potential for side effects such as psychiatric disorders (Isaac et al., 2016; Mitchell et al., 2016).
Mitchell et al. (2016) also noted a varying level of opinion across the differing demographics. A different pattern of awareness was observed among pharmacists working in British Columbia and Quebec compared to those working in other provinces, as these two provinces have a long history of cannabis use and were early adopters of CTP. Overall, pharmacists in the studies acknowledged the importance of education and continued training regarding the information on CTP, as well as the need for nationalized legislation to maintain uniformity of CTP-related policies (Isaac et al., 2016; Mitchell et al., 2016).
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Knowledge, Attitude, and Beliefs of Nurse Practitioners and Other Health Care Providers.
In three different studies of allied health care professionals, respondents were largely supportive of CTP and while not all HCPs supported the use of CTP, very few rejected its clinical use. Depending on the survey questions, these three studies reported different interests of HCPs. Carlini et al. (2017) reported that HCPs believe CTP is useful for chronic conditions, Ananth et al. (2018) reported on the willingness of HCPs to help children with cancer access CTP, and Baleaves et al. (2018) reported on HCPs comfort level with supporting a patient’s right to access CTP. In a cross-sectional survey by Ananth et al. (2018), most of the pediatric oncology providers were in favor of considering CTP use in children with cancer despite limited knowledge of state and federal regulations. Additionally, HCPs were increasingly amenable to CTP use for advanced stages of cancer or near the end of a patient’s life.
As noted in previous studies, the most significant barrier to recommending CTP was the absence of standards regarding formulations, potency, and dosing and a lack of clear dosage guidelines. An exclusive survey of NPs conducted by Balneaves et al. (2018) reported the existence of a huge knowledge gap related to CTP dosing and creating effective treatment plans for CTP users. The self-perceived knowledge of allied health professionals relating to the pharmacology of the cannabinoid system and the components of cannabis was considered mainly poor in all three studies (Ananth et al., 2018; Balneaves et al., 2018; Carlini et al., 2017). Like the other studies discussed above, the findings from these three studies also suggest a lack of knowledge surrounding procedural aspects of CTP such as formulation differences, dosing, distribution, legislation surrounding access, and supply. Balneaves et al. (2018) and Carlini et al. (2017) reported that the pooled sample of health care professionals strongly desired additional education regarding CTP. Additionally, 90% of the allied HCPs stated they would feel more comfortable engaging with CTP after more training and education (Carlini et al., 2017). Concerns were also raised that the side effect profile of CTP might be a considerable reason for therapy avoidance (Ananth et al., 2018; Balneaves et al., 2018; Carlini et al., 2017). Collectively, the findings from all the studies suggest the need for clinical research on cannabis for medical use in order to inform the development of clinical practice guidelines to support all allied health care providers in providing safe and effective care related to CTP.
Significant Findings of the Literature Review
The current literature review identified the factors that prevent health care providers from providing quality care to CTP users in acute care settings. Health care professionals’ knowledge, beliefs, attitudes, and concerns regarding the delivery of CTP were four significant factors identified during the review. These significant factors were then identified among different health care providers such as physicians, pharmacists, and NPs. Support for CTP was measured using several methods including the belief in HCPs right to prescribe CTP, the belief in cannabis users right to obtain CTP, and the belief in the clinical usefulness of CTP. In general, HCPs were more supportive of using CTP in specialty fields such as oncology than in general practice.
The concerns regarding HCPs were subdivided into two major categories: indirect societal harm and direct patient harm. HCPs were mainly concerned about the risk of psychiatric disorders and generally understood the risks of other effects. Additionally, HCPs raised concern regarding the potential for the drug to drug interactions as patients with comorbidities and polypharmacy often require CTP use. Several indirect social concerns emerged as being problematic; however, none were more prominent than the fear that CTP would be obtained for recreational use.
Furthermore, knowledge was divided across clinical fields and legislations. Clinical knowledge included pharmacology, pharmacodynamics, pharmacokinetics, dosing, efficacy, and adverse reactions of CTP. Legislative knowledge included the cultivation of cannabis, distribution, and acquisition among patients. Most of the studies reviewed discussed self-perceived knowledge. It is interesting to note the consistency of the self-perceived knowledge, beliefs, and concerns of HCPs that emerged on a Likert scale and as free-text responses. There was no significant difference between the responses from HCPs in the fields of nursing, pharmacy, or medicine. It is evident from the research that health providers are in great need of education on CTP irrespective of their area of practice.
Limitations of the Search
The limitation of the current literature review was the lack of a theoretical framework for exploring the factors underpinning the delivery of CTP. It is important to note that the results in this literature review were limited to the knowledge, attitudes, and beliefs of HCPs. Due to time constraints and the limited number of articles included in the review, not all factors were examined, and as such, the results only reveal a partial description of the factors underpinning the delivery of cannabis. There could be other influencing factors such as institutional and state policies that discourage HCPs from actively recommending or procuring CTP for patients and the attitudes and perspectives of the general public. Additionally, people caring for CTP users and individuals who use CTP for severe illnesses are essential to report and could be examined in future studies.
Furthermore, most of the studies reviewed in this paper stem from the U.S. and Canada. Since countries differ widely in terms of their CTP regulatory systems and use prevalence rates, results from these countries may not be generalized to other geographic areas. In order to better understand different regulatory systems related to CTP and factors influencing care among CTP users, there is a need for studies outside of the U.S. and Canada. Furthermore, limitations include the sole recruitment of self-selected HCPs and reliance on self-reported service provision. Additionally, the surveys used in few studies were not validated, which may be an internal threat to the validity of the questionnaires, thus restricting the generalizability of the study results.
This literature review reveals three significant points. Firstly, HCPs are relatively supportive of CTP in clinical settings. However, their support is often neutralized by a lack of self-reported competence, a lack of confidence, and concerns for the CTP-related risks. Secondly, there was a universal lack of knowledge among HCPs regarding CTP-related clinical domains and legislation. Finally, the most alarming direct harm of CTP was the risk of psychiatric issues, and indirect societal harm was the potential misuse of medically acquired cannabis. The literature reveals various barriers and factors associated with CTP in clinical settings, suggesting that CTP is a complex treatment for various illnesses. The experiences among HCPs related to CTP are individual, social, cultural and unique. This review of literature reveals several gaps in the field of medical cannabis. There could be other factors preventing HCPs from providing quality care to CTP users that can be included in future literature reviews. I propose that addressing the topic in a way that is timely and unique is essential to improving the quality of life among CTP users.
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