Concerns, beliefs and attitudes of pharmacists and pharmacy students on cannabis use in Canada

Abstract

Introduction

In October 2018, the Cannabis Act went into effect, whereby the Government of Canada legalized the possession, use, cultivation and purchase of cannabis for recreational use by individuals who are, depending on the province, 18, 19 or 21 years of age and older. ¹ From a health care perspective, medicinal use of cannabis refers to use based on a prescription or recommendation by a registered physician or nurse practitioner, for a known medical condition, with evidence demonstrating its indication and efficacy.

Pharmacists play a frontline role in helping guide patients through their medical cannabis therapy and must uphold the principles of beneficence and nonmaleficence. Indeed, the lack of strong evidence for medical cannabis therapy ensures continued ethical and legal concern among practising pharmacists. Evidence of clinical efficacy does exist, however, and a recent systematic review of 79 randomized controlled trials showed that there was moderate-quality evidence to support the use of cannabinoids for the treatment of chronic pain and spasticity, whereas low-quality evidence suggested that cannabinoids were associated with improvements in nausea and vomiting due to chemotherapy, weight gain in HIV infection, sleep disorders and Tourette syndrome. ²

Although cannabis research and training is still in its infancy, some professional associations have developed educational materials on cannabis. ³ Of concern, however, a recent survey of Canadian undergraduate pharmacy programs found that on average, merely 4 hours were devoted to cannabis-related material among the 9 faculties, ranging from as little as 0.5 hours up to 12.5 hours in any given program. ⁴ In an attempt to balance gaps in training and continuing education, the Ontario College of Pharmacists recently mandated that all practising pharmacists complete a Canadian Council on Continuing Education in Pharmacy (CCCEP) 2.5 CEUs in order to renew their practice licences. ³ To date, Ontario is the only province that mandates this training.

It is known that health care provider attitudes and beliefs can influence the care that they provide.^5,6 As a result, there is a growing body of evidence assessing the attitudes and beliefs of health care providers as they relate to the use of medical cannabis. Because of the increased need for cannabis counselling, evidence on perceived knowledge of cannabis and the pharmacist’s comfort level on providing cannabis counselling is growing.^7,8 However, there is a gap in the literature when it comes to Canadian pharmacists’ attitudes and perspectives toward cannabis; ⁹ furthermore, as far as the authors are aware, no studies have assessed attitudes and perspectives on use in pediatric patients. Since pharmacists play a pivotal role in medication management and safety, as well as public education, it is imperative to understand their attitudes towards the consumption of cannabis.

The objective of this study was to explore the attitudes of pharmacists and pharmacy students in Canada towards using cannabis for both medical and recreational purposes. More specifically, we wanted to identify their concerns over providing advice and on the legality of dispensing cannabis to patients. Secondary objectives were to examine potential differences in responses by geographic location (i.e., Ontario, Quebec, Canada) and explore potential differences in responses by sex. It was hypothesized that due to the recent mandatory cannabis e-learning requirements by the Ontario College of Pharmacists, respondents from Ontario would have fewer concerns regarding providing advice on medical and recreational cannabis.

Methods

Results

Table 1 shows the demographic characteristics of the participants, geographically grouped by Ontario, Quebec or all of Canada (n = 654).

There were significantly more females than males who responded to the survey for all of Canada (p < 0.01), as well as in the provinces of Ontario (p < 0.01) and Quebec (p < 0.001). There were significantly more community pharmacists than hospital pharmacists, respectively, who responded to the survey for all of Canada (p < 0.01), as well as in the provinces of Ontario (p < 0.01) and Quebec (p < 0.001).

Discussion

The objective of the current study was to determine the attitudes of pharmacists and pharmacy students in Canada towards the use of cannabis for both medical and recreational purposes, as well as to identify their concerns regarding providing advice and on the legality of dispensing cannabis to patients. In all of Canada, approximately 24% of the survey respondents had used cannabis since it was legalized. Ontario had nearly identical numbers (~23%), but Quebec had significantly fewer who indicated they had used cannabis since its legalization (~12%). The fact that Quebec respondents had a nearly 50% lower frequency of cannabis use since legalization could have had effects on their concerns, beliefs and attitudes about both medical and recreational cannabis.

Interestingly, when compared with the rest of Canada, fewer females from Quebec indicated they had used cannabis since legalization. This was a stark difference, where only 1% of females in Quebec, but 20% of females in the rest of Canada, had used cannabis. This disproportionately larger number of female respondents from Ontario who had used cannabis since legalization could have affected perceptions on the safety and efficacy of medical cannabis and could have played a role in the increased comfort in providing this advice when compared with Quebec and the rest of Canada.

The fact that respondents from Quebec were more conservative in their beliefs about the legality of cannabis use is contrasted by their being less concerned over the legal repercussions of dispensing it, as well as being less concerned about the potential legal repercussions of providing advice on medicinal and recreational cannabis. This effect seems to be driven by differences in response by sex. Specifically, females from Quebec were less concerned about potential legal repercussions to dispensing medical cannabis to patients when compared with females from Ontario and from Canada.

Regarding the question of whether cannabis should even be legal, responses from all of Canada indicated that 69% believed cannabis should be legal for medical and recreational use, 29.5% believed it should be available only for medical use and 1.5% believed it should be completely illegal. The current findings suggest that respondents from Ontario were more liberal in their views about the legality of cannabis use compared to Quebec and to the rest of Canada. Furthermore, compared to Ontario, those from Quebec were more likely to think that cannabis should be “illegal for medical and recreational use.” It would have been interesting to examine the role that stigma may have had in differences in response by geographic location, as past research on pharmacists’ perspectives on medical cannabis identified stigma as a major barrier that needed to be mitigated in order for medical cannabis to be successfully rolled out. ¹¹

Another factor that can influence attitudes and beliefs about cannabis use can be the openness to changing one’s opinion when presented with more evidence. In all of Canada, 34.1% of respondents indicated their perceptions towards cannabis had become more positive, 59.5% indicated perceptions were the same and 6.3% indicated that their perceptions had become more negative. It was found that significantly fewer respondents from Quebec indicated that their perceptions of cannabis were more negative when compared to Ontario and to the rest of Canada. This is interesting in the context that fewer from Quebec indicated that they had tried cannabis since legalization, while at the same time, those from Quebec were more likely to be worried that medical or recreational cannabis use may lead to the use of other drugs (i.e., a gateway effect).

When examining how often advice is provided to patients on medical and recreational cannabis, there were no significant associations by geographic location. In all of Canada, ~40% of respondents had never provided advice on medical cannabis and ~50% had never provided advice on recreational cannabis. In all of Canada, ~70% of respondents agreed that medical cannabis should be dispensed only by a licensed pharmacy. This is contrasted by the fact that approximately 20% respondents agreed that they were concerned there may be legal repercussions to dispensing cannabis and providing medical advice to patients.

In all of Canada, approximately 48% agreed they were comfortable providing counselling and answering questions from patients on the safety of medicinal cannabis, and approximately 40% agreed they were comfortable counselling on efficacy. It was found that relative to the rest of Canada, those from Ontario were significantly more likely to be comfortable discussing the safety and efficacy of medical cannabis with patients. When compared with Ontario or the rest of Canada, those from Quebec were significantly less likely to be comfortable discussing safety and efficacy of medical cannabis. Although the current study was not designed to specifically examine the role that the mandatory pharmacy education had on responses from Ontario pharmacists, these results are consistent with a recent study on the knowledge and attitudes of US neurologists, nurses and pharmacists, where health care providers’ education was correlated to more favourable attitudes surrounding cannabis therapy. ⁸ Our findings are also consistent with those from a recent Canadian study of nearly 800 hospital pharmacists, where two-thirds (64.5%) disagreed with the statement, “I consider myself knowledgeable about marijuana for medical purposes,” and half were uncomfortable with the prospect of providing advice to patients or other health professionals. ¹²

Examining sex differences, it was found that across all of Canada, males were more comfortable counselling patients on the efficacy of medical cannabis. Specifically, the fraction of male pharmacists who chose “strongly agree” was 71% higher compared to female pharmacists. There were also sex differences by geographic location, where females from Quebec were less comfortable than females from the rest of Canada providing counselling on the safety of medical cannabis. Similarly, females from Quebec were less comfortable counselling on efficacy than females from Ontario.

Taken together, a relationship emerged where the more comfortable one is talking to patients about the safety/efficacy of medical cannabis, the more worried one is over the legal repercussions surrounding dispensing and providing advice on medical cannabis. In this sense, the online training could be said to have helped Ontario pharmacists with their knowledge of safety and efficacy, but the current findings suggest that they are still wary about providing this advice on medicinal cannabis due to potential litigation.

When comparing the indications for whether medical cannabis has a place in adult therapy and child therapy, respondents were more likely to choose that cannabis has a place in child therapy only for seizures. A plausible explanation for this is that there are data on the effectiveness and safety of medical cannabis for seizures, more particularly for drug-refractory childhood epilepsy. ¹³

Notably for all other indications beside seizures, respondents were less likely to consider cannabis as a therapy for children than for adults. Indeed, there is less evidence to support cannabis for pediatric use, but this is also a broad theme that applies to many pharmacotherapies. ¹⁴ The 3 most selected indications for medical cannabis for adults were cancer associated with severe/chronic pain, nausea or severe vomiting, or cachexia or severe wasting and terminal illness. This is consistent with the indications in other studies (cancer, pain, nausea). ¹⁵ On the other hand, indications such as autism or posttraumatic stress disorder, for which cannabis is known to be effective, were selected by <10% of pharmacists and students.

The 3 most selected indications for medical cannabis for children were seizures, including those characteristic of epilepsy, cancer associated with severe/chronic pain and nausea or severe vomiting, or cachexia or severe wasting. For children and adolescents, the clinical and ethical trade-offs are more complex than those for adults; the younger the individual, the higher the risk for cannabis dependence or adverse outcomes. ¹⁶ The current finding that respondents were less likely to choose that cannabis should be a therapy in children for most indications is not surprising. This suggests that pharmacists and pharmacy students recognize the differential clinical effects and adverse risks of cannabis on various subpopulations and the need for more evidence-based research.

Conclusions

The current findings suggest that those from Ontario are more liberal in their views about the legality of cannabis use compared with Quebec and to the rest of Canada. Furthermore, relative to Quebec or the rest of Canada, respondents from Ontario were significantly more likely to be comfortable providing counselling and answering questions on medical cannabis use from patients about safety (adverse effects, drug interaction, contraindication) and efficacy (indications, doses, types, routes of administration, medication regimen, monitoring). Overall, males were more comfortable than females counselling patients on the safety and efficacy of medical cannabis. Pharmacists base their practice on a strong body of evidence and may be more worried about cannabis because of their lack of education and practice on the topic. The current results reinforced the perceived need by pharmacists and pharmacy students for targeted education, and future research in education should consider potential gender differences in concerns, beliefs and attitudes surrounding cannabis therapy. ■

Acknowledgments

Footnotes

Contributor Information

Régis Vaillancourt, Department of Pharmacy, Children’s Hospital of Eastern Ontario, Ottawa. Department of Family Medicine, University of Ottawa Faculty of Medicine, Ottawa.

Rahim Dhalla, Hybrid Pharm, Ottawa, Ontario.

Piotr Merks, Cardinal Stefan Wyszyński University, Faculty of Medicine, Warsaw and the Department of Pharmaceutical Technology, Faculty of Pharmacy, Collegium, Medicum, Bydgoszcz, Poland.

Taylor Lougheed, Section of Emergency Medicine, Northern Ontario School of Medicine, Sudbury.

Gary Goldfield, Healthy Active Living and Obesity (HALO) Research Group, Children’s Hospital of Eastern Ontario, Ottawa.

Holly Mansell, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan.

Jameason Cameron, Department of Pharmacy, Children’s Hospital of Eastern Ontario, Ottawa. Department of Family Medicine, University of Ottawa Faculty of Medicine, Ottawa.

References