Attitudes Toward the Use of Medical Cannabis and the Perceived Efficacy, Side-effects and Risks : A Survey of Patients, Nurses and Physicians

Neta HaGani, Sharon Sznitman, Michael Dor, Gil Bar-Sela, Dana Oren, Lilia Margolis-Dorfman, Itay Goor-Aryeh & Manfred S. Green

Journal of Psychoactive Drugs, 2021, 1-10.

Doi : 10.1080/02791072.2021.2009598

ABSTRACT

Introduction

Medical cannabis (MC) is used to control the symptoms of a variety of diseases such as cancer, the side-effects of chemotherapy, chronic pain, developmental disorders of children and neurological conditions such as epilepsy and multiple sclerosis (Benbadis et al. 2014; Hadland, Knight, and Harris 2015; Naftali et al. 2019; Patel et al. 2019). The use of MC is increasing worldwide and each country has regulations for its distribution (Health Canada 2020; The European Cannabis Report, 3rd edi- tion 2018).

In Israel, a MC license is given according to a list of indications and contraindications as detailed in the Israeli Ministry of Health (IMOH) procedures. The indicators for receiving a MC license include medical conditions from the fields of oncology, gastroenterology, neurology, infectious diseases, palliative care and psy- chiatry (Israel Ministry of Health 2021). Physicians offer the treatment to patients who suffer from symptoms as a result of their illness or treatment side effects such as pain, nausea, sleep disturbances, or anxiety. In order to apply for a MC license, a referral may be obtained through a physician that is certified by the Medical Cannabis Unit of the IMOH to issue permits or by a specialist physician in the disease for which MC is recommended. The license is valid for a period of 1– 12 months and varies among patients. Patients may purchase MC in a pharmacy or directly through a MOH licensed MC company. The number of licenses for MC has increased dramatically in recent years, from 154 licensed patients per 100,000 in 2013 to 340 in 2018. Oncology patients constitute 9.4% of MC consumers and patients with chronic pain constitute 59% (Sznitman 2020).

Although an increasing number of patients use MC for different medical conditions, there is a lack of sound clinical evidence for the effectiveness of MC in some of those conditions (Amato et al., 2017; Abrams 2018; Schlag et al. 2021). Still, for some symptoms such as pain, chemotherapy-induced nausea and vomiting, there is substantial evidence for MC efficacy (Abrams2018). The lack of sound scientific evidence is exacer- bated by the legal status of cannabis, social stigma, risk factors related to use, disagreement about efficacy and lack of clear guidelines for treatment (Melnikov et al. 2021; National Academies of Sciences, Engineering and Medicine 2017; Sagy et al. 2018). In addition, there is a substantial amount of stigma toward MC. While patients report they are limited in their ability to gain information regarding MC due to the fear of social stigma (Brady et al. 2020), among physicians and nurses it was found stigma toward MC mitigated their inten- tion to recommend MC to patients (Melnikov et al. 2021). On the other hand, the media tends to present a positive view of the medical effects of cannabis (Sznitman and Lewis 2015) which is likely to influence the general public and patients to consider MC treat- ment (Lewis and Sznitman 2017, 2019; Sznitman and Lewis 2018). The conflicting status of MC might have implications on differences in perception between health professionals and patients who are using MC or consider MC treatment, regarding the positive and negative effects of its use.

Among patients who are using MC, it is generally perceived to be effective in improving symptoms such as anxiety, lack of appetite, depression, disturbed sleep, fatigue, pain, and nausea and vomiting (Anderson et al. 2019; Steele, Arneson, and Zylla 2019; Van Ameringen et al. 2020). However, among health profes- sionals (including physicians, assistant doctors, pharma- cists and nurses), lack of knowledge and discomfort in recommending MC to their patients has been reported (Braun et al. 2018; Carlini, Garrett, and Carter 2017; Lombardi, Gunter, and Tanner 2020; Sideris et al. 2018; Szyliowicz and Hilsenrath 2019). Studies that examine physicians’ considerations of recommending MC suggest that clinical practices may be influenced by non-medical factors (such as favorable attitudes toward MC and perceived knowledge), especially in the cases of chronic pain patients (Zolotov, Vulfsons, and Sznitman 2019a; Zolotov et al. 2018).

Among nurses, studies report a supportive approach to the use of MC in patients (Mathern, Beninsig, and Nehlig 2015; Zolotov et al. 2021). One study showed nurses had more favorable attitudes toward MC compared to physi- cians and higher perceived knowledge compared to phar- macists (Szaflarski et al. 2020). However, a study of nursing students showed that, although they support the legalization of MC, their knowledge and confidence levels regarding efficacy, safety and drug interactions of MC were low (Pereira et al. 2020). Nurses’ negative attitudes toward MC and lower intention to recommend MC for patients were associated with higher stigma toward MC (Melnikov et al. 2021).

There may be gaps in the perceptions of the effective- ness of MC and the reasons of its use, between physi- cians, nurses and their patients. The low evidence base, the existing stigma of MC use and difficulties in

regulating treatment might lead physicians and nurses to have more negative perceptions regarding MC. The widespread media coverage of MC as legitimate and effective may lead the public to have a more positive perception toward MC (Sznitman and Lewis 2015). Gaps between physician’s and patients’ perceptions are not uncommon (Street and Haidet 2011) and may lead to misunderstanding about the treatment, mismanage- ment of side effects and dependency, and lack of dis- closure of MC use (Bylund et al. 2010; Bonn-Miller et al. 2014; Kondrad et al. 2018).

Although MC is authorized frequently for patients according to their medical condition, it is not clear how they perceive the positive and negative effects of this treatment compared to physicians and nurses. The aim of the current study was to examine attitudes toward MC, its perceived efficacy, side effects and risk of depen- dency, among patients, nurses and physicians.

Methods

A cross-sectional survey was administered among three groups: patients (who are using MC, have used it in the past or have never used MC), nurses and physicians. The face-to-face questionnaires which included questions about MC attitudes, perceived efficacy, side effects and risk for dependency. The data were gathered for all three groups between February 2018 – January 2019.

Sample and sampling methods

Samples of 430 patients, 65 nurses and 65 physicians, were recruited through a convenience sampling from two oncology departments, one hematology department and two pain clinics, in two large medical centers in the north and center of Israel. These departments were chosen based on national data showing that most MC patients are either oncology patients or patients in pain clinics (Sznitman 2020). Physicians and nurses were also recruited through MC courses conducted by the IMOH in the two medical centers.

Patient inclusion criteria were: age 18 and over, trea- ted in the oncology/ hematology departments or the chronic pain clinics, were using MC currently, have used MC in the past or have never used MC. Exclusion criteria among the three groups were: people who did not speak Hebrew/ Arabic/ English/ Russian and people with disabilities that limited study participation.

The heads of the oncology departments and pain clinics were approached to obtain the departments’ staff cooperation in the recruitment of physicians, nurses and patients. All questionnaires were adminis- tered face-to-face by the research staff who included

nursing students or public health students. The research staff received training on the aim of the study and received supervision throughout the data collection process.

Patients were approached by the research staff during day treatment or while waiting in outpatient clinics. Those who were willing to participate received an explanation about the study, and those who verbally consented were given a questionnaire to complete.

A total of 430 surveys were conducted among patients. Two hundred and eighty-four patients refused to participate because they were not interested, not feel- ing well or did not have time to complete the question- naire. Four hundred and sixty-nine patients were excluded due to: receiving medical treatment or sleeping when approached, their cognitive status did not allow them to answer the questionnaire, or they completed a partial questionnaire. Patients who were unavailable when the interviewer approached them were given the option of a later interview at a more convenient time. The overall response rate was 42.0%.

Physicians and nurses were recruited during staff meetings or through the MC courses conducted by the two medical centers. Most nurses were recruited from the departments, apart from five nurses who were recruited from the MC course. Among physicians, 50% were recruited from the MC course. Physicians and nurses were offered an incentive of a coffee-pastry cou- pon for their participation. A total of 65 physicians and 65 nurses filled self-administered questionnaires. At least five attempts were made to approach each partici- pant. The physicians’ response rate was 67.7% and the nurses’ response rate was 68.4%.

The questionnaires were adopted from research tools in the literature (Adamson et al. 2010; First et al. 1995; Lee et al. 2009; Nunberg et al. 2011; Swift, Gates, and Dillon 2005) and further developed in consultation with oncologists and pain specialists and were translated to Hebrew, Arabic and Russian and validated through back-translation. The questionnaires were examined using a test-retest format among a sub-sample of 20 patients. Adjustments were made in the questionnaires according to the preliminary test, as needed. Later the questionnaires were tested for internal validity (Cronbach’s alpha). Based on the patients’ question- naire, a questionnaire was created for physicians and nurses, using the same questions. The physicians and nurses were asked to report about their impressions of how the patients responded to MC. The patient’s ques- tionnaire can be found at: doi.org/10.6084/m9.fig- share.17041133. Study procedures were approved by the ethics board of the University of Haifa and IRBs of the Rambam medical center and Sheba medical center.

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