Available but inaccessible: patient experiences during the first 2 years of a primary care-based medical cannabis program at an academic medical center.

BACKGROUND: Medical cannabis use and public acceptance in the United States have increased over the past 25 years. However, access to medical cannabis remains limited, particularly for underserved populations. To understand how patients experience medical cannabis accessibility, we measured medical cannabis use and barriers to use after medical cannabis certification in an urban safety-net academic medical center. METHODS: We conducted a retrospective cohort study among patients seen in Montefiore's Medical Cannabis Program (MMCP) from 2017 to 2019. Patient demographic and clinical characteristics, as well purchase history of medical cannabis, were extracted from electronic medical records. We also administered a phone questionnaire to a subset of patients to assess usage patterns, effectiveness, and barriers to medical cannabis use. RESULTS: Among 562 patients who were newly certified for medical cannabis between 2017 and 2019, 45% purchased medical cannabis, while 55% did not. Patients who purchased medical cannabis were more likely to be white and have private insurance or Medicare. Unregulated cannabis use and current tobacco use were less common among those who purchased medical cannabis. In multivariable logistic regression analysis, unregulated cannabis use remained negatively associated with purchasing medical cannabis. Patients reported that affordability and dispensary accessibility were their main barriers to purchasing medical cannabis. CONCLUSION: Among patients certified for medical cannabis use, fewer than half purchased medical cannabis after certification. Improving access to medical cannabis is crucial for ensuring equitable access to regulated cannabis, and to reducing unregulated cannabis use.

Long-term medical cannabis use and risk factors for diversion: Report on physician's guidance and patients' behaviour.

OBJECTIVES: Various jurisdictions have legalized cannabis for medical purposes. As with all psychoactive medications, medical cannabis carries a risk of diversion and accidental ingestion. These risks may be particularly high among long-term medical cannabis patients as safety practices may become less salient to patients once the treatment becomes part of everyday life. The current study examines whether patients who have used medical cannabis for longer periods differ from those who have used for shorter periods in terms of sociodemographic background and other key aspects of medical cannabis use. Furthermore, the study examines the relationship between length of medical cannabis treatment and risk factors related to storage and diversion. Finally, the study examines the extent to which oncologists provide information to their patients about safe storage and disposal. METHODS: One hundred twenty-one medical cannabis oncology patients were interviewed face-to-face and 55 oncologists participated in a survey about safe storage and disposal practices related to medical cannabis. RESULTS: Length of medical cannabis treatment was related to administration by smoking and using higher monthly dosages. In terms of risk for unsafe storage and diversion, length of medical cannabis was positively associated with using cannabis outside the home and having been asked to give away medical cannabis. Physicians did not report providing information to patients regarding safe storage and disposal practices in a regular manner. SIGNIFICANCE OF RESULTS: Results suggest that there is an ongoing risk of unsafe storage and diversion over the course of medical cannabis treatment. Oncologists may need to give more consistent and continued training in safe storage and disposal practices, especially among long-term medical cannabis patients.

Validation of Clinical Vignettes to Explore Medical Cannabis Practices.

BACKGROUND: The policies and practices related to medical cannabis are currently in flux. These changes have been associated with many controversies, and there is a lack of consensus within the medical community regarding medical cannabis practices. OBJECTIVES: To validate clinical vignettes that can be used to examine and improve medical cannabis practices. METHODS: Ten physicians participated in a Delphi survey of two consequent rounds in which they quantified the eligibility of medical cannabis therapy for six clinical vignettes describing both chronic pain and cancer patients. RESULTS: Higher consensus was achieved for the vignettes of cancer patients, which were additionally rated as more eligible for medical cannabis therapy. The highest level of consent (4.3 out of 5) was achieved regarding a vignette of a metastatic cancer patient. While in some cases physicians consolidated their ratings toward the group's average, in other cases they remained stable in their responses. CONCLUSIONS: While controversies related to medical cannabis are expected to remain rampant, the validated vignettes may facilitate assessment of clinical practices, which is essential for a successful implementation of medical cannabis policies. These vignettes may additionally be used in medical training for appropriate patient selection for medical cannabis authorization.

Assessment of Israeli Physicians' Knowledge, Experience and Attitudes towards Medical Cannabis: A Pilot Study.

BACKGROUND: Cannabis has been used throughout history for different purposes but was outlawed in the United States in 1937; many countries followed suit. Although recently reintroduced as a medical treatment in several countries, the use of cannabis in Israel is permitted for some medical purposes but is still controversial, eliciting heated public and professional debate. The few published studies on physicians' attitudes to medical cannabis found them to be generally unsupportive. OBJECTIVES: To examine, for the first time, the experience, knowledge and attitudes of Israeli physicians towards medical cannabis (MC). METHODS: A 32 item questionnaire reflected physicians' demographics, knowledge of and experience with MC and their attitudes to this treatment. RESULTS: Seventy-two physicians participated in this study. Physicians generally agreed that MC treatment could be helpful for chronic and for terminally ill patients (n = 61, 79.2%). Oncologists and pain specialists did not agree unanimously that MC can undermine mental health, whereas other physicians did (P < 0.001, df = 4). Physicians who recommended MC in the past (once or more) agreed, more than physicians who did not, with the statement "MC treatment in Israel is accessible to patients who need it" (P < 0.05, df = 2). CONCLUSIONS: In contrast to other studies we found partial acceptance of MC as a therapeutic agent. Further in-depth studies are needed to address regulatory and educational needs.

"It doesn't make any sense to even try": the disruptive impact of COVID-19's first wave on people with chronic pain using medical cannabis in New York.

BACKGROUND: The COVID-19 pandemic disrupted health care but it is unknown how it impacted the lives of people using medical cannabis for chronic pain. OBJECTIVE: To understand the experiences of individuals from the Bronx, NY, who had chronic pain and were certified to use medical cannabis during the first wave of the COVID-19 pandemic. METHODS: We conducted 1:1 semi-structured qualitative telephone interviews from March through May 2020 with a convenience sample of 14 individuals enrolled in a longitudinal cohort study. We purposively recruited participants with both frequent and infrequent patterns of cannabis use. Interviews addressed the impact of the COVID-19 pandemic on daily life, symptoms, medical cannabis purchase, and use. We conducted a thematic analysis, with a codebook approach, to identify and describe prominent themes. RESULTS: Participants' median age was 49 years, nine were female, four were Hispanic, four were non-Hispanic White, and four were non-Hispanic Black. We identified three themes: (1) disrupted access to health services, (2) disrupted access to medical cannabis due to the pandemic, and (3) mixed impact of chronic pain on social isolation and mental health. Due to increased barriers to health care in general and to medical cannabis specifically, participants reduced medical cannabis use, stopped use, or substituted medical cannabis with unregulated cannabis. Living with chronic pain both prepared participants for the pandemic and made the pandemic more difficult. CONCLUSION: The COVID-19 pandemic amplified pre-existing challenges and barriers to care, including to medical cannabis, among people with chronic pain. Understanding pandemic-era barriers may inform policies in ongoing and future public health emergencies.

Factors Associated with Medical Cannabis Use After Certification: A Three-Month Longitudinal Study.

Background: Over the past decade, there has been increased utilization of medical cannabis (MC) in the United States. Few studies have described sociodemographic and clinical factors associated with MC use after certification and more specifically, factors associated with use of MC products with different cannabinoid profiles. Methods: We conducted a longitudinal cohort study of adults (N=225) with chronic or severe pain on opioids who were newly certified for MC in New York State and enrolled in the study between November 2018 and January 2022. We collected data over participants' first 3 months in the study, from web-based assessment of MC use every 2 weeks (unit of analysis). We used generalized estimating equation models to examine associations of sociodemographic and clinical factors with (1) MC use (vs. no MC use) and (2) use of MC products with different cannabinoid profiles. Results: On average, 29% of the participants used predominantly high delta-9-tetrahydrocannabinol (THC) MC products within the first 3 months of follow-up, 30% used other MC products, and 41% did not use MC products. Non-Hispanic White race, pain at multiple sites, and past 30-day sedative use were associated with a higher likelihood of MC use (vs. no MC use). Current tobacco use, unregulated cannabis use, and enrollment in the study during the COVID-19 pandemic were associated with a lower likelihood of MC use (vs. no MC use). Among participants reporting MC use, female gender and older age were associated with a lower likelihood of using predominantly high-THC MC products (vs. other MC products). Conclusion: White individuals were more likely to use MC after certification, which may be owing to access and cost issues. The findings that sedative use was associated with greater MC use, but tobacco and unregulated cannabis were associated with less MC use, may imply synergism and substitution that warrant further research. From the policy perspective, additional measures are needed to ensure equitable availability of and access to MC. Health practitioners should check patients' history and current use of sedative, tobacco, and unregulated cannabis before providing an MC recommendation and counsel patients on safe cannabis use. clinicaltrials.gov (NCT03268551).

Gaming Disorder and Psycho-Emotional Wellbeing among Male University Students and Other Young Adults in Israel.

The aim of this cross-sectional study was to examine the impact of gaming and gaming disorder on the wellbeing of Israeli male university students and other adults. Gaming disorder (i.e., persistent, and recurrent gaming activity associated with a lack of control that may be clinically diagnosed) was determined using the Internet Gaming Disorder Scale-Short-Form (IGDS9-SF). Survey participants were recruited from gaming associations, clubs and the gaming community using Facebook. Data were collected in June 2022. A total of 526 males completed the survey (30.9% university students and 69.1% other young adults). Various statistical methods of analysis including regression were used for this study. Significant study group differences revealed university students with more indications of gaming disorder, more burnout, less loneliness, more stimulant (i.e., Ritalin) use, a greater consumption of salt- and/or sugar-loaded foods and lower economic wellbeing. The levels of resilience (i.e., the ability to recover from stress), substance use (e.g., tobacco and alcohol) and weight gain were similar for the two groups. Regression analysis showed gaming disorder as a key predictor of burnout, economic wellbeing and resilience. This study examined only male gamers because of the small number of female respondents. However, additional research is needed about female internet gamers, including their possible exposure to online harassment and sexual degradation. Additionally, additional research should be considered to verify the present study's findings about gamers based on demographic factors and gaming disorder levels. Prevention and treatment intervention measures, including those that can be made available on campus, should be thought about by university administration personnel and student association leaders in consultation with professionals who are experienced in reducing gaming disorder and other harmful behaviors among students.

Medical cannabis education among healthcare trainees: A scoping review.

OBJECTIVES: It has been previously demonstrated that healthcare professionals would like additional education on medical cannabis. However, there has not yet been a review of the status of medical cannabis curriculum for medical and allied healthcare trainees worldwide, even though future healthcare workers will be placed on the forefront of patient care and must be prepared to counsel patients. This study was designed to address this gap in knowledge. DESIGN: A search syntax was generated and databases PubMed, ERIC, CINAHL, and Web of Science were searched for relevant articles. A grey literature search of Google Scholar, MedEd, Medline, and the Proquest Dissertations and Theses section was also performed. All titles and abstracts were screened. Selected articles were subsequently screened using predetermined inclusion and exclusion criteria. RESULTS: Allied healthcare trainees lacked sufficient knowledge about medical cannabis and did not feel prepared to counsel patients on this subject. Additionally, they expressed a growing interest in medical cannabis and would like more standardized education on the topic. Finally, faculty and deans in various institutions agreed on the need to educate students on the subject, and aimed to implement courses on medical cannabis or expand their existing curricula. CONCLUSIONS: While the medical cannabis landscape is developing, medical and allied health students are not properly educated and knowledgeable on this emerging field of clinical care. The findings suggest that the implementation of competencies-based curricula on medical cannabis is essential for medical and allied healthcare trainees to have the appropriate level of knowledge to counsel and educate their patients.

Preliminary assessment of medical cannabis consumption by cancer survivors.

OBJECTIVES: To assess the motivation of cancer survivors to consume medical cannabis and to assess the patterns of use, perceived efficacy, as well as side and adverse effects. METHODS: Cross-sectional survey among 190 Israeli cancer survivors who were licensed to use medical cannabis in a single institution. In addition to demographic information, the questionnaire examined patterns of use (including dosage, type of cannabis and way of administration), motivation for medical cannabis consumption, perceived efficacy, adverse and side effects, motivation for ceasing cannabis consumption, and tobacco smoking. RESULTS: The mean monthly dosage of cannabis consumed was 42.4 grams; 95.8% of respondents reported not consuming cannabis regularly before being diagnosed with cancer; the most common way of administration was smoking, and most of the participants reported taking cannabis throughout the day. The most common symptoms for which participants took medical cannabis were pain (n = 169, 88.9%), sleeping disorder (n = 144, 75.8%) and anxiety (n = 79, 41.6%). Twenty patients (10.5%) reported on mild side (or adverse) effects. CONCLUSIONS: This study indicates that cancer survivors may indeed consume cannabis for symptom relief, and not merely for recreational purposes. Although our findings point to perceived safety and efficacy of medical cannabis for cancer survivors, more research is needed to study the adequate role that cannabis may have for treating symptoms associated with cancer survivorship.

Cross national comparison of medical students' attitudes and beliefs about medical cannabis and its application for pain management.

OBJECTIVES: To examine attitudes and beliefs about medical cannabis (MC), and specifically about its application for pain management, across medical students in Israel and Thailand. DESIGN: Cross-sectional survey which measured attitudes and beliefs about MC. Participants were additionally asked to rate the perceived efficacy of MC for different medical conditions that are related to pain (arthritis, chronic pain, fibromyalgia and multiple sclerosis). Pearson's Chi-squared test was used to compare between students from the participating universities. RESULTS: 430 medical students participated, 37.9 % (n = 163) from Israel and 62.1 % (n = 267) from Thailand. Personal cannabis use was reported by 55.6 % of the Israeli and only by 6.9 % of the Thai students (p < .001). Israeli secular students, compared to those from Thailand, were more likely to recommend MC for patient treatment, less concerned about serious physical and mental health risks, and more inclined to support legalization of recreational cannabis. Israeli students reported more permissive attitudes toward MC, but reported feeling less prepared to answer patient/client questions about MC than their Thai counterparts. CONCLUSIONS: The findings of this study accentuate the need for curriculum designed around MC use to promote students' preparedness to serve patients in pain or with other medical conditions that may benefit from MC use.

Attitudes and knowledge about medical cannabis among Israeli and American nursing students.

BACKGROUND: Although medical cannabis regulations are emerging in many places around the world, a contentious conundrum remains within the medical establishment regarding the appropriate part that cannabis may have in the provision of health care. Nurses have an indispensable role in the care management of patients, and given the consideration of cannabis as a possible treatment, they are warranted to be aware of its medical properties, as well as to be able to adequately answer patient queries. Nevertheless, very little is currently known about nurses' perceptions related to medical cannabis. OBJECTIVE: To assess attitudes, beliefs and knowledge about medical cannabis among nursing students. METHODS: Cross-sectional study in two universities: Rutgers University (RU) in New Jersey and Ben Gurion University of the Negev (BGU) in Israel. In addition to demographic data, the survey instrument included questions about attitudes, beliefs, knowledge, and training. RESULTS: Overall, 387 students participated, mainly females (87.8%). The vast majority from both sub-groups stated they would recommend cannabis to their patients if allowed to do so (91.2%), and were in agreement that medical cannabis is associated with significant benefits for physical (93.5%) and mental (87.8%) health. Compared to the BGU sub-group, more students from RU stated that they feel prepared to answer patient questions about medical cannabis (19.5% vs. 33.5%, respectively; χ2 = 9.74, p < 0.01). While the majority of respondents stated they have not received any formal education related to medical cannabis, they expressed endorsement for such training and education. CONCLUSIONS: In light of the expanding number of patients who use medical cannabis, this study highlights the importance of incorporating medical cannabis education for nurses in academic and clinical curricula.

Toward medical cannabis education in Israel.

OBJECTIVES: To assess knowledge, attitudes and beliefs regarding medical cannabis among Israeli medical, nursing, social work and other health related students as well as to outline the formation of an instrument for standardized data collection on these topics. METHODS: An invitation to participate with a link for the online survey was sent to all students pursuing a degree in medicine, nursing, social work, and other health disciplines in the Ben Gurion University of the Negev, Israel. The instrument included 32 items that measured knowledge, attitudes and beliefs regarding medical cannabis. In addition, demographic data were collected and participants were asked about the frequency of medical or recreational cannabis use. RESULTS: Among the 763 participants, 596 were females (78 %), and the mean age was 25.8 years. While the reported personal use of medical cannabis was minimal (1.9 %), cannabis use for recreational purposes was relatively common (54.0 %). The vast majority believed that medical cannabis holds significant health benefits but expressed concerns regarding potential risks of cannabis use. Additionally, the vast majority of students felt unprepared to answer patients' questions about medical cannabis and expressed a desire to receive more training. Several significant differences between the different academic disciplines were observed. CONCLUSIONS: In light of current regulatory and scientific developments, it is apparent that students of health professions will need a greater level of understanding of medical cannabis than previous generations of students. This study emphasizes the ample need for more knowledge and formal education to students of health and related professions.

Do Users of Diverted Medical Cannabis Differ From Other Cannabis Users?

OBJECTIVE: Policy discussions amidst recent changes in the legal status of cannabis for medical purposes have raised concerns regarding the diversion of medical cannabis to nonlicensed users. This study examined factors that predict frequency of use of diverted medical cannabis. METHOD: Data were collected from an online convenience sample of 1,387 cannabis users in Israel. Linear regression was used to examine whether sociodemographic background, number of licensed acquaintances, patterns of use, and problematic cannabis use predicted frequency of use of diverted medical cannabis. RESULTS: In all, 70% of respondents reported using diverted medical cannabis at least once in their lifetime, but far fewer (30%) reported use 6 times or more. Reporting more acquaintances with a medical cannabis license, more cannabis use problems, higher cannabis use frequency, and more hours feeling "stoned" were all significantly related to more frequent use of diverted medical cannabis. CONCLUSIONS: This study suggests that diversion of medical cannabis exists among cannabis users in Israel and that use of diverted medical cannabis may be associated with adverse effects. Before direct intervention and policy recommendations can be developed, however, more evidence is needed about the extent of and how medical cannabis is diverted to the underground market and the potential detrimental effects of using this type of cannabis.

Predicting Physicians' Intentions to Recommend Medical Cannabis.

CONTEXT: Although medical cannabis (MC) policies continue to evolve around the world, the integration of MC into clinical practice remains highly debated within the medical community. OBJECTIVES: Relying on the Theory of Planned Behavior (TPB), this study aim was to identify underlying factors that influence physicians' intentions to recommend MC to patients and to examine whether there are differences in the strength of these associations across three medical specialties (family medicine, oncology, and pain medicine). METHODS: 247 physicians completed questionnaires including measures of TPB constructs (attitudes, subjective norms, and perceived behavioral control) and intentions to recommend MC to two clinical vignettes describing medical background of a cancer and a chronic pain patient. Regression models were used to measure the extent to which perceived knowledge and TPB constructs predict physicians' intentions to recommend MC. RESULTS: Physicians' intentions to recommend MC to the cancer patient vignette was higher than their intentions to recommend to the chronic pain patient vignette. Intentions to recommend MC to the patient with cancer were associated with more favorable attitudes toward MC, whereas intentions to recommend MC to the patient with chronic pain were associated with more favorable attitudes, higher levels of perceived control, and lower levels of perceived knowledge. CONCLUSION: Clinical practices related to MC may be influenced by nonmedical factors, and this may be particularly prevailing in the field of chronic pain, suggesting that MC may be particularly contentious in this field.

Medical cannabis: An oxymoron? Physicians' perceptions of medical cannabis.

BACKGROUND: Medical cannabis policies are changing in many places around the world, and physicians play a major role in the implementation of these policies. The aim of this study was to gain a deeper understanding of physicians' views on medical cannabis and its possible integration into their clinic, as well as to identify potential underlying factors that influence these perceptions. METHODS: Qualitative narrative analysis of in-depth interviews with twenty-four Israeli physicians from three specialties (pain medicine, oncology and family medicine). FINDINGS: Physicians disclosed contrasting narratives of cannabis, presenting it as both a medicine and a non-medicine. These divergent positions co-existed and were intertwined in physicians' accounts. When presenting cannabis as a non-medicine, physicians drew on conventional medicine and prohibition as narrative environments. They emphasized the incongruence of cannabis with standards of biomedicine and presented cannabis as an addictive drug of abuse. In contrast, physicians drew upon unconventional medicine and palliative care as narrative environments while presenting cannabis as a medicine. In this narrative, physicians emphasized positive hands-on experiences with cannabis, and pointed to the limits of conventional medicine. CONCLUSION: Physicians did not have a consolidated perspective as to whether cannabis is a medicine or not, but rather struggled with this question. The dualistic narratives of cannabis reflect the lack of a dominant narrative environment that supports the integration of cannabis into medical practice. This may in turn indicate barriers to the implementation of medical cannabis policies. An awareness of physicians' views and the different levels of their willingness to implement medical cannabis policies is essential for policy developments in this evolving field.

Adherence to Medical Cannabis Among Licensed Patients in Israel.

Objectives: To evaluate adherence among Israeli patients who are licensed to use medical cannabis and to identify factors associated with adherence to medical cannabis. Methods: Ninety-five novice licensed patients were interviewed for this cross-sectional study. The questionnaire measured demographics, the perceived patient-physician relationship, and the level of patients' active involvement in their healthcare. In addition, patients were queried about adverse effect(s) and about their overall satisfaction from this medical treatment. Results: Eighty percent (n=76) has been identified as adherent to medical cannabis use. Variables found associated with adherence were "country of origin" (immigrant status), "type of illness" (cancer vs. non-cancer), and "experiencing adverse effect(s)." Three predictors of adherence were found significant in a logistic regression model: "type of illness" (odds ratio [OR] 0.101), patient-physician relationship (OR 1.406), and level of patient activation (OR 1.132). 71.5% rated themselves being "completely satisfied" or "satisfied" from medical cannabis use. Conclusions: Our findings show a relatively high adherence rate for medical cannabis, as well as relative safety and high satisfaction among licensed patients. Additionally indicated is the need to develop and implement standardized education about this evolving field-to both patients and physicians.

Cannabis for therapeutic purposes and public health and safety: a systematic and critical review.

BACKGROUND: The use of Cannabis for Therapeutic Purposes (CTP) has recently become legal in many places. These policy and legal modifications may be related to changes in cannabis perceptions, availability and use and in the way cannabis is grown and sold. This may in turn have effects on public health and safety. To better understand the potential effects of CTP legalization on public health and safety, the current paper synthesizes and critically discusses the relevant literature. METHODS: Twenty-eight studies were identified by a comprehensive search strategy, and their characteristics and main findings were systematically reviewed according to the following content themes: CTP and illegal cannabis use; CTP and other public health issues; CTP, crime and neighbourhood disadvantage. RESULTS: The research field is currently limited by a lack of theoretical and methodological rigorous studies. The review shows that the most prevalent theme of investigation so far has been the relation between CTP and illegal cannabis use. In addition, the literature review shows that there is an absence of evidence to support many common concerns related to detrimental public health and safety effects of CTP legalization. CONCLUSION: Although lack of evidence provides some reassurance that CTP legalization may not have posed a substantial threat to public health and safety, this conclusion needs to be examined in light of the limitations of studies conducted so far. Furthermore, as CTP policy continues to evolve, including incorporation of greater commercialization, it is possible that the full effects of CTP legalization have yet to take place. Ensuring study quality will allow future research to better investigate the complex role that CTP plays in relation to society at large, and public health and safety in particular.