Clinicians should be aware of dispensary staff practices when treating patients who use cannabis

When treating patients who use medical cannabis, clinicians should find out what those individuals were told by employees at the dispensary, particularly when it comes to cannabis-related risks.

Cannabis access has been on the rise across the U.S. for the past decade, and many individuals rely on cannabis dispensaries to obtain the drug for medical purposes. However, most patients who use cannabis for medical reasons report getting advice about cannabis formulations and use patterns from dispensary staff, often called “budtenders,” rather than their clinicians—which begs the question—what are these workers telling their customers?

In order to characterize the practices of dispensary workers selling cannabis to customers for medical purposes, Jessica S. Merlin, MD, PhD, Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, and colleagues surveyed dispensary employees, hypothesizing that respondents in states with more “medicalized” cannabis programs—distribution programs that resemble regulation of prescription/over-the-counter drugs—would rely more on clinician input and employer training when discussing cannabis risks with customers compared to respondents in less medicalized states.

Their findings were published in JAMA Network Open.

“In this national survey study, most dispensary staff had worked in the cannabis industry for 1 or more years, were college-educated, and many used cannabis for medical or adult-use purposes,” Merlin and colleagues wrote. “Staff often relied on personal and coworker experience to make recommendations. While most staff reported routinely counseling customers about safe storage of cannabis and routine cannabis adverse effects such as sleepiness, few reported routinely counseling customers about cannabis-related risks such as psychosis, motor vehicle collisions, cannabis withdrawal syndrome, or cannabis use disorder.”

As predicted, workers in states with medicalized programs were more likely to rely on employer training and clinician input when making clinical recommendations, suggesting that “medicalization is associated with an environment where physician or clinician input is more likely to be incorporated.” However, “state medicalization and adult use were generally not associated with counseling about cannabis-related risks.”

“There is likely a gap between the way cannabis is perceived by dispensary staff and the way it is perceived by clinicians,” Merlin and colleagues argued. “Our findings suggest that dispensary staff are comfortable giving advice from an experiential standpoint. Conversely, clinicians may view cannabis through a traditional pharmacotherapeutic lens and be troubled at the lack of standardized dosing, regulatory oversight, and the uncertainties in the evidence base, leading to a low comfort level related to recommending medical cannabis.”

They concluded that their findings may be useful for clinicians counseling patients who purchase cannabis, customers who want to prepare for a dispensary visit, and policy makers whose decisions impact state cannabis laws.

“Although most patients obtain their information on medical cannabis from cannabis dispensaries, the study by Merlin et al suggests they may not be receiving balanced information and advice,” Theresa E. Matson, MPH, of Kaiser Permanente Washington Health Research Institute in Seattle, and colleagues wrote in an accompanying editorial. “This imbalance is an important gap in medical care that will widen as the prevalence of cannabis use continues to increase. Clinicians can meet this need by asking patients about their cannabis use and offering patients shared decision-making about the potential risks as well as the benefits of medical cannabis use.”

They added that, while preventive counseling about cannabis use has not been shown to decrease use of the drug, “offering patients information on known risks and benefits of medical cannabis use may be considered an appropriate action for all clinicians.”

For example, there is evidence that cannabis has benefits for chronic pain, chemotherapy-induced nausea and vomiting, and multiple sclerosis spasticity symptoms, as well as improved sleep outcomes for some individuals with chronic conditions; however, they pointed out that there are other effective medications out there for most of these conditions. As for other conditions that people use cannabis for, such as depression, anxiety, post-traumatic stress disorder, cancer, and irritable bowel syndrome, the evidence is limited or insufficient.

“Studies suggest that 25% to 50% of patients who use cannabis daily develop a cannabis use disorder and approximately 54% of outpatients who use cannabis regularly experience withdrawal, characterized by irritability, nervousness, and anxiety, which can lead patients to increase cannabis use thereby worsening these symptoms,” Matson and colleagues wrote.

The study authors identified U.S. dispensaries and mailed hard copies of surveys to all them, including instructions for online completion. Participants were considered eligible if they reported working at a dispensary and interacting with customers about cannabis product use. Dispensaries had to sell tetrahydrocannabinol (THC)-containing products for medical use, adult-use purposes, or both—stores were excluded if they only sold cannabidiol products, and employees were excluded if they were less than 18 years of age or were in their current position for less than 3 months. Surveys were delivered online via Qualtrics from May 2019 through January 2020.

The researchers also developed state cannabis medicalization scores based on a review of cannabis laws. “This score includes 7 domain scores (patient-clinician relationship, manufacturing and testing, product labeling, types of products, supply and dose limit, prescription drug monitoring program, and dispensing practices) and a summary score for each state that had enacted medical cannabis laws as of July 2019. Herein, we used the summary scores, which range from 23 (least medicalized) to 86 (most medicalized),” they wrote. “The statewide adult use variable was whether the state had legal adult use as of July 2019.”

The primary analysis included 434 eligible respondents from 351 unique dispensaries; 391 of these were included in the sensitivity analysis.

“Most respondents reported basing customer recommendations on the customer’s medical condition (74%), the experiences of other customers (70%), the customer’s prior experience with cannabis (67%), and the respondent’s personal experience (63%); fewer respondents relied on clinician input (40%), cost (45%), or inventory (12%),” Merlin and colleagues found. “Most respondents routinely advised customers about safe storage and common adverse effects, but few counseled customers about cannabis use disorder, withdrawal, motor vehicle collision risk, or psychotic reactions. A higher state medicalization score was significantly associated with using employer training (odds ratio, 1.41; 95% CI, 1.18-1.67) and physician or clinician input (odds ratio, 1.23; 95% CI, 1.05-1.43) as a basis for recommendation. Medicalization score was not associated with counseling about cannabis risks.”

Merlin and colleagues noted that it could be expected that dispensary workers do not routinely discuss cannabis risks with customers, given that surveys of the general population indicate that less than half of individuals who reported cannabis use were concerned with risks. “To our knowledge, no current research clearly outlines the balance of cannabis benefits and harms,” they added.

While Matson and colleagues pointed to this lack of research as an issue, they also noted that there are several steps that can be taken now to support clinicians in offering care for individuals using cannabis for medical purposes.

“Health systems can begin by routinely asking patients about their cannabis use, as recommended by the U.S. Preventive Services Task Force,” they wrote. “Routine screening has the potential to reduce stigma around cannabis use and normalize patient opportunities to discuss cannabis use with their clinician. Alongside brief screens to identify use, electronic health records can support documentation, consistent with practices for other over-the-counter medical products. Continuing medical education focused on potential risks as well as benefits is critical. Development of patient decision aids including current evidence on potential benefits and risks could support shared decision-making. Among patients who report frequent cannabis use, placing them at risk for addiction, substance use disorder symptom checklists can help patients and their clinicians to identify symptoms of a cannabis use disorder.”

Study limitations included that responses were self-reported and may not reflect actual staff practice; the degree to which respondents are representative of dispensary workers/practices nationally is not known; the relatively small sample size limits statistical power to detect small effects; and, Merlin and colleagues added, “the field is dynamic: dispensaries open and close and laws and policies change.”

  1. While most cannabis dispensary staff reported routinely counsel customers about safe storage of cannabis and routine adverse effects, few reported routinely counseling customers about cannabis-related health risks.

  2. Offering patients information on known risks and benefits of medical cannabis use may be considered an appropriate action for all clinicians.

John McKenna, Associate Editor, BreakingMED™

Merlin reported grants from Cambia Health Foundation outside the submitted work. Coauthor Bulls reported grants from NIH. Starrels reported grants from NIH salary support during the conduct of the study and grants from Opioid Post-marketing Requirement Consortium Subcontract for an observational study of the risks of prescription opioids outside the submitted work.

Editorial coauthors Bradley and Lapham reported receiving grants from the National Institute on Drug Abuse, Clinical Trials Network outside the submitted work.

Cat ID: 192

Topic ID: 86,192,730,192,144,151,925