Prescribing Health Care Providers’ Attitudes, Experiences, and Practices Surrounding Cannabis Use in Patients with Anxiety Disorders and Post-Traumatic Stress Disorder
Jake Rosenberg, Mallory J.E. Loflin, Yasmin L. Hurd, and Marcel O. Bonn-Miller
Cannabis and Cannabinoid Research, 2019, Volume 4, Number 2,
Background : Preliminary evidence suggests that certain cannabinoids may be beneficial for the treatment of anxiety and post-traumatic stress disorder (PTSD). However, it is unclear whether prescribing health care professionals view medicinal cannabis as a safe and effective option for treatment of these disorders.
Methods : Three hundred fifty-two prescribing health care professionals across the United States completed an online survey assessing attitudes, knowledge, and practices surrounding the recommendation and evaluation of cannabis use for their patients with anxiety and/or PTSD.
Results : The majority of providers reported seeing at least some potential benefit in the therapeutic application of cannabinoids for PTSD (z = 7.24, p < 0.001) and anxiety symptoms (z = 8.15, p < 0.001), although they neither viewed it as safe for patients with PTSD (90%) or anxiety (92%), nor recommended it to their patients (98%). Meanwhile, nearly all providers (89%) in this survey reported being interested in receiving more formal training related to cannabis. Prescribing health care professionals were largely aware of the legislative status of medicinal cannabis within their state.
Conclusions : While the majority of medical providers are generally aware of their state’s cannabis laws and believe that cannabis might be at least somewhat helpful for PTSD or anxiety symptoms, most providers do not currently recommend medicinal cannabis for the treatment of PTSD or anxiety.
Keywords : anxiety; medicinal cannabis; physician recommendation; PTSD
Emerging research suggests that certain cannabinoids may be therapeutic for mental health conditions defined by high physiological arousal and avoidance, such as anxiety disorders and post-traumatic stress disorder (PTSD).1,2 Early clinical trials have demonstrated initial efficacy of particular cannabinoids, including cannabidiol and low doses of delta-9-tetrahydrocannabinol, as potential treatments for these populations/targets.3,4 However, rigorous clinical trials supporting the efficacy of cannabis remain generally lacking, particularly for psychological conditions. Moreover, prospective and cohort studies of cannabis-using patients with anxiety and trauma-related symptoms have generally documented a worsening of symptoms over time5,6 and increased risk for developing cannabis use disorders (CUDs),7,8 adding complexity and nuance to the therapeutic use of cannabis or specific cannabinoids in these populations.
Despite a lack of rigorous evidence regarding therapeutic use and literature highlighting potential negative consequences associated with use, individuals with anxiety and PTSD are turning to cannabis and specific cannabinoid preparations as a means of coping with their conditions,9–11 including co occurring symptoms such as sleep disturbances.12 As a schedule 1 controlled substance, however, physicians cannot legally prescribe cannabis to these patients. Instead, health care providers residing within states with medicinal cannabis laws are legally allowed to recommend medicinal cannabis and certify documentation that patients qualify for state-sponsored medicinal cannabis programs. The term ‘‘medicinal cannabis’’ (also referred to as ‘‘medical marijuana’’) denotes the use of cannabis plant material or extracts to treat a medical or psychological condition after the recommendation of a physician. Anxiety and PTSD represent two of the primary psychological conditions for which medicinal cannabis is sought.13,14
The use of a drug (e.g., cannabis) for the treatment of symptoms before the emergence of scientific evidence is typically not seen with traditional pharmaceuticals, which require studies of efficacy before distribution and use. This dynamic has thus placed the burden of guidance in this ever-changing field squarely on those allowed to recommend (primarily physicians) and dispense medicinal cannabis.
A recent study by Haug et al.15 assessed the knowledge and practices of cannabis dispensary staff in a number of U.S. states. This study highlighted that generally untrained dispensary staff were providing specific cannabis recommendations to patients, and that the advice provided was often inconsistent with existing scientific literature. Prescribing health care providers represent the most equipped and appropriate ‘‘front line’’ to provide sound medical advice to patients regarding medicinal cannabis use. However, existing literature suggests that physician attitudes and practices surrounding medicinal cannabis has been largely incongruent with cannabis policy.16,17 Indeed, many providers report that they are uncomfortable recommending medicinal cannabis, or lack the knowledge necessary for them to do so.
Several factors may contribute to physician hesitancy to recommend medicinal cannabis for psychological conditions. Most notably, there are no published large randomized-control trials that compare medicinal cannabis, or individual cannabinoids/ combination, to placebo for anxiety or PTSD. Meanwhile, problems associated with long-term recreational use of cannabis are well established (see Karila et al. review18), and some cannabinoids can produce anxiogenic, rather than anxiolytic, effects.19 Given the current state of policy surrounding medicinal cannabis, it is likely that many providers have not received proper medicinal cannabis training or education, particularly with respect to anxiety and PTSD. This poses a major barrier for patients who are interested in medicinal cannabis, as it is necessary that providers be well trained, knowledgeable, and comfortable providing a treatment if they are expected to recommend it. This study sought to fill a large gap in the literature by examining prescribing health care professionals’ attitudes, knowledge, and practices surrounding the recommendation and evaluation of cannabis use for their patients with anxiety and/or PTSD.