An investigation of the use, effectiveness, and prescription of medical cannabis from a prescribers' perspective in Malta

Abstract

Background, Literature on the use and effectiveness of medical cannabis remains contradictory, despite its legalisation across many countries and states. Malta legalised the prescription of medical cannabis on the 18th of December 2018, by amending the Drug Dependence (Treatment not Imprisonment) Act, Cap 537. However, there remains uncertainty amongst Maltese prescribers on the use, effectiveness, and prescription of medical cannabis. Aims, The overall aim of this study was to gain a better insight into medical prescribers’ attitudes and beliefs, regarding the prescription of medical cannabis in Malta. Methods, In the first phase, an extensive scoping review was carried out to formulate the interview guide and the questionnaire with relevant questions regarding the use, effectiveness, and prescription of medical cannabis. In the second phase, a qualitative interview with a prescriber of medical cannabis in Malta was carried out. The interview guide was made of pre-determined open- ended and probing questions, based on the extensive literature review carried out and the tripartite structure of attitudes that was selected to be the study's theoretical framework. The initial objective of this study was to carry out qualitative interviews with registered active medical cannabis prescribers in Malta, but due to the exceptionally low engagement by registered cannabis prescribers, it was decided to reformulate the interview guide into an anonymous online questionnaire to be distributed to all potential prescribers in Malta. Therefore, in the third phase, the quantitative electronic questionnaire was posted to the Facebook group “Tobba Maltin” (Maltese Doctors) for the members to answer. Since, both a qualitative and a quantitative approach were chosen as data collection methods for this study, the study used a mixed-method approach. The questionnaire was based on the tripartite structure of attitudes framework, the literature review carried out for the interview guide, and some of the questions in the interview guide itself. The interview guide and the questionnaire were formulated to gain a better understanding of the prescription of medical cannabis in Malta, to identify the perceived effectiveness and safety concerns of medical cannabis amongst prescribers, and to gain insight into the regulatory approach involved in the prescription of medical cannabis. The results obtained from the two different data sets were first investigated separately and then together in the light of current research. Results, The interview and questionnaire findings were limited due to the low response rate but there was a decent representation of active medical cannabis prescribers in the questionnaire responses (31.25% response rate). The main findings were: - Prescribers decided not to prescribe medical cannabis because of a lack of confidence in their knowledge of medical cannabis, because its indications did not match their patients’ needs, and because of the limited evidence on medical cannabis effectiveness. - Most of the prescribers who prescribed medical cannabis did not have a high level of confidence when prescribing it. - Pain management was the most common indication for medical cannabis. - The use of international prescription guidelines has been shown to increase the level of confidence that prescribers have in prescribing medical cannabis. - Prescribers have a level of concern regarding the safety of medical cannabis, especially regarding dependency/addiction. - Local healthcare professionals do not possess the knowledge and skills to manage patients who are on medical cannabis. - There needs to be a balance between control and convenience regarding the regulatory process involved in prescribing medical cannabis. - Prescribers want more guidance when it comes to prescribing medical cannabis. - The prescription of medical cannabis has been affected by the legalisation of recreational cannabis. Conclusion, Findings indicate that no standard approach is being followed by Maltese prescribers regarding the prescription of medical cannabis. There is a need for interventions to teach and train Maltese prescribers how to manage patients on medical cannabis, promote local or international prescription guidelines, and remove the stigma associated with medical cannabis now that it has been legalised. The legalisation of recreational cannabis has further emphasised the need for national guidelines and policies guiding healthcare professionals on how to prescribe medical cannabis and how to manage patients on medical cannabis.