Factors Contributing to Low Uptake of Prescribing Medicinal Cannabis among Phyisicians in Melbourne

The context.

Cannabis is the most cultivated, trafficked and abused illicit drug in the world according World Health organisation. Cannabis is a general name which refers to a drug which is produced from a plant of cannabis family. The drug has been in use since ancient times and is the most controversial drug leading to its discrimination in some countries. Cannabis sativa Vitoria Commission(2018) is widely used both for recreational as well as therapeutic purposes. The drug is the most banned drug in most countries due to its perceived psychotic or euphoric effects which leads to its being widely abused drug.

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The drug was first listed in United States of America’s drug list in 1850, criminalised in 1937 and removed from the list in 1943 (). Since then the drug has been on and off drug lists in various countries. Currently, there is a global debate about its therapeutic use. This necessitated the countries to review policies and legislatures regards use of cannabis’ therapeutic purposes.

Cannabis or cannabinoids is the form which is widely used for its medicinal properties. It is this therapeutic effect which made other countries to legalise it. The drug is legalised in 26 states in United States of America, Canada, Israel and The Netherlands among other countries. Netherlands government has hospitals where diseases and conditions are treated with medicinal cannabis. However, the government strictly controls the drug.

Several studies have documented the health benefit of medicinal cannabis like alleviating vomiting and nausea in HIV and cancer patients and treatment of epilepsy in children (O’Connell). In Australia, the first ever medicinal cannabis trial is underway at Newcastle hospital in New South Wales. The study to explore whether medicinal cannabis can improve quality of life for the terminally ill patients. However, in other countries, medicinal cannabis is not easily accessed and deserving patients cannot access the drug.

There is increasing public support on use of medicinal cannabis. According to 2016 National Drug strategy report, in Australia, 85% of the people support change in legislature to use medicinal cannabis and 87% supported use of clinical trials to treatment of medicinal cannabis. This has led to change of policies in Australia. Despite the enabling environment patients still have problems accessing the drug.

The Australian Federal Parliament amended the Narcotic Drugs Act 1967 to allow for the cultivation of cannabis for medicinal or scientific purposes in 2017.The commonwealth Therapeutic Goods Administration (TGA) approved the drug Nabiximols (Sativex) for treatment of multiple sclerosis. To access the drug, a physician has to apply for Schedule 8 treatment and a Special Access Scheme. In Victorian access is through the TGA’s single online application. This was done to simplify the bureaucracy around the drug and to improve access.

The Victoria government under the Drugs, Poisons and Controlled Substance considers medicinal cannabis when it has been prescribed by a professional practitioner to treat a condition or as a remedy and the individual should be taking the drug under supervision.

However, medical colleges (regulatory bodies) came up with position papers cautioning the physicians on prescribing medicinal cannabis citing inadequate evidence to guarantee quality and safe clinical prescription of medicinal cannabis and inadequate education and training to the physicians. The position statements form regulatory bodies impacts on physicians. The regulatory bodies argue that the process of legalizing cannabis did not involve the correct procedure of drug trials in Australia. This can create a sense of un certainty in the physicians towards prescribing medicinal cannabis.

Consequently, there is low uptake of medicinal cannabis and well deserving patients are not accessing the drug or they take to long to get the drug due the process one has to go through.

Literature review

Several studies were conducted to examine the benefits of using medicinal cannabis on certain diseases. Medicinal cannabis relieved pain and had some therapeutic effect on certain disease conditions like epilepsy in children (Ziemmeinsk, 2013) as well as chronic pain and headaches. This study, however, suggested the need for more randomised studies are necessary could have been significant if a randomised trial had been conducted to further understand the results

Carey in his study, found that cannabis was effective in treating neuropathic pain. However, the weakness with this argument is that the comparison was done between a placebo and cannabis, of which a placebo could not produce the same pain relief effect as the drug under study. Further studies on the placebo are needed for further analysis.

On the contrary, a study by Konrad, found that ninety percent of the physicians did not agree with the therapeutic effects of medicinal cannabis and they felt that cannabis carried a risk to the patients and feared potential risks Ziemienski). They also expressed lack of knowledge gap to be problematic for prescribing the medicine.

Other studies found There is knowledge gap on use of medicinal cannabis. Caligiuri stated that there was knowledge gap among pharmacy students qualifying conditions on cannabis for medical use. This study assessed knowledge and attitudes towards curriculum coverage of medicinal cannabis. This implies that if there is knowledge gap an individual lack confidence in the task they are expected to perform

In additiona,Karen’s study, on pharmacy students’ knowledge, attitudes and perceptions towards medicinal use and effect on what conditions, the students identifies cancers as the only condition. This showed inadequate knowledge among health professional which can have implications on their capacity to prescribe.

In Australia, few studies looked at knowledge and perceptions of the Australian physicians towards prescription. Kalanges at el, stated that there was knowledge gap among the physicians to prescribing and most participants indicated training as a solution to empower. This understanding is crucial, because from this research we come to understand why the physicians are hesitant to prescribe cannabis to patients giving the impression that perhaps they are not well prepare in terms of knowledge. Capacity building for the physicians is vital.

From the studies so far, many studies have explored health benefits of medicinal cannabis and knowledge gaps among physicians, but no studies have explored the experiences, attitudes and perceptions of Australian physicians to wards prescribing medicinal cannabis. This proposed study will explore the physician’s experiences which hinder up take of prescribing medicinal cannabis in Melbourne, Victoria.

Although the use of medicinal cannabis was legalised, Physician attitude towards medicinal cannabis plays a role in prescribing medicinal cannabis. Studies have indicated that physicians feel that there is no enough evidence to guarantee quality and safety of clinical prescription (RACP) of medicinal cannabis. This study proposal, therefore intends to explore the experiences, perceptions and attitudes of the physicians towards prescribing medicinal cannabis.

Limitations

The limiting factor in this study was funding. The research did not interview patients to find out their experiences towards accessing medicinal cannabis. The data would have been used to triangulate and validate the data from the physicians to provide a better understanding of the factors contributing to low utilisation of medicinal cannabis.

The Paradigm

This study will take the constructivist paradigm. A paradigm can be defined as “an overarching philosophical or ideological stance, a system of beliefs about the nature of the world” McKenzie,(2006). it is how the researcher looks at and how they understand the world around them. In Constructivist paradigm the researcher does not have a pre-set standard or measure rather through interaction with participants, the researcher will construct the reality and understand the social phenomenon the researcher is interested in. the participants express themselves through their own words.

The Research Question

The study is trying to understand the social problem of low utilisation and uptake of prescribing cannabis in Melbourne through the following research questions; the public is demanding prescriptions of medicinal cannabis for treatment of some disease conditions and relief of symptoms and pain in other disease conditions. There is some documented evidence towards the health benefits of using medicinal cannabis. In response to the public outcry of medicinal cannabis the government enacted some regulations to facilitate uptake. Despite the need and enabling legislature, there is low uptake on prescribing medicinal cannabis. Why is the uptake of medicinal cannabis among the physicians so low? Are the physicians facing barriers to prescribing medicinal cannabis in Melbourne? What can be done to facilitate uptake of prescribing medical cannabis? What are the General Practitioners experiences and perceptions towards accessing and prescribing medicinal cannabis? This research question clarifies the issues around prescription of medicinal cannabis.

The Link.

Despite legalisation and amendment of legislature and regulations, the General practitioner’s interest to prescribe medicinal cannabis is low and not many are utilising their rights to prescribe leading to low number of patients benefiting from the drug. What are the barriers? How can this be addressed? What are their experiences and perceptions. What are the factors which can facilitate uptake of the prescribers?

Understanding the general practitioners and specialists’ experiences, attitudes, perceptions and hindrances and or enablers to prescribing medicinal cannabis we can contribute to the knowledge and much needed evidence to enable policy makers to come up with favourable regulations and policies to improve prescriber’s uptake of prescribing medicinal cannabis.

Broad Objective of the Study

The broad objective of the study is to explore the experiences, attitudes and perceptions of the GPs towards prescribing medicinal cannabis.

Study population

The study population is defined a population as all potential participants who can give information needed to answer the research question on utilisation and uptake of medicinal cannabis in Melbourne.

The study population will be General Practitioners and specialist on the Register in Melbourne. An inclusion criterion is that they should speak English, be practicing and have an email address. These criteria will carter for those who have had an experience to prescribe medicinal cannabis and those who have had no experience however, their contributions also are important to input the study.

Sampling

The proposed design will use purposeful sampling to recruit specialists and General practitioners on Medical college registers who are practicing in Melbourne. Purposeful sampling is ideal because it allows a good representation of the category of participants to be interviewed. According to the Liamputtong, (2010). researcher is concerned with description of the phenomenon and experiences from the participants which enables the researcher to construct the social reality. The General practitioners and physicians otherwise known as physicians are best placed to provide first-hand experiences in their words on what problems they go through or why they are not prescribing medicinal cannabis to deserving patients and they can give suggestions as how to overcome the barriers.

Sample size

Sample is defined as the actual participant taking part in the study. The initial estimate of sample size is 25 General Practitioners for in depth individual interview and five focus group discussions with General Practitioners and specialists. The figures are just estimating for purposes of planning. However, the researcher will interview until saturation is reached. According to Liamputtong, (2010) saturation is when there is no new ideas or information coming up or when there are no more participants coming up. This point determines the number of participants so the sample size changes. To test saturation, the researcher will analyse few questionnaires to determine if the they are new ideas coming in or if there is need to modify the questions.

Recruiting method.

The participants will be recruited via email. As a state government health official in Melbourne, First I will have a meeting with the Hospital Directors in Melbourne to sensitise them on the study and then I will ask them to inform their members of staff. Then I will get email addresses from the register and from the Directors and send invitation emails to participate. After this, I will give invitation emails to Directors of the hospitals to give to their members of staff and I will send some through the emails gotten from the register. The emails will ask those interested and willing to participate in the study to respond to the researcher directly on my email. Sending emails through the directors of the institutions and the specialist medical colleges will ensure that most of the medical practitioners including those in remote areas will be reached.

Secondly, I will send a plain language statement for the potential participants to read about the study in advance for them to make an informed choice.

Data collection

Data collection will be collected through in-depth individual interviews and focus group discussions. In depth individual interviews will enable collection of rich information and the story from the participants’ own words which will enable the researcher to understand the social reality according to the themes the researcher is looking for because they are experts in their field. The researcher will be able to probe for clarification. The interviews will be conducted as close to the participants’ venues as possible for convenience.

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Focus group discussion will be used to complement and triangulate the experiences and the insights shared and collected through in-depth interviews. This method is ideal because the participants are from the same profession, so they have common qualities and experiences. According to Leavy (2013),through focus group, the researcher will be able to obtain ideas and perception from group members. The participants will be able to comment on each other ideas before reaching a consensus. This is important for example question like “what can be done as a profession?”. The interviews will be audio recorded after getting consent from participants.

Interview questions

The question guide will consist of the following questions:

1. Have you prescribed medicinal cannabis to a patient? If yes, please explain how did you go about accessing the drugs? If no, what is the procedure for accessing medicinal cannabis?
2. What are the barriers to prescribing and accessing medicinal cannabis?
3. What can the government do to provide an enabling environment for prescribing medicinal cannabis in Melbourne?
4. what do the physicians think can facilitate uptake of prescribing medicinal cannabis?
5. How can the medical colleges (regulatory bodies) help the physicians increase the uptake of prescribing medicinal cannabis?
6. Any general comment?

Themes

The data will be analysed and coded according to the following themes:

1. Introduction and demographic questions.
2. General views about prescribing medicinal cannabis.
3. Knowledge about factors facilitating or hindering prescription of medicinal cannabis.
4. Pathway to patient accessing medicinal cannabis.
5. Any themes merging from the general comments.

Data analysis

Since data will be generated from open ended questions, it will be analysed using thematic data analysis method. Thematic analysis is defined as “identifying, analyzing, and reporting patterns (themes) within data” Braun at el (2006) and themes will be coded and sub coded accordingly. Further sorting will be done by NVivo software. Demographic data will be analysed through Stata 14 software.

The researcher will keep field notes and any observations will be part of the data and will be part of the analysis

Ethical consideration

First, I will seek approval from the Human Research Ethics Committee of Victoria Government department of health and Melbourne department of health. Secondly, the plain language statement will explain that participation is voluntary, and participant can opt out at any point and that participants will be asked to sign a consent form if they agree to participate. The consent will be sought again before interview.

Confidentiality and privacy

Confidentiality and privacy will be maintained throughout the study. Names and personal details will be kept separate from the responses and the computer will have a password known to few key people. Questionnaires will not bear participants names and the report will have use pseudonyms to prevent identification and ensure privacy. However, there is a small risk of identification when sending interview transcript for checking this will be explained. The data will be archived for 5 years thereafter it may be destroyed.

The study will be designed in such a way that it will pause no harm to the participants. However, the results will benefit the population by contributing to knowledge and evidence base for decision makers.

The participants will be given contact numbers of the researcher and the number of the Office of the Human Research Ethics and Integrity and Ethics ID number to contact if there is any need. This will show the integrity of the study.

For participants coming from far transport will be reimbursed as a thank you but not to coerce the participants.

Implication of the study.

The researcher believes that this study is timely, the results of which will contribute to body of knowledge on prescription of medicinal cannabis and contribute towards the current debate. As the Australian government is considering more reviews on the legislature policies and regulation on cultivating manufacturing and prescription of medicinal cannabis, the results may input the revision.  Additionally, the results are also going to contribute to evidence on which to base decisions toward increasing medicinal cannabis as access as stated by the medical colleges and regulatory bodies for physicians. In addition, policy makers would use the results to make decisions on issues of medicinal cannabis.

Related content

• The Political Divide and the Moral and Legal Concerns of Medical Marijuana

• Research Study: Factors Causing Cannabis Use

• Medical Cannabis: A Review of the History, Pharmacology, and Clinical Implications

• Efficacy of Medical Cannabis for the Treatment of Chronic Pain

References

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1. Karanges E, Suraev A, Esau N, Manocha R and McGregor 2018 Knowledge and attitudes of Australian general practitioners towards medicinal cannabis: a cross-sectional survey. BMJ Open. Published online 2018 Jul 3 doi 10.1136/bmjopen-2018-022101
2. Karen E. Moeller, Barbara Woods (2015)Pharmacy Students’ Knowledge and Attitudes Regarding Medical Marijuana 79(6): 85. doi: 10.5688/ajpe79685
3.  Konrad E and Reid (2013) Colorado family physicians’ attitudes toward medical marijuana A J Am Board Fam Med. Jan-Feb;26(1):52-60. doi: 10.3122/jabfm.2013.01.120089.
4. Leavy, P., & Hennink, M. (2013). Introducing Focus Group Discussions. In Focus Group Discussions (pp. 1–34). Oxford University Press USA. Retrieved from http://ebookcentral.proquest.com/lib/unimelb/reader.action?docID=1630622&ppg=10
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