Cannabis use guidance from dispensary workers often lack clinician input, safety warnings

Medical cannabis dispensary workers such as budtenders, managers and pharmacists often made recommendations on cannabis use to customers based on their personal or coworkers’ experience, according to findings published in JAMA Network Open.

The data further showed that customers rarely received guidance from these staff members on cannabis use disorder, withdrawal, dangers of driving while using cannabis and psychotic reactions.

Dispensaries are not medical environments, Jessica S. Merlin, MD, PhD, MBA, an associate professor of medicine at the University of Pittsburgh and director of the Challenges in Managing and Preventing Pain Clinical Research Center, told Healio Primary Care.

“Just like we would not expect a bartender or a liquor store checkout clerk to have a medical discussion with an individual about the types of risks with alcohol, we can’t expect that from a dispensary staff member,” she said.

In a nationwide cross-sectional survey study, Merlin and colleagues analyzed the practices of frontline dispensary workers who interacted with individuals purchasing medical cannabis. The survey included 434 staff members from 351 dispensaries in the U.S.

Responders were sampled over the phone or via mailers from February to October 2020. Each individual who participated was offered a small monetary compensation. The dispensaries were given a summary cannabis medicalization score ranging from 23 (least medicalized) to 86 (most medicalized). The score was based on several factors like dispensing practices, patient-clinician relationship and product labeling.

Trends in cannabis recommendations

Surveys were most often completed by budtenders (40%), followed by managers (32%), pharmacists (13%) and physicians, nurse practitioners or physician assistants (5%), according to Merlin and colleagues. Among the respondents, about half reported working in the cannabis industry for more than 2 years; 15% reported receiving sales commissions; about two-thirds reported having a medical cannabis card and using cannabis multiple times per week or daily; and 78% reported that they agree or strongly agree that personal cannabis use has helped them advise customers.

When questioned on how they make recommendations to customers, most staff said they based their advice on the customer’s medical condition (74%), experiences of other customers (70%), the customer’s experience with cannabis (67%), the customer’s preference (66%), preferred time for consumption (65%), respondent’s personal experiences (63%), employer training (61%), other staff recommendations (56%) and product availability (50%), according to the researchers.

Merlin and colleagues reported that 37.6% and 42.2% of respondents, respectively, said they always addressed potential adverse effects of cannabis use and safe storage practices. However, only 5.3%, 5.1% and 12.7% of respondents reported always addressing the possibility of a cannabis use disorder, withdrawal and psychotic reactions with customers.

The mean medicalization score among the 351 dispensaries included in the study was 46. States with higher medicalization scores were associated with a greater likelihood of a physician or clinician being included in the cannabis product selection process, according to the researchers.

Merlin noted that the lack of evidence on medical cannabis prevents clinicians from being able to make specific recommendations about its use.

“I think for the majority of primary care physicians, something like cannabis dosage is probably outside the scope of what they might be expected to know,” Merlin said. “But just like with any other medication, I tell my patients to treat symptoms starting low and going slow titrating up.”

She added that while there probably should be more safeguards in place at dispensaries, counseling from a physician or collaboration between a physician and dispensary staff member can be invaluable.

‘Gap in medical care’

In a related commentary, Katharine A. Bradley, MD, MPH, a senior investigator, Gwen T. Lapham, PhD, MPH, MSW, an assistant investigator, and Theresa E. Matson, MPH, a research interventionist at the Kaiser Permanente Washington Health Research Institute, suggested steps that clinicians can take to normalize cannabis use and educate patients about associated risks. For example, clinicians can adopt routine screening, complete continuing medical education on the potential risks and benefits of cannabis use, and utilize substance use disorder symptom checklists.

“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,” Bradley, Lapham and Matson wrote. “This imbalance is an important gap in medical care that will widen as the prevalence of cannabis use continues to increase.”

References:

Matson ET, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.25262.

Merlin JS, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.24511.