The presented results of this study showcased that despite adequate knowledge, there is an apparent gap in pharmacy students’ behavioral intention to counsel. Pharmacy students were reasonably knowledgeable regarding CUD, scoring above 80% on average. Their attitudes towards MC use were relatively high compared to a slight decrease in attitudes towards RC use, but overall positive. However, their behavioral intentions regarding their confidence in counseling for CUD were largely negative. The discrepancy between attitudes toward MC use and RC use might be associated due to a variety of reasons, such as a lack of regulatory control and clinical oversight of individuals using cannabis recreationally, the general demographic of those using cannabis recreationally, and, potentially, the lack of comfort to address appropriately and counsel those using cannabis recreationally. However, after controlling for age, gender, ethnicity, academic year, and awareness of the policies of MC and RC use in the students’ respective states, the multivariate linear regression indicated that pharmacy students with positive attitudes towards RC use, compared to MC use, were more likely to have the intent to counsel patients. Performance in knowledge scores and the overall positive attitudes towards MC use and RC use were consistent with the current literature and the low behavioral intentions scores’ association with a general lack of confidence in counseling patients [16,20]. This study showed similar results to other study cohorts reporting a desire for more CUD-related content to be incorporated into their respective curriculums [20]. In addition, behavioral intentions scores further varied based on most sample characteristics measured except on the awareness of RC legality and the legality in the respondent’s state. The students in this sample were more likely to obtain most of their knowledge of cannabis from non-pharmacy curriculum lectures or past recreational use before an accredited pharmacy curriculum lecture taught by appropriately distinguished educators and professors. A cause for concern rises, as many outside sources are not subjected to the validation or falsifiability in which healthcare curriculums founded on the evidence-based literature typically are. This inevitably raises the concern for spreading misinformation, further driving a gap in knowledge, attitudes, and BI. All of which brings to question how to standardize education and attain the necessary knowledge regarding cannabis therapeutics, safe administration, and management of potential adverse effects regardless of the student’s characteristics or experience with cannabis.

As for potential limitations, only a few pharmacy colleges responded, despite the survey being sent out to schools nationwide. In addition, the schools that responded were heavily biased toward Texas-based pharmacy schools. While this study takes a significant step in covering students’ perceptions at a large scale, to achieve generalizability with minimal bias, students from all geographical and societal backgrounds must be accounted for. A skewness in the distribution of the geographical location of responses will sway the outcomes in favor of the population in those respective locations.

All the while, this study does display various strengths. This study highlights how a partial lack of knowledge about cannabis is associated with a corresponding lack of confidence in preparedness to council patients over CUD. The results of this study can help promote the need for additional training amongst students to tackle CUD counseling scenarios in the field. The results also propose the need for additional education and preparation on cannabis-related topics and patient counseling initiatives to help build students’ confidence in conveying the clinical information necessary to meet patient demands. Lastly, a significant number of surveys were incomplete, leading to the exclusion of potentially valuable data. While the complete survey responses provided valuable insights, the necessity to exclude incomplete data may have impacted the comprehensiveness of the findings.

Since the legalization of medical cannabis use in California (1996), 41 states have followed with legalization, along with 4 states allowing for CBD oil containing THC, while only 5 states that completely criminalize the use of cannabis medically or recreationally remain [21,22]. Perceptions of cannabis use amongst cannabis users and abstainers have varied widely but remained optimistic regarding its potential benefit and its management of possible harmful adverse effects. However, due to public information lacking in quantity and quality, the results and adverse effects of cannabis can easily be interpreted and misrepresented, calling for more attention to be placed on providing educational information for the public [23].

The current literature reports a general desire among healthcare trainees for increased training on knowledge of cannabis use to counsel patients. While previous studies have highlighted the benefits of integrating or further supplementing CUD education into pharmacy school curriculums, the findings are often limited to single or a small number of local pharmacy school cohorts. Therefore, there is a crucial need to expand research efforts to assess the overall readiness and behavioral intentions of pharmacy students on a comprehensive national scale. By doing so, a better understanding would be attained to address the broader education needs and perspectives of future pharmacists in counseling patients on CUD across diverse healthcare settings [24,25]. Based upon the domains of CUD knowledge identified in the existing literature such as pharmacology, therapeutic uses, legal considerations, communication skills, and patient-centered care, educators can develop tailored educational programs to equip current pharmacy students with the necessary knowledge base and capability to counsel patients on CUD [26,27]. Specifically, incorporating experiential learning opportunities, such as case-based learning and simulated patient encounters, can enhance students’ ability to apply theoretical knowledge in practical scenarios, thereby improving their readiness and confidence in counseling patients [28,29]. Moreover, effective communication skills training would facilitate open and non-judgmental discussions about cannabis use, inevitably fostering trust and rapport between pharmacists and patients, ultimately geared towards improving patient outcomes [30,31]. By further implementing these practices into pharmacy curriculums, institutions can better prepare future pharmacists to address the complex challenges and evolving landscape of cannabis use within various healthcare settings.