The study objective was to explore attitudes and practice patterns of Canadian physiatrists regarding the use of MC. To our knowledge, this is the first study to examine this sub-population of practitioners. MC is often considered a favourable treatment option for patients suffering from chronic pain, neuropathic pain, spasticity and post-traumatic stress disorder (PTSD).

Results indicated that newer physiatrists were as likely to acknowledge the medicinal benefits of MC and to feel comfortable discussing it with patients though they were less comfortable authorizing its use compared to those with over 11 years of experience. This may be attributed to more first-hand experiences witnessing the therapeutic benefits of MC.

Interestingly, whilst more than half of the participants agreed to feeling comfortable discussing MC, many participants did not feel comfortable authorizing it. Most participants reported inadequate training in both medical school and residency related to MC. This notable discrepancy between respondent willingness to discuss the use of MC but unwillingness to authorize MC usage highlights the tension in treatment implementation, which may reflect the uncertainties regarding evidence, guidelines and insufficient training in MC prescribing (17).

Many respondents believed that research did not provide satisfactory evidence to support the use of MC. A study conducted by Ng et al. noted similar results, and participants had concerns about the long-term effects and lack of rigorous and high-quality studies monitoring vulnerable populations. Additionally, due to the lack of evidence in research, physicians felt that clinical trials have been poorly designed (26). A likely reason for the lack of such high quality, large multi-centred studies is the extreme cost associated with such a study; normally, studies that meet these quality guidelines are patented, pharmaceutical backed medications. However, in Canada, THC and CBD products are not patented, and there are no large industries backing these products, which prevents the typical multi-million-dollar studies that physicians want to see. Some researchers have performed survey and cohort-type studies, including surveys of experienced physicians treating patients with cannabis in their daily practice, and those studies, along with the present one, allow for consideration of the accumulated clinical experience as a source of knowledge and information in guiding physiatrists’ practices.

Previous literature has shown mixed attitudes for the use of MC. This study along with studies conducted in New York (19), Israel (20) and Australia (21) shows physicians generally have positive attitudes towards MC, whilst physicians in Colorado (18) and Ireland (22) showed generally negative overall attitudes. The vast majority of respondents agreed cannabis has a medicinal value (Fig. 1), but physiatrists with less experience felt less comfort discussing it and even more uncomfortable authorizing it, compared to the physiatrists with more experience (Fig. 2).

It was discovered that physiatrists believe that MC has a higher value when utilized in a non-smoked (oral or vaporized) form. Azcarate et al. conducted a study on the use of MC regarding medical conditions and the form of use. Their results supported this belief as smoking form was believed to make recreational use more likely (27). Additionally, it is generally believed that smoked/combusted forms are more hazardous to health than when vaporized or used orally. Also, the smoked form allows for rapid onset with short lasting effects, making it an ineffective medication for patients with a chronic, constant condition such as pain and spasticity that need longer acting, stable dose in an oral form.

The subspecialties that prescribed MC most often included neurological rehabilitation, SCI rehabilitation, pain medicine and general physiatry. Previous studies serve as evidence in supporting the use of cannabinoids as treatment for pain and spinal medicine (28–29); hence, explaining why physiatrists in these specialties are more likely to be treating patients with MC.

Some respondents chose “neutral” when answering whether there are different side effect profiles of cannabis with predominant THC as opposed to CBD. This could be due to (i) an absence in comparison trials between THC vs CBD, as only anecdotal evidence currently exists, and most research has been done using THC dominant strains only, and/or (ii) participants remaining neutral may not have been familiar with cannabinoids to express an opinion at the time.

Although this study was conducted prior to legalization of cannabis, study results are important as it is still mandatory to have a physician authorize the use of MC in Canada, and the patient cannot access MC without this authorization. There are many benefits of accessing a medical source as opposed to a recreational source, including being able to use the cost as a medical expense for tax purposes and being able to use cannabis in recreational locations that would otherwise be banned e.g. in public places. Obtaining MC allows for patients to access formulations tailored to specific conditions and allows access to cannabinoids that are of higher quality.

Overall, this study has shown that physiatrists generally have a positive attitude towards MC. MC has been demonstrated to have positive effects in the management of medical conditions. To increase physiatrists’ comfort using MC to help their patients lead a better life, more research, education and clear guidelines are needed. Even after the legalization for recreational purposes, there are many benefits for patients obtaining MC through medical authorization, such as claiming health coverage or compassionate pricing, writing off cost as a medical expense, using MC in settings where recreational cannabis would be forbidden and receiving guidance from a physician regarding dosing, forms of administration, side effects and balance of THC and CBD. Though many respondents stated they would not feel comfortable using MC after legalization, it would be worth studying how physiatrist’ attitudes and practice patterns have changed. Introducing courses in medical school and training in residency, particularly online learning programs, and small group workshops will be able to increase comfort levels for practitioners.

This study started prior to legalization of recreational cannabis; therefore, respondents answered the survey at a time when their patients did not have legal access to cannabis through recreational means. Although recreational source of cannabis is now available in Canada, medical counselling and authorization remain critical for patients in Physical Medicine and Rehabilitation. It is necessary to ensure that practitioners feel both competent and comfortable at the possibility of considering MC for their patients. Some practitioner attitudes may have changed since legalization, highlighting the need for ongoing research and updated guidance from Health Canada, Canadian Medical Protective Association and provincial regulatory bodies. In addition to this, national-level guidelines with consultations from physiatry specialists would be significantly beneficial. Addressing cannabinoids in medical schools is of utmost importance, not only from the therapeutic side but also from the point of view of counselling patients about safe use and preventing misuse of recreational cannabis. It is evident that teaching in Physical Medicine and Rehabilitation residency programs is lacking, and given our patient population with a high prevalence of pain and spasticity, this needs to be addressed nationally at the Royal College level and within individual programs. With clearer guidelines, more education and better research, physiatrists will be more knowledgeable and to be able to create appropriate treatment plans to improve the lives of their patients.