Medical cannabis’ clinical importance in Poland increased dramatically following its legalization in 2017 as the 12th country in Europe [13]. It is expected that Poland will play a crucial role in expanding the European cannabis market. Even before the legalization of THC-containing cannabis, there had been an increase in interest in industrial hemp-based products. The demand was created through intensive marketing of CBD oils, cosmetics, food, and other products. According to the 2019 report, it is estimated that the total value of the cannabis market will reach USD 2 billion in 2028 [41].

The Polish legal framework in which cannabis is considered a raw pharmaceutical material is unique in Europe [42]. On the one hand, it implies no restrictions for cannabis use in terms of gender, symptoms, or age. However, hospice and hospital pharmacies cannot dispense cannabis because they cannot make magistral preparations, limiting access to an important target group, namely palliative patients [13,17]. Additionally, there are no approved indications list, contraindications, or national recommendations to define the dosing and other vital aspects for making magistral preparations of adequate quality [40].

Given the complex legislative solutions and growing patient demand, increasing the awareness, knowledge, and skills among prescribing physicians seems necessary. Although physicians generally favored cannabis legalization, 91.3% declared they had no (or minimal) clinical experience with cannabinoids. At the same time, 49.7% declared they had patients for whom cannabinoids might be beneficial, and 53.8% of participants admitted they had at least one patient asking about cannabinoid therapy in the last 6 mo. While medical doctors declared they would use cannabinoids for pain treatment (77/173—chronic non-cancer pain; 60/173—neuropathic pain) and cancer-related symptoms (pain—128/173; 57—cachexia related to cancer; CINV and other—56/173), only 15 of them had prescribed cannabis in the past.

Notably, on average, Polish physicians agreed with the statement that the number of products containing medical cannabis should be increased and strongly agreed that the legalization of cannabis is the right move. More than a quarter also declared that cannabinoids would be the first-choice treatment for high-intensity pain for themselves or their relatives. We also confirmed that past cannabis use increased the odds for selecting cannabinoids in these instances and favoring legalization. We found that younger physicians were more open to legalization and increasing the number of products and use of cannabis in the treatment of their relatives. However, an Irish study among general practitioners found the opposite effect of age, and older physicians were more inclined towards medical cannabis [22]. Furthermore, Crowley et al. found that those with training in addictions declared more support for medical uses of cannabis, and we observed a contrary effect [22]. Other reports have suggested that gender might also play a role in perspectives on cannabis, but we did not observe such a correlation [21,22,33]. Surprisingly, doctors working primarily in the private sector were not different from those in the public sector. Knowing that patients pay the total cost of treatment, those who can afford such therapy would rather use private healthcare, which is easier to access and offers a shorter waiting time for a consult than public healthcare. Nonetheless, the sector of work was not found to influence physicians’ perspectives.

It might be concerning that almost 40% of Polish physicians participating in this study had used cannabis in their lifetime. According to the 2019 report by Polish National Office for Counteracting Drug Addiction, 7.8% of the Polish population aged 15 y or more used cannabis in the last year; this makes cannabis the most prevalent illicit drug in Poland [43]. In studies conducted in other countries, the proportion of users was similar. In a 2012 study, the average proportion of the population aged 15 y or more declaring cannabis use in the EU for the adult population was 23.3%, ranging from 1.6% in Romania to 40.9% in France [44]. This is higher than the population’s average for Poland (12.2%) and lower than that found in our study [44]. Nonetheless, in other studies, such discrepancies between the official reports were also identified. In a study by Perreira et al., 48.9% of nursing students from Spain had used cannabis. In contrast, in official statistics, it reaches 30% [35]. In a study conducted among medical students from Serbia, a country that used to be a part of the Soviet Union, the proportion of users of cannabis also exceeded the one found in official reports similarly to our findings (34.9% vs. 12.4%) [45]. A plausible explanation is that most of our participants were from larger cities, where illicit substances are more accessible. In contrast, medicine students from other countries from the former Soviet Union, such as Belarus and Russia, rarely consume cannabis for recreational purposes (10.6% and 3.3%, respectively) [33,34]. That might indicate some social changes arising between counties of the former Soviet bloc: some are now drifting towards the Western countries of Europe, and some are more inclined towards the East. Nonetheless, other possible explanations could be investigated in other research.

Past use of recreational cannabis is an important factor influencing perspectives on medical cannabis in numerous studies. We found that it increases the odds of using cannabinoids as the first-choice therapy for severe pain by 2.17-times. It was also shown that these physicians presented a more positive attitude toward legalization, use in the treatment of their relatives or themselves, and increasing the number of cannabinoid-containing medicines in Poland (p < 0.001 for comparison with nonusers). In other studies, it was also demonstrated that this factor has a significant influence on opinions. In a study among nursing students in Spain, users were more inclined towards medical cannabis legalization than nonusers (85.4% vs. 72.6%; p = 0.003), as well as recreational (44.3% vs. 17.7%; p < 0.0001) [35]. In Belarus, medicine students who used marijuana more often declared they would recommend cannabis to patients in the case it was legal (85.9%; 61.8%; p < 0.001) and more rarely admitted that it could be addictive (33.9%; 12.1%; p < 0.001), that it has the potential to cause serious side-effects, and is dangerous for physical (53.1%; 27.9%; p < 0.001) and mental health (55.6%; 23.3%; p < 0.001) [45]. A similar relationship was identified in Serbia for medical and recreational cannabis legalization [34].

In the authors’ opinion, Polish physicians’ optimistic attitude towards the legalization of medical cannabis is a positive finding, given that pain is one of the most common qualifying conditions for such treatment in numerous reports from patient registries [46,47,48]. Pain treatment was also the most frequently chosen indication for using cannabinoids by Polish physicians. In previous studies involving physicians, it was consistently ranked among the best-known indications for cannabis use, together with palliative care and multiple sclerosis [18,19]. Sixty-three percent of Irish GPs agreed that cannabis is a legitimate treatment option for chronic pain, and almost forty percent of Norwegian physicians believe that its addition to the treatment schedule can reduce opioid consumption [21,22]. Moreover, almost 80% of primary care physicians from Minnesota agreed that cannabis should be offered for cancer pain and almost 70% for both pain as a symptom and pain refractory to treatment [24]. A similar proportion was found among physicians from New York [23]. In another study comparing the perceptions of clinicians and patients from San Francisco, both groups admitted that cannabis could alleviate pain, at least to some extent, and both groups were less concerned about co-use of cannabis and prescription pain medication than cocaine or opioid abuse [27]. The clinicians in that study reported that they were less likely to ask or conduct cannabinoid tests than for other controlled substances.

Despite the openness and encouraging attitude towards medical cannabis use, a limited proportion (8%; n = 15/173) have ever issued a prescription. Similarly, access to adequate pain treatment in Poland is limited, as evidenced by official reports; however, it is estimated that 20% of the 38 mln Polish population lives with chronic pain [49]. That topic was raised on numerous occasions by the Ombudsman, Patient Ombudsman, and parliamentary interpellations [16,49]. The National Institute of Audit published a report revealing that in 94% of hospitals inspected, no evidence of regular pain evaluation was documented, and almost 70% did not establish any procedures to treat pain effectively, including patients undergoing surgical interventions. In addition, they revealed that the inhabitants of 266 out of 373 counties that were distinguished in Poland in 2016 did not have access to public pain treatment centers [49,50]. While countries of the West report higher use and aim to introduce more control measures in the case of opioids, in Poland, many patients struggle to receive adequate medication for pain of strong intensity [11,12]. The bad reputation of opioids makes them stigmatized by society, including healthcare professionals, which was raised by one of the regional consultants in palliative care in an open letter in 2017 [51].

When access to pain treatment is limited and the knowledge about controlled substances is low among healthcare professionals, this might have severe consequences for patients who decide to self-medicate to alleviate their symptoms. It has been observed that patients devoid of professional pain treatment tend to overuse over-the-counter (OTC) pain relievers, mainly non-steroid anti-inflammatory drugs (NSAIDs) and paracetamol. In a study conducted by the Chief Statistical Office, 33% of surveyed Polish citizens took OTC pain medication in the previous 14 d and a similar proportion OTCs for the common cold and its symptoms [52]. In most cases, these medications also contain acetaminophen and ibuprofen (or other NSAIDs). According to a 2016 paper, ¼ admits to modifying the recommended doses of NSAIDs [53]. The poisonings with OTC pain medication, namely acetaminophen, are responsible for up to 70% of acute liver failure cases in Europe and more than 50% of drug-induced liver damage [54]. This class of drugs was considered safer than THC in our study, although the consequences of an overdose of NSAIDs might be severe and even fatal, while most side-effects for medical users of cannabinoids are short-lasting, and a fatal overdose is extremely unlikely [53,54,55]. The OTC status of some pain medications might give a false sense of safety to both patients and healthcare workers, and the stigma surrounding pain medications based on controlled substances leads to suboptimal prescription rates [11]. This leads to inadequate pain treatment (or self-treatment with OTC medications) for severely ill patients and overdose-related side-effects [11,52,53,54,55]. We believe that the introduction of medical cannabis is a reasonable opportunity to initiate comprehensive education for physicians on pain management, which would also help identify the right place for cannabinoids in daily practice.

An essential complication for a smooth introduction of medical cannabis into regular clinical practice is the lack of consensus of medical society in its recommendations. In the case of Poland, there is a lack of local recommendations that would consider local specifics [9,40]. Although pain treatment is the most studied and least controversial of the indications for cannabis use, its place in clinical practice is yet to be defined. Available recommendations in Europe are primarily heterogeneous, even for indications without mounting evidence to support cannabis use, such as pain [9,56,57,58]. The British National Institute for Health and Care Excellence (NICE) and the Finnish Medical Association have stated that they are not in support of the use of cannabis-based products for pain, whereas EFIC, the Dutch Office of Medicinal Cannabis (OMC), and the German Pain Society list chronic pain as one of the possible indications for use, especially neuropathic and cancer-related pain [9,56,57]. Still, the recommendations from these organizations are different in many aspects, with some restricting cannabis use to unspecified, refractory cases, while EFIC proposes cannabinoids as the third-line treatment in neuropathic pain, after gabapentinoids and lidocaine [58]. Although a considerable population could potentially benefit from using cannabinoids, the availability of such medications remains limited for many patients [59,60]. That could be improved by creating clear recommendations, standardizing the use of cannabinoids, acknowledging local legislative solutions, and educating healthcare professionals involved in patient care.

According to physicians‘ declarations, our results and previous studies might give the illusion that there are few (if any) barriers to cannabinoids’ use for the most studied indications. A lack of experience is one of them. Most participants (91.3%) reported having no clinical experience with cannabis. Furthermore, Arnfinsen et al. demonstrated that only four out of three-hundred thirty-four doctors ever recommended cannabis to a patient [21]. However, data from other papers revealed that there might be other factors than personal opinion and experiences that limit access to medical cannabis [18,19]. We hypothesize that one of them is a lack of awareness by medical professionals of the hazards related to illegal cannabis consumption and the perception that prescribing such a prevalent drug is not a burning need. Patients who are denied access to such treatment turn to illegal sources, creating a gap between the number of official prescriptions and the number of people declaring the use of cannabis for medical reasons. Discrepancies between the number of cannabis users and prescriptions are becoming evident in other countries. In the U.K., 2 y after the legalization of cannabis for medical purposes, only 60 prescriptions in total were issued, whereas the target population was estimated at 1.5 mln (2% of the total population) [59,61]. In The Netherlands, only 16,000 patients benefited from the Medical Cannabis Programme from its beginning until 2016 [62]. At the same time, other reports demonstrated that numerous users of recreational cannabis take it for medical reasons [61]. That is disturbing as recreational cannabis of unknown sources is likely to be contaminated with herbicides, pesticides, heavy metals, and other substances absorbed to the lungs when inhaled [63,64]. In contrast, pharmaceutical-grade cannabis is routinely tested to exclude its presence.

In recent years, a new hazard has emerged of so-called “designer drugs”. Synthetic cannabinoids and other new psychoactive substances (NPSs) are sold as herbal cannabis on the black market. Usually, herbal material is sprayed with these substances [65]. Some of them, such as “Spice” or “K2”, are now widely available in Europe [66]. It is worth highlighting that the patients declare that they would prefer to have qualified physicians’ supervision and obtain a legal prescription; this has been observed in the authors’ clinical practice [61]. Considering that the risk associated with cannabinoids’ use was considered equal to the most commonly used classes of medicines by Polish physicians, education about the potential health hazards related to the consumption of illegal cannabis (including medical purposes) is vital.

Although it is likely a coincidence, in 2017, the same year when the use of medical cannabis was permitted, the Patient Rights Act was updated with a statement that each patient has the right to proper pain management [16]. The Ministry of Health draft legislation debated at that time, which was meant to improve pain management in patients, did not come into force [49]. A new project prepared in 2020 was also meant to standardize the management of patients with pain, but was not welcomed by the medical society because of the extra workload and no additional financing [67,68]. However, our study revealed that Polish physicians are open to new options for managing pain and other symptoms that cannabinoids might alleviate. They also declared that the safety profile is comparable to other commonly used classes of medication. In summary, it becomes urgent to enable Polish patients to access adequate pain treatment by increasing the number of trained medical professionals and medical facilities that would provide medical advice and care.

This study has certain limitations. One of the most important is the small sample size; therefore, we did not recruit enough representatives of different medical specialties to enable subgroup analysis. We did not include nurses, pharmacists, and representatives of other medical professions involved in direct patient care. The correlation between past cannabis use and a more positive attitude towards cannabinoids found in our study might have influenced the overall result. Nonetheless, we demonstrated that the nonusers (60% in our group), when considered separately, were also in favor of medical cannabis legalization and use in the treatment of relatives.