The legalization of recreational cannabis in Canada has sparked an increased interest is exploring the potential uses of cannabis and CBM to provide relief for various symptoms which may be refractory to first line treatments. Legalization has also contributed towards increased dialogue about a substance whose use still remains stigmatized. Our pan-Canadian survey of HCPs aimed to understand knowledge, comfort, and practice of cannabis for medical and recreational purposes, and respondents’ opinions on various topics related to CMP, as well as how the COVID-19 pandemic may have affected this aspect of respondents’ practices. This latter aspect is unique to our study.

Most of the respondents answering our survey were attending physicians, and a large proportion were from Ontario and Quebec. This may be because these two provinces have a higher concentration of HCPs compared to the rest of the country. For example, they make up 63% all physicians in Canada [14].

Over half of our overall sample already prescribe and/or recommend cannabis. However, as may be expected, those who are actually prescribing MC (Group D) felt, on average, comfortable with their level of knowledge related to MC. Of these respondents, most had sought out education about CBM outside of their medical training. Many HCPs in Canada may not be familiar with CBM due to the lack of coverage of this topic in professional school. Studies assessing medical education in Canada and around the world have found that most trainees have minimal exposure to CBM-related topics in their curricula [15–18]. With strong media and public interest surrounding CBM, HCPs are likely to be asked more questions about the topic. Therefore, even if they do not support or promote the use of CBM themselves, HCPs should be sufficiently knowledgeable to counsel patients. Going forward, advocacy is required to increase the coverage of CBM in the educational curriculum. Given the most commonly selected reasons for MC use in this survey (cancer or terminal-illness related symptoms and intractable pain) this may ideally take place during training in fields such as family medicine, palliative care, and pain management. This process could be facilitated by the creation of standardized teaching materials as well as the inclusion of cannabis-specific learning objectives in licensing exams and in the curricula of accreditation committees like the Committee on Accreditation of Canadian Medical Schools [15, 19]. Our results suggest that increased training, as in Group D, correlates with a stronger feeling of comfort in knowledge of, counselling on, and prescribing MC.

We originally conceived of this study prior to the COVID-19 pandemic and did not want to delay its execution given the uncertainty surrounding the pandemic. With increased numbers of people working from home, and with increased levels of isolation and mental health issues, we postulated that cannabis use may increase during the pandemic. Our hypothesis was supported by a study which reported increased MC use by cancer patients following the legalization of recreational cannabis in Canada [4]. In addition, lockdown measures aimed at limiting the number of infections and deaths from the COVID-19 was associated with increased cannabis use in the Netherlands between January 2019 and May 2020 [20]. Canadians who engaged in self-isolation during the pandemic were also found to have a 20% increase in cannabis use compared to those who did not[21], reflecting prior research that demonstrated increased cannabis use in times of economic recession [22]. Most respondents in our study reported no change in the frequency of prescriptions they made and questions they received regarding MC, and this makes sense, as most of the sample did not prescribe it themselves. However, the majority of respondents in Group A + B, C, and E (i.e., HCPs who do not prescribe it themselves and may therefore see a smaller proportion of their patients using cannabis regularly) noted a greater frequency of cannabis use among their patients during the pandemic. This was most commonly for anxiety and depression. This echoes research on the rise of anxiety and mood disorders as a consequence of the COVID-19 pandemic [23] and, indeed, preceding pandemics [24]. Importantly, however, the use of cannabis with comorbid mental illness is associated with an increased risk of adverse effects like psychosis and cannabis use disorder [25]. A recent scoping review demonstrated that feelings of boredom, depression, and anxiety during the pandemic contributed to increased cannabis use, which was associated with adverse clinical and psychiatric outcomes among users [26]. Furthermore, in another study, among participants who started using or increased their use of non-cannabis drugs during the pandemic, 40% reported doing so due to a change in access to MC [27].

Even outside the context of the pandemic, several respondents reported cannabis use among their patients, despite half the sample neither recommending nor prescribing MC. Furthermore, some reported being uncomfortable with the medico-legal aspects of MC access. The lack of HCP knowledge in this area could increase the risk of misuse, adverse effects, as well as poor clinical response in their patients. Altogether, these findings highlight the importance of i) more research and knowledge dissemination on safe and effective use of MC, particularly in depression and anxiety and ii) increasing HCP ability to counsel patients on appropriate use of MC, even if they do not recommend or prescribe it themselves.

The lack of scientific evidence to support the use of MC for certain indications was identified as a key barrier to recommending and prescribing MC. This echoes previous research [16] and may be overcome as more clinical trials are performed, and high-quality evidence accumulates. However, this may be hampered by the strict regulatory requirements for clinical trials involving CBM [28]. Furthermore, the private cannabis industry may be reluctant to invest in research due to the lack of intellectual property rights associated with naturally-occurring compounds [19]. Nevertheless, research in this area must be prioritized, as HCP uncertainty in the safety and efficacy of MC appears to be the strongest factor preventing more widespread adoption in clinical practice. By extension, results of clinical research should inform educational material on dosages, routes of administration, and proper prescription, as lack of such information was identified in our survey as a significant barrier to cannabis prescribing across all respondents. Clinical guidelines and webinars were the most popular methods of learning. This is possibly rooted in a preference for up-to-date, real-world evidence and clear guidance, i.e., training that is directly applicable to clinical practice. It is plausible that webinars were the most popular learning medium since the data collection period occurred during the pandemic, and this may have influenced the preference of learning.

Our study had important limitations which must be taken into consideration. First, we encountered challenges obtaining a sufficiently large sample to compare groups statistically. Although we requested for associations and colleges to forward our invite to members, some organizations cited specific policies regarding the distribution of surveys. For example, they would only distribute a survey if a member of their organization was involved or if it involved a school of pharmacy. Other organizations requested fees for survey distribution or denied the request on the basis that they receive too many survey invitations. While this survey was distributed to organizations across Canada, only 70 individuals completed the survey. Furthermore, as most respondents were from Ontario, Quebec, and Manitoba, results may not be representative of HCPs in other provinces and territories. Similarly, it is not clear whether this sample is representative of HCPs within each province. Therefore, results should be interpreted with caution as they may not be representative of the experiences and opinions of HCPs across Canada nor within particular provinces or territories.

In addition, it is plausible that members of an organization may respond to survey questions in a certain way, biasing results. For this reason, we provide a list of the organizations approached and those which agreed to distribute the survey. We also did not formally examine whether there was a relationship between years of training and participants’ responses, although it is possible that years in practice could potentially affect results. It is unclear exactly when MC training officially began in Canada and there remains a lack of standardized MC training among Canadian professional schools. Despite 20 years since the legal recognition of patients’ right to access MC, studies have consistently noted gaps in cannabis knowledge among trainees and professionals in medicine [17, 18], nursing [29], and pharmacy [30]. In one notable attempt at increasing knowledge, the Canadian Consortium for the Investigation of Cannabinoids initiated a continuing education program consisting of 64 live events in 26 locations in 2009–2010 [31]. Thus, it is appropriate to consider historical aspects of MC training when interpreting results related to educational needs. Furthermore, it is possible that the response rate would have been higher had the survey not been conducted during the pandemic, due to increased demand for HCP working hours and subsequent burnout.

Finally, some elements of our survey design could have been optimized. For example, the ordering of some questions could have been modified to assist the flow of data collection.

In some questions, only the option of unidirectional change in use was provided (i.e., increase, no change), but it would have been better to provide the option for change in bilateral directions (i.e., increase, no change, or decrease). Future surveys of this nature may wish to focus on HCPs most likely to be asked questions related to MC, such as family physicians, to determine more specific barriers to particular groups of HCPs. Similarly, future surveys may wish to focus on HCPs already involved in recommending and prescribing MC, to better understand their specific continuing education needs. Another limitation is that we did not specifically ask respondents whether they had authorization to prescribe MC. In Canada, MC is authorized by a prescriber who provides a medical document allowing individuals to obtain from a licensed producer or apply to Health Canada to grow their own. Physicians who choose to prescribe cannabis for medical purposes must be authorized by their provincial regulatory body [32]. We did not specifically ask HCPs to indicate whether they were authorized to prescribe cannabis for medical purposes. Over half of our survey respondents already recommend and prescribe MC, and many respondents endorsed a high level of comfort with their knowledge related to it. Although we examined individuals’ comfort with their level of knowledge, we did not measure knowledge objectively. Kruger et al. recently developed an 18-item questionnaire designed to assess knowledge of MC in relation to the current scientific knowledge[33]. Overall cannabis knowledge was related to perceived knowledge, and perceived competence in identifying harmful and irresponsible use of cannabis medicinally, but not comfort integrating cannabis into patients’ treatment regimens [33]. Nevertheless, understanding subjective barriers to recommending and prescribing MC remains a priority in order to inform policies that improve access.