As the medical cannabis market grows in Poland, it becomes essential to understand physicians’ perspectives on this controversial topic. This study was the first performed among Polish physicians to investigate their beliefs about medical cannabis and views on the shape of policy in their country. Most participants (93.1%) confirmed a need to prepare medical guidelines about cannabinoids use. While most supported reimbursement of medicines containing cannabinoids (71.7%) for herbal cannabis, this percentage was lower (52%). We also found a legitimate need to provide educational interventions to train medical professionals in medical applications of cannabinoids and the physiological basis of their mode of action. Over 1/3 also declared that they have safety concerns regarding medical uses of cannabinoids (39.9%). It is worth noting that medicinal cannabis was also considered safer than one bought from illegal sources by the vast majority (97.7%); 71.1% claimed their knowledge level to be too low to provide advice to patients. Almost all physicians agreed (92.4%) that they would prefer to be more knowledgeable on this topic to fulfill patient’s expectations. The factors encouraging them to seek more information about medical cannabis and cannabinoids were mostly patient-centered (seeking new treatments for cases with no other acceptable therapeutic options, clarifying safety concerns). At the same time, most declared that personal motives are not a factor that could increase their willingness to learn more (only 22% agreed).

A lack of clear guidelines regarding medical applications of cannabinoids is one of the commonly listed barriers to cannabis use [12,16,22]; 93.1% of Polish physicians declared a need to formulate clear guidelines to inform physicians how to incorporate cannabinoids into their clinical practice. Similar findings come from studies conducted in other countries; 93% of prospective medical doctors from Serbia and 64% of physicians from Canada also claimed that such guidelines are essential [12,16]. Still, a survey covering European countries demonstrated that medical associations published position papers about medical cannabis and cannabinoids in only three of them [11]. Given that cannabis use and patient demand are increasing, the unresolved issue of formulating clinical management guidelines should be addressed urgently by relevant medical associations in Poland.

Over 71% of physicians declared that their knowledge level about cannabinoids is “not” or “rather not” sufficient for patient counseling. Our finding that MDs self-evaluated knowledge about cannabinoids is not sufficient is repeatedly found in studies from other countries [12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28]. In Norway, 71% of surveyed physicians declared that they would like to be more knowledgeable about this topic [22]. Similarly, 74% of Canadian physicians felt not sufficiently informed about medical cannabis [24]. In another study conducted among physicians from Minnesota, 50% felt prepared for answering patient questions, and 77% were interested in learning more, in comparison with 92% of participants of our study [23]. In another study with a mixed group of HCPs (including pharmacists and nurses) involved in oncology care, the percentage of professionals who self-evaluated their knowledge level to be too low was 84%, similar to our findings [28].

Studies conducted among healthcare practitioners (including prospective HCPs) show that, even when the proportion of participants with enough confidence to counsel patients is relatively low, the support for the use of cannabinoids remains high for patients with short life expectancy or no alternatives for treatment [12,13,18,22]. This group encompasses terminal cancer patients and patients with symptoms refractory to standard treatment, such as cancer and neuropathic pain. In most studies among physicians, pain and cancer-related symptoms are most commonly mentioned as indications for cannabis use [12,13]. In an Irish study, 63.5% of physicians claimed that cannabinoids might be prescribed for pain management, and 68%-in terminal patients [18]. Additionally, 88% of physicians from Norway chose adverse effects of cancer treatment as an indication [22]. Similar findings described Gardiner et al. in their systematic review among oncologists and general practitioners [13].

Solid background education increases the confidence in using cannabinoids in clinical practice. Studies were also conducted among physicians in Europe, includng those with either specialist training or those who received training in the treatment of addictions were more inclined towards using medical cannabis [12,18,22]. Furthermore, 70% of physicians from Canada indicated that they would be more comfortable if they had received any formal education [13]. Another systematic literature review of studies conducted among representatives of medical professions has demonstrated a lack of knowledge as a barrier for authorizing treatment with cannabis [13]. Results from these studies underline the importance of educational interventions that would explain basic scientific concepts and give practical instructions on how to use medical cannabis.

The lack of professional training declared by Polish physicians is concerning. Previous studies have found that the source of information consulted for healthcare professionals’ clinical practice is also questionable. Previous studies have shown that their primary source of knowledge was seldom medical courses or medical faculty, but rather media and the internet [12,13]. In a Norwegian study, news and television were the most frequently mentioned sources of knowledge, indicated by 39% of physicians, whereas medical literature was picked by roughly a quarter [22]. Likewise, a survey among Canadian hospital pharmacists demonstrated that most (66%) did not receive any formal education about cannabinoids. They also admitted that the sole educational resource available is an online self-study course [13]. News or websites dedicated to medical cannabis often raise unrealistic expectations about its properties and propagate information only partly based on medical literature. Furthermore, in reliable, evidence-based websites for Polish physicians, medical use of cannabinoids topic is somewhat absent. Access to professional training is also problematic for young adepts of medical sciences. Currently, medical curricula at Polish universities do not include the endocannabinoid system and pharmacology of cannabinoids. This problem could be solved by incorporating the pharmacological aspects (including the ECS physiological and pathophysiological aspects) and clinical use as a part of pain treatment courses, free conferences run by regional medical chambers, and other independent sources of training for certified HCPs, and also by introducing these topics to curricula at Polish medical universities.

Our results show that there is a need for such educational interventions for Polish medical doctors. As indicated in previous studies, professional training encourages the use of cannabinoids. It is essential for patients for whom it is impossible to offer alternative treatments or available methods that were not well-tolerated. Proper training also helps medical professionals identify and advise against their use in patients for whom cannabinoids might be harmful. However, it is worth noting that a self-assessed level of knowledge, often used in such studies, should not be perceived as equal to a measure of competence. Previous research in various domains has shown that doctors tend to underestimate their actual level of knowledge or overestimate it, regardless of training and specialty and the domain of self-assessment [32]. Similar findings were the outcome of studies among other professions [33]. Therefore, self-evaluation is instead a measure of confidence than a factual knowledge level. A study by Zolotov et al. revealed that doctors who were more likely to recommend medical cannabis had less confidence in their knowledge about medical cannabis [15]. We agree with the authors that this could mean that individuals with higher awareness are more knowledgeable of the uncertainties regarding the medical uses of cannabinoids. In summary, these aspects should be considered when interpreting the results of our study.

In one of the previously conducted studies among medical students in Russia, religiousness significantly correlated with a more restrained approach to using cannabinoids in medicine; 57% of secular students declared they would recommend cannabis to a patient, in comparison with 27% of religious students (p < 0.001), and more often claimed it has positive effects on physical and mental health (54.3% vs. 28.2%; p < 0.01) [12]. Poland is considered a conservative country, with almost 89% of citizens declaring themselves as catholic, according to the Chief Statistical Office [34]. Interestingly, most physicians participating in the survey opted for solutions giving the most freedom when deciding how to approach a potential medical cannabis patient. Any restriction in prescribing, such as the requirement of having a specialist title, approval of regulatory body for medical cannabis treatment, or a formal requirement of obtaining a second opinion of a psychiatrist, was considered redundant. However, it is worth noting that they might have been taking into account other factors, such as long waiting times for additional consults, the cost for the patient, others which would cause a delay in initiating treatment. and, as a result, the alleviation of the patient’s ailments.

Nonetheless, in other European countries, such as the United Kingdom and Ireland, having a specialist title is one of the mandatory requirements for the prescription of cannabis [11,35]. The European Pain Federation (EFIC) report indicates that this state of affairs opposes trends found in other European countries. For the most part, medical cannabis is available to well-defined patient populations, and how it is dispensed is tightly controlled [11]. In several other countries, according to a report published by the European Pain Federation, access to medicinal cannabis is limited in other ways. For example, it is only available through compassionate use programs (in Sweden, Norway), or, although technically legal, the supply of cannabis for medicinal purposes is not available (in Slovenia) [11]. Poland, in contrast, presents a liberal approach to medical cannabis in the current legal framework, where there is no approved dosing indications list. The MoH requires no additional training or certificates for prescribing herbal cannabis. Therefore, the clinical decision to initiate treatment in each case and dosing or duration of treatment rely solely on the prescribing physician [36].

Contrary to prescribing controlled substances, such as cannabinoids in Poland, the restrictions are tighter in other medical fields. At times, the reasoning behind those regulations is difficult to understand. Before the COVID-19 pandemic, according to the act on preventing and combating infections and infectious diseases in Poland, performing qualification for vaccination and the procedure itself was only possible for healthcare professionals who had attended an additional certified vaccination course or received this training during the specialization [37]. Although vaccine hesitancy is primarily based on the uncertainties regarding the safety profile of vaccines, the risk-benefit profile of vaccination in both the short- and long-term favors its use indisputably [38,39]. Vaccination is a very safe procedure, and no long-term side effects that would be unquestionably related to vaccination were identified [39]. Paradoxically, with current regulations, it is much easier for patients to buy opioids and cannabinoids, who now require only one visit to the doctor’s office and pharmacy before getting vaccinated. To receive a vaccine, at least two visits to the doctor’s office are necessary (one to get a prescription and then the other to get qualified for vaccination), and 1–2 visits at the pharmacy, depending on the availability of the vaccine.

Prescribing controlled substances is associated with the risk of developing dependence and abuse [40]. Additionally, in the case of opioids, abuse might result in fatal overdose in the sole 2019 in the USA, whereby more than 14,000 cases of deaths related to consumption of prescription opioids were recorded [40,41]. Even though the risk associated with medical uses of cannabinoids is incomparable to opioids, improper use can lead to addiction, traffic accidents, and risks to children who accidentally consume it [42,43,44]. Therefore, an optimal solution would embrace much tighter regulation of medical cannabis prescribing. In 2020, electronic prescriptions were introduced and made mandatory in Poland and replaced the paper form. This system allows physicians and patients to track prescriptions made in the past easily. It also requires the physician to confirm his identity before issuing any prescription via an official certificate or bank account [45]. Such a system could also enable rapid assessment of the situation and catch worrying phenomena related to prescription narcotic substances early on. In New York, mandatory electronic prescribing of controlled substances (including opioids) has reduced the number of prescriptions by 53% [46]. In Poland, to date, the consumption of medications using controlled substances is low (<2000 DDD for opioids), but there are some increasing trends observed for some of these substances, such as tramadol, which needs further monitoring [29]. Therefore, some control over prescriptions involving controlled substances should be warranted, which might be implemented as part of the electronic prescriptions system.

This study has some limitations. The most important is the small study size which does not enable a subgroup analysis to confront opinions of medical professionals of different backgrounds and identify associations of different demographic factors with participant’s decisions. A significant limitation is that we have only targeted physicians and not representatives of other medical professions such as nurses and pharmacists, who are also directly involved in patient care. Because it was an open survey, people with more interest in medical cannabis were more likely to participate, and, as a result, we might not have recruited a representative sample. The proportion of MDs with experience with recreational cannabis (39.9%) was higher than according to a survey conducted among the general Polish population aged 15–64 years (7.7% for females and 16.4% for males) [47]. It could have influenced the acceptance of cannabinoids as medicines and support for their legalization. However, considering that the participation was voluntary and anonymous, and that no tracking data were collected, the answers were more sincere than in the study conducted by National Bureau for Drug Prevention.