In this study, 89 of 143 participants (62.3%) reported moderate or high perceptions of cannabis usefulness, whereas only 60 of 143 (42.0%) correctly identified FDA-approved therapeutic indications. By contrast, risk awareness was stronger, with 104 of 143 (73.0%) identifying adverse effects and 132 of 143 (92.3%) identifying drug interactions. Preparedness to counsel patients was limited, as 55 of 143 (38.5%) reported low or very low confidence. Female pharmacists also reported lower confidence in the adequacy of their undergraduate training, suggesting a possible gender-related difference in perceived preparedness.

The imbalance between recognition of usefulness and stronger awareness of risks appears consistent with reports from other prohibition contexts. In Jordan, pharmacists expressed interest in the therapeutic potential of cannabis but also reported substantial knowledge gaps and limited confidence in counseling, with attitudes shaped by concerns over safety and misuse.^[17–19] Systematic reviews of health professionals similarly suggest that uncertainty regarding efficacy and safety often outweighs comfort with therapeutic use.^[20] These findings are broadly comparable to the present study, where most participants recognized risks but fewer than half identified therapeutic indications, pointing to a knowledge imbalance that may be reinforced by prohibition and the absence of curricular training.

In partial legalization contexts such as the United States, pharmacists seem to demonstrate greater recognition of therapeutic benefits but continue to report deficits in confidence and clarity regarding legal frameworks. Surveys have noted that while a large proportion acknowledged the usefulness of medical cannabis, many did not feel sufficiently knowledgeable to counsel patients.^[21] Confusion about legislation and reliance on informal learning sources were also reported, patterns that may echo the uncertainty observed in this study.^[22,23] This suggests that exposure to legalized cannabis can increase awareness of potential benefits but does not necessarily overcome barriers to patient counseling.

In legalized contexts such as Canada and Australia, pharmacists generally report higher recognition of therapeutic indications, yet significant gaps in counseling preparedness remain. In Canada, approximately two-thirds of pharmacists indicated the need for further education despite legalization.^[22] Qualitative research likewise suggested that pharmacists were more comfortable dispensing cannabis products but still perceived gaps in training related to safety and efficacy.^[23] In Australia, pharmacists identified inadequate understanding of legislative requirements and limited preparation for patient counseling.^[18] Taken together, these studies imply that legalization may enhance familiarity with therapeutic roles but does not, in itself, ensure clinical preparedness.

Confidence in patient counseling also appears limited among pharmacy students, with surveys in North America reporting inadequate curricular exposure and a strong demand for expanded training.^[24,25] Proposals for experiential and case-based learning may improve preparedness,^[24] while professional associations have noted that pharmacists remain underutilized in patient education due to weaknesses in training frameworks.^[26] These observations are consistent with the present findings, where risk recognition was high but preparedness to counsel patients was low.

The gender-related difference observed in this study should be interpreted cautiously. Although female pharmacists reported lower confidence in the adequacy of their training, pharmacy education in Saudi Arabia provides equivalent access across genders. Literature in health professions education suggests that male students often rate their competence more highly, whereas female students are more likely to underestimate their abilities.^[27,28] Self-assessment accuracy also may not improve with seniority.^[29] These patterns have been described as “confidence misalignment,” where perceptions of competence diverge from actual ability.^[30] While such explanations are plausible, further research would be needed to clarify whether the observed differences in this study reflect self-assessment bias, sociocultural influences, or unaddressed educational needs.

The educational implications of these findings are noteworthy. The limited recognition of approved indications and low counseling preparedness may indicate a need for structured reform in pharmacy curricula and professional development. Similar gaps have been documented in Saudi pharmacy education in relation to pharmacogenomics, pharmacoeconomics, and public health.^[13–15] Studies of targeted training programs in areas such as anemia and diabetes management suggest that structured education can improve pharmacist preparedness.^[31,32] Moreover, research during the COVID-19 pandemic showed that pharmacists in Saudi Arabia and Jordan were willing to assume frontline roles but reported inadequate training and low confidence in public health responsibilities.^[16,33,34] These parallels imply that the gaps observed in this study may not be unique to cannabinoid pharmacotherapy but instead reflect broader systemic challenges in pharmacy education and continuing professional development.

This study has limitations. It was restricted to hospital pharmacists in public-sector institutions within a single metropolitan region, which may limit the generalizability of findings to other practice settings. The cross-sectional design precludes causal inference, and reliance on self-reported knowledge and attitudes introduces the potential for reporting bias and may not fully reflect actual competence. Nonetheless, the study provides important baseline evidence on pharmacists’ preparedness for cannabinoid pharmacotherapy in Saudi Arabia.

Future research could include pharmacists from diverse practice settings and make use of longitudinal and qualitative approaches to evaluate educational interventions. Further exploration of gender-related differences in self-assessment may also be informative. Such work may contribute to curriculum development and professional training, supporting pharmacists’ preparedness for cannabinoid pharmacotherapy should regulatory changes occur. These findings may also be relevant to ongoing healthcare reforms in Saudi Arabia, where national authorities are considering frameworks for emerging therapies.