Paper: ‘The wild west of medicine’: A qualitative investigation of the factors influencing Australian health-care practitioners’ delivery of medicinal cannabis

1 INTRODUCTION

Medicinal cannabis has garnered significant community interest as an emerging therapeutic modality in recent decades [1]. This interest has been attributed to the influence of patient advocacy groups, extensive media coverage about the benefits and safety of medicinal cannabis, and a burgeoning body of research examining treatment efficacy [2, 3]. However, the evidence base for medicinal cannabis remains controversial [4]. While emerging evidence suggests therapeutic effects for a range of conditions, findings are heterogeneous across studies [5]. Rigorous evaluation (e.g., randomised controlled trials) and comprehensive pharmacovigilance approaches are needed to better characterise efficacy and long-term safety [2, 6]. Nevertheless, real-world data sourced from patient registries, electronic medical records and social media suggests that patients prescribed medicinal cannabis report improvements in symptomatology across various indications, including pain, psychiatric and neurological conditions [7].

Strong patient demand for legal access to medicinal cannabis has sparked global legislative changes, allowing therapeutic use to circumvent the research and regulatory processes that are typically necessary before widespread integration into clinical practice [2, 8]. In 2016, the Australian Government legalised the prescription of medicinal cannabis. The majority of medicinal cannabis products are unapproved, necessitating that practitioners obtain approval to prescribe from the Therapeutic Goods Administration (TGA) via the Special Access Scheme or Authorised Prescriber Scheme [9]. Further details on these schemes have been described elsewhere [10]. Consistent with many jurisdictions worldwide, practitioners may be perceived as ‘gatekeepers’ to medicinal cannabis in Australia [11]. As such, understanding the factors influencing prescribing decisions is instrumental to ensuring patient access is safe, effective and appropriate [12].

Previous international and Australian research has explored practitioners’ knowledge, beliefs and concerns regarding medicinal cannabis [12–20]. Findings have consistently identified that while practitioners receive frequent patient enquiries, the majority are uncomfortable or unwilling to prescribe medicinal cannabis. Barriers to prescribing include poor knowledge of clinical and pharmacological features, insufficient evidence to support use, and concerns that medicinal cannabis may lead to adverse effects and patient harm [13, 20]. Moreover, practitioners commonly report that prescribing medicinal cannabis is highly burdensome in Australia and that products are prohibitively expensive for many patients [12, 14, 16, 17]. These pervasive barriers may have contributed to very low rates of medicinal cannabis prescription approvals in the first 3 years (2016–2018) following its legalisation in Australia [21], with a 2020 Senate Inquiry concluding that practitioner unwillingness to prescribe was a significant barrier to patient access [22]. Similar mismatches between patient demand and practitioner willingness to prescribe have been observed in other jurisdictions internationally [23].

Despite the observed hesitancy among practitioners, there has been an unprecedented surge in applications to prescribe in Australia since 2020 [21]. As of January 2024, there have been over 450,000 approved Special Access Scheme Category B applications [24]. Furthermore, there has been considerable practitioner interest in the Authorised Prescriber Scheme, with over 39,000 aggregate Authorised Prescriber approvals between 2016 and 2023 [25].

Given the rapidly changing landscape of this novel area of medicine, and to better understand what factors are driving the surge in Special Access Scheme and Authorised Prescriber applications since 2020, updated research is needed on the perspectives of experienced medicinal cannabis prescribers. Commentators have also called for a more comprehensive evaluation of the factors shaping medicinal cannabis prescribing behaviour, drawing on empirically established determinants of behaviour [13, 20].

Behaviour science theories offer insights into the multitude of individual, social and organisational factors influencing health-care providers’ behaviour [26]. Only a few of these determinants have been examined in the context of medicinal cannabis prescribing, with most studies focusing primarily on the role of knowledge [20]. This is a significant gap in the literature, as there are complex socio-environmental factors surrounding medicinal cannabis prescribing, including lack of endorsement from professional colleges, passionate consumer beliefs about the effectiveness of medicinal cannabis for treating illness, and social stigma associated with the recreational use of cannabis [3, 27]. To address this gap, the present study used the Theoretical Domains Framework (TDF) (Table 1) to explore the cognitive, affective, social and environmental influences on medicinal cannabis prescribing behaviours [28]. The TDF is a validated framework designed to systematically examine barriers and facilitators to behaviour change among health-care professionals, synthesising 33 theories into 14 domains [29].

Patient demand for medicinal cannabis is growing in Australia, with significant investments in the medicinal cannabis market expected to drive further increases in the coming decade [30, 31]. With recent rapid increases in applications to prescribe, the Australian context provides a unique backdrop to examine current factors influencing practitioners’ prescribing behaviours in this novel and contested area of medicine, in which patient demand has outpaced scientific evidence. This study used in-depth, semi-structured interviews with Australian practitioners, informed by the TDF, to examine practitioners’ perspectives on prescribing medicinal cannabis. In doing this, we provide a comprehensive exploration of the potential factors influencing the uptake of medicinal cannabis in clinical practice.

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