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BMJ Open
Knowledge and attitudes of Australian general practitioners

towards medicinal cannabis: a cross-sectional survey
Journal: BMJ Open
Manuscript ID bmjopen-2018-022101
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Article Type: Research
Date Submitted by the Author: 01-Feb-2018

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Complete List of Authors: Karanges, Emily; The University of Sydney, The Lambert Initiative for
Cannabinoid Therapeutics
Suraev, Anastasia; The University of Sydney, The Lambert Initiative for
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Elias, Natalie; The University of Sydney, The Lambert Initiative for

Manocha, Ramesh; Healthed
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McGregor, Iain; The University of Sydney, The Lambert Initiative for

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MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, PRIMARY

Keywords:
CARE
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For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 1 of 30 BMJ Open
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3 Knowledge and attitudes of Australian general practitioners towards medicinal cannabis: a
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6 cross-sectional survey
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9 Iain McGregor
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11 The Lambert Initiative for Cannabinoid Therapeutics
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13 The University of Sydney
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15 Level 6, Building M02F, Brain and Mind Centre,
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17 94 Mallett St, Camperdown, NSW, 2050
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19 iain.mcgregor@sydney.edu.au
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23 Emily A Karanges1
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25 Anastasia S Suraev1
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27 Natalie Elias1
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29 Ramesh Manocha2
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31 Iain S McGregor1
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The Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney,
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37 Australia
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39 Healthed, Sydney, Australia
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44 Word count: 2,675
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60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open Page 2 of 30
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3 Abstract
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5 Objectives: To examine the knowledge and attitudes of Australian general practitioners (GPs)
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8 towards medicinal cannabis, including patient demand, GP perceptions of therapeutic effects
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10 and potential harms, perceived knowledge and willingness to prescribe.
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13 Design, setting and participants: A cross-sectional survey completed by 640 GPs (response rate
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15 = 37%) attending educational seminars in five major Australian cities between August and
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November 2017.
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20 Main outcome measures: Number of patients enquiring about medicinal cannabis, perceived
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knowledge of GPs, conditions where GPs perceived it to be beneficial, willingness to prescribe,
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25 preferred models of access, perceived adverse effects, and safety relative to other prescription
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27 drugs.
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30 Results: The majority of GPs (61.5%) reported one or more patient enquiry about medicinal
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32 cannabis in the last 3 months. Most felt that their own knowledge was inadequate and only
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35 28.8% felt comfortable discussing medicinal cannabis with patients. Over half (56.5%)
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37 supported availability on prescription, with the preferred access model involving trained GPs
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prescribing independently of specialists. Support for use of medicinal cannabis was condition-
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42 specific, with strong support for use in cancer pain, palliative care and epilepsy, and much lower
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support for use in depression and anxiety.
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47 Conclusions: The majority of GPs are supportive or neutral with regards to medicinal cannabis
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49 use. Our results highlight the need for improved training of GPs around medicinal cannabis, and
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52 the discrepancy between GP-preferred models of access and the current specialist-led models.
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3 Article Summary
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6 Strengths and limitations of this study
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9 • This is the first study to have examined the attitudes and knowledge of Australian
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general practitioners (GPs) about medicinal cannabis.
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14 • It shows that most GPs report inadequate knowledge of available medicinal cannabis
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16 products and patient access routes, confirming the need for better training and support
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19 for GPs in this area.
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21 • Limitations include a self-selected sample who attend GP training events and are
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24 motivated to complete a survey on the topic.

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3 INTRODUCTION
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There is strong and increasing public support for the use of medicinal cannabis in Australia.[1]
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9 This support has been a driver of a number of legislative and policy changes enacted over the
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11 last two years. These changes have allowed approved companies to cultivate cannabis plants
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14 and manufacture cannabis products, and have facilitated legal access to medicinal cannabis for
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16 approved patients.[2]
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19 Despite this, patient access remains complex and highly restricted. Doctors wishing to
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22 prescribe medicinal cannabis products must either apply to become authorised prescribers for
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24 a class of patients, or apply for access for individual patients under the “Special Access Scheme
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Category B (SAS-B)”[3] via the Therapeutic Goods Administration (TGA), a regulatory body for
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29 therapeutic goods in Australia. Parallel approvals are also required from the relevant State or
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Territory Department of Health. Even with these approvals in place, patients often find
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34 available products prohibitively expensive.
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37 Consequently, few doctors and patients are accessing medicinal cannabis in Australia.
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Currently, there are only about 30 authorised prescribers, servicing around 100 patients, and a
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42 further 150 patients granted SAS-B approval (TGA, personal communication, November 2017).
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This contrasts with the more mature access schemes of countries such as Canada, where
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47 approximately 200,000 patients are serviced.[4]
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50 Under current schemes, Australian GPs are typically only permitted to prescribe medicinal
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cannabis if supported by a specialist.[3] Nonetheless, GPs are generally the first point of contact
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55 for patients enquiring about, or seeking access to, medicinal cannabis. Australian medical
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3 bodies have warned that patient demand for medicinal cannabis is set to increase.[5] With
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6 ongoing media coverage fuelling unrealistic patient expectations regarding therapeutic efficacy
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8 and cannabis access,[6] GPs may be forced into the role of gatekeepers despite having limited
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11 knowledge and training in the field.
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14 The attitudes of Australian GPs towards medicinal cannabis are unknown. Statements from
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16 peak medical bodies such as the Royal Australian College of General Practitioners (RACGP),
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19 Australian Medical Association (AMA) and the Australian, and New Zealand College of
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21 Anaesthetists’ (ANZCA) Faculty of Pain Management generally advise caution on the basis of
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limited evidence for efficacy and safety.[5,7-9] Surveys from other countries suggest that
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26 clinicians are generally more reticent toward medicinal cannabis than the general public,
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particularly in the US,[10,11] with concerns centred on limited evidence for efficacy and
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31 adverse effects, including abuse and dependence.[10-12] Nevertheless, recent analyses suggest
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36 for specific conditions.[13]
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39 This article describes the results of a survey of Australian GPs on medicinal cannabis,
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including their clinical experiences, perceived knowledge, and beliefs about its regulation,
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44 safety, indications for use, and the preferred role of GPs in its prescription.
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47 METHODS
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50 Printed surveys were distributed at one-day general practice educational seminars held in
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five major Australian cities (Sydney, Melbourne, Brisbane, Adelaide, and Perth) between August
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55 and November 2017. All GPs and GP registrars were eligible to participate (n = 1728). Seminars
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1
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3 covered a range of topics relevant to general practice with around 18 different topics covered
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6 on the day in consecutive 20 - 30 minute presentations. One of the authors (ISM) spoke on the
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8 topic of medicinal cannabis at each event, but surveys were completed and collected prior to
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11 this presentation.
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14 Participants first completed a series of closed questions on demographics, vocational
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16 experience (years in practice, registrar status, hours per week), and practice characteristics
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19 (size, state/territory, geographical classification). The survey proper consisted of 46 items on
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21 topics related to medicinal cannabis including clinical experience (4 items); perceived

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knowledge (5 items); concerns and awareness about safety and efficacy (18 items); appropriate
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26 indications for use (14 items); and views on the role of GPs, and specialists in its prescribing (5
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items).
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Participants rated the extent to which they agreed with 44 statements on a 5-point Likert
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34 scale (1 = strongly disagree; 5 = strongly agree). There were also two multiple-choice questions
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concerning patient demand and prescribing preferences (role of GPs/specialists). The latter was
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39 introduced after the first seminar (included in 73% of completed surveys). A space for open-
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ended comments was provided at the end of the survey. The study was approved by The
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44 University of Sydney Human Research Ethics Committee (2017/692) and questions were
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46 reviewed by an advisory group of GPs (copy of full survey available in the online supplementary
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49 material).
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52 Results were summarised using descriptive statistics (frequency, percentage of valid
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54 responses). As responses were largely complete, missing data were excluded from analyses.
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3 Likert scale responses were generally collapsed into three categories: Agree, Neutral, and
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6 Disagree. Open-ended comments were reviewed for common themes. A composite score for
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8 Perceived Knowledge was created by summing scores from five knowledge-related questions.
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11 Age, sex, and perceived knowledge were tested as potential predictors of views on medicinal
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13 cannabis availability using separate ordinal logistic regression analyses. Chi-square tests were
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16 used to investigate differences in responses after stratifying on specific items. Analyses were
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18 conducted using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, N.Y., USA),
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and graphs were created using GraphPad Prism version 7.02 for Windows (GraphPad Software,
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23 La Jolla, California, USA).
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26 RESULTS
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29 Demographic data
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32 Demographic and practice details of the 640 participants are shown in Table 1. The majority
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of participants were female (67.3%), aged between 35 and 64 years (77.5%), and residing in
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37 Victoria (30.3%) and New South Wales (27.5%). Over half of respondents had been practicing
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39 for >15 years (56.7%), worked >30 hours/week (63.4%), and serviced metropolitan areas
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42 (60.3%). Only 8.2% were in single-GP practices and 7.9% were registrars.
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3 Table 1. Demographic and practice characteristics of GPs in this study, and all GPs in Australia.
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5 GP survey (n = 640) Australia p (X2 test)
6 (n = 34606)[25]
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n Valid % %
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9 Age (n = 640) <0.001
10 <35 57 8.9 13.4
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35-44 134 20.9 24.9
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13 45-54 177 27.7 24.9
14 55-64 185 28.9 23.1
15 65+ 87 13.6 13.7
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18 Sex (n = 636) <0.001
19 Female 428 67.3 44.7
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22 GP registrar (n = 611) 0.08
23 Yes 48 7.9 10.0
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26 State/territory (n = 627) 0.001
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27 New South Wales 175 27.9 30.6

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29 Victoria 193 30.8 24.1
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30 Queensland 129 20.6 21.7

31 South Australia 81 12.9 7.8
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Western Australia 39 6.2 10.2
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35 Geographical area (n = 611)
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Metropolitan 381 62.4 68.2 0.01
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39 Remote 24 3.9 3.9
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42 Years as GP (n = 637)
43 <2 38 6.0
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2-5 90 14.1
46 6-15 148 23.2
47 16-25 136 21.4
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26+ 225 35.3
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3 Experience, practice and general attitudes
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6 A majority of GPs (61.5%) had experienced at least one patient enquiry regarding medicinal
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9 cannabis in the prior three months, with 7.5% reporting more than five enquiries. When
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11 considering GPs working >30 hours/week, the proportion with at least one enquiry increased to
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14 69.0% and 11.8% received more than five enquiries (Table 2).
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20 Table 2. Reported number of patient enquiries about medicinal cannabis in the prior three months,
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21 for all respondents and those working over 30 hours per week, on average.
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23 Number of patients All respondents (n = 615) Respondents >30 h/week (n = 391)
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N % N %
26 0 237 38.5 116 31.0
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28 1 159 25.9 90 24.1
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2-5 173 28.1 124 33.2

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31 6-10 33 5.4 32 8.6
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33 >10 13 2.1 12 3.2

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More than half of GPs agreed with the statement that medicinal cannabis should currently
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40 be available on prescription for certain indications (strongly agree: 19.6%, n = 125/637; slightly
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agree: 36.9%), while 14.9% disagreed (Figure 1). GPs were more likely to agree if they were
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45 older (χ2 (4) = 25.63, p < 0.001) and had greater perceived knowledge (χ2(2) = 5.54, p = 0.02),
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47 but there was no difference between sexes (χ2 (1) = 2.55, p = 0.11).
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More GPs agreed that they had patients who would benefit from medicinal cannabis
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53 (44.0%, n = 280/636) than disagreed (21.4%), with 34.6% expressing a neutral opinion (Figure
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55 1). Conversely, fewer respondents agreed that they would like to be able to prescribe medicinal
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3 cannabis (28.9%, n = 183/633) than disagreed (33.8%), again with a high number of neutral
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6 responses. Approximately half of respondents (n = 51.9%; n = 328/632) did not feel comfortable
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8 discussing medicinal cannabis with their patients.
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11 Perceived knowledge
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GPs generally rated their knowledge of medicinal cannabis as poor (Figure 2). On all five
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19 the topic in question. Notably, 65.4% (n = 417/638) ‘strongly disagreed’ that they knew how to
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22 access medicinal cannabis for patients, and more than half ‘strongly disagreed’ that they knew
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24 about available products (55.5%, n = 354/638) or the current regulatory approach (57.8%, n =
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370/630).
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30 Views on medicinal cannabis access models

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33 Respondents were more likely to endorse an access model permitting prescribing by

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40 283/634). When asked to choose one preferred model, 41.2% (n = 164/398; excludes Sydney
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43 participants) indicated trained GPs as their preferred prescriber, followed by shared care
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45 (29.6%). Specialist-only prescribing was preferred by 14.6% of respondents, while only 12.1%
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preferred that all GPs have the right to prescribe.
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3 Indications for use and evidence for efficacy
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Almost half of respondents (48.0%, n = 305/635) were neutral as to whether there was
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9 sufficient scientific evidence for the efficacy of medicinal cannabis, with 22.8% supporting the
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11 statement. Those who agreed that medicinal cannabis should be available on prescription had
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14 higher endorsement of the statement than those who disagreed (40.2% versus 11.7%). The
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16 most highly endorsed indications for use were chronic cancer pain (80.2% agree, n = 506/631),
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19 palliative care (78.8%, n = 494/627), and intractable epilepsy (70.3%, n = 441/627; Figure 3).
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21 Use in chronic non-cancer pain and neuropathic pain was endorsed by 39.1% (n = 246/629), and
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38.3% (n = 241/630) of respondents respectively, with a high degree of neutrality. Less than
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26 15% of GPs supported use in anxiety, insomnia or depression.
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29 Perceived features and adverse effects of medicinal cannabis
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32 Approximately two-thirds of respondents disagreed with the statement that medicinal
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35 cannabis was no different to street cannabis (43.9% strongly disagree; n = 271/640; 20.5%
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40 The side effects of medicinal cannabis endorsed by more than half of respondents were
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43 driving impairment (64.9% agree, n = 408/629), adverse effects on the developing brain (58.4%,
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45 n = 366/627), cognitive impairment (56.5%, n = 356/630), and addiction and dependence
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(56.3%, n = 353/627); psychosis was endorsed by 49.9% (n = 313/627).
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51 Overall, 27.7% of respondents (n = 177/637) agreed that they would not prescribe
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other side effects. These proportions were higher among GPs who disagreed with the
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3 availability of medicinal cannabis on prescription (58.1% and 44.2% respectively) and among
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6 those who disagreed that they would like to prescribe medicinal cannabis (47.6% and 34.6%
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11 A high proportion of GPs were neutral with respect to whether medicinal cannabis was
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14 more hazardous than other prescription medicines (range: 43.7% to 51.3%; Figure 4). Of the
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16 remaining responses, a majority believed that medicinal cannabis was safer than chemotherapy
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19 drugs (78.1%, n = 278/356), opioid analgesics (75.6%, n = 248/328), benzodiazepines (74.5%, n
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21 = 248/333) and antipsychotics (68.3%, n = 209/306), and over 50% for antidepressants and
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statins.
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Open-ended responses
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32 about medicinal cannabis and/or the desire for training. Other common themes included the
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made with opioids/benzodiazepines (n = 6) and other side effects (n = 4).
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43 DISCUSSION
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46 To our knowledge, this is the first study of the experiences, attitudes and knowledge of
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48 Australian GPs regarding medicinal cannabis. The survey demonstrates that many GPs have
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51 fielded recent enquiries about medicinal cannabis from their patients, yet half were not
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53 comfortable dealing these enquiries and most felt poorly informed about medicinal cannabis
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and its current regulation and uses. This perceived lack of knowledge was strongly conveyed in
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6 responses to questions regarding therapeutic and adverse effects.
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9 In agreement with international clinician surveys,[10,11] Australian GPs were somewhat
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11 conservative in their attitudes about medicinal cannabis: only about half agreed that medicinal
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14 cannabis should be available on prescription compared to approximately 85% of the general
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16 Australian population.[1] GPs were generally more supportive of use of medicinal cannabis in
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19 conditions with a stronger evidence-base (such as spasticity in multiple sclerosis,
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21 chemotherapy-induced nausea/vomiting) and/or where few effective alternatives exist

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(palliative care, cancer pain, intractable epilepsy).[14] This also aligns with the indications for
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26 use suggested by various state governments.[15,16] By contrast, less than 40% of GPs
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supported use of medicinal cannabis in chronic non-cancer pain. This may reflect the mixed
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31 findings regarding efficacy for this indication,[14,17] concerns about inappropriate use,
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36 endorsement by Australian government and medical organisations.[9,15] Similarly, concerns
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41 underlie the very low support for use in depression, anxiety and insomnia.[14,15] It is
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43 somewhat troubling that these latter indications were among the most common reasons for
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illegal use of cannabis for medicinal purposes in a survey of more than 1700 current users in the
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48 Australian community (Lintzeris et al, under review).
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51 Although GPs exhibited responses that suggested at least some familiarity with the
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scientific and clinical literature, perceived knowledge about the effects, products and process of
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56 accessing medicinal cannabis was generally very low. Less than 10% of GPs in our survey
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3 reported understanding the current regulations concerning medicinal cannabis or how it can be
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6 accessed for patients. It is well known that poor knowledge and low levels of comfort discussing
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8 issues with patients are barriers to optimal patient care.[11,19] Provision of continuing medical
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11 education and guidelines on the regulatory, pharmacological and clinical aspects of medicinal
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13 cannabis are vital for equipping GPs to manage patients effectively.
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16 One surprising aspect of this survey was how GPs rated medicinal cannabis relative to other
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19 common classes of prescription medicines. Of those expressing a non-neutral opinion
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21 (approximately 50%), about three-quarters rated medicinal cannabis as less harmful than
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opioids and benzodiazepines, and notably, just over half rated it less harmful than
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26 antidepressants and statins. This perception of the relative safety of medicinal cannabis
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compared to opioids and benzodiazepines may reflect its negligible rate of mortality and
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31 relatively mild dependence and withdrawal syndrome.[20] Nonetheless, cannabis can clearly
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33 produce dependence; recent estimates suggest that there are over 45,000 treatment episodes
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36 each year for Australians seeking control over their cannabis use.[21] Concerns about abuse,
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38 misuse and dependence was an identified theme of the open-ended comments in our survey.
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41 Moreover, almost half of the GPs who did not want to be able to prescribe cannabis cited the
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43 risk of abuse and dependence as a primary concern.
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46 Although there was a high degree of neutrality with respect to the desire of GPs to
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49 prescribe medicinal cannabis, the vast majority supported a model of prescribing in which GPs
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specialist input received the strongest support, followed by GP prescribing in a ‘shared care’
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56 arrangement with a specialist. This contrasts with the current model in Australia, where
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6 possible.[3] Although specialist-only prescribing may provide greater restrictions on use, the
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11 patient care, more frequent monitoring, better detection of adverse effects, and more timely
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13 treatment.[22] It is notable that GPs are empowered to prescribe, or permit access to,
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16 medicinal cannabis products in countries such as Canada and the United States.[11,19,23]
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19 The strength of the study is the unique nature of the survey and the relatively large
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21 sample size enabled by accessing the GPs attending popular educational events. While our
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response rate of 37% appears relatively low, it exceeds typical published response rates of GP
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26 surveys[24]. Limitations relate to accessing a subpopulation of GPs that are motivated to attend
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such events and to fill out a survey on medicinal cannabis. Another limitation of the study is
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31 that the findings cannot be generalised to other countries such as the United States and
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33 Canada, among others, where access to medicinal cannabis is not as strictly regulated. There
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36 was also a disproportionate representation of female GPs in our study, which may be due to a
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In conclusion, our results demonstrate guarded support for medicinal cannabis

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44 availability among Australian GPs, but very low levels of perceived knowledge. Clearly, there is
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46 an urgent need for improved training of GPs around medicinal cannabis, and, in the future, a
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49 reconsideration of the role of GPs in its prescription.
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3 Acknowledgements
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The authors gratefully acknowledge the contribution of ‘HealthEd’ seminar organisers, who
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9 assisted with recruitment, printed and administered the questionnaires.
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14 Funding statement
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17 This work was supported by The Lambert Initiative for Cannabinoid Therapeutics, The
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19 University of Sydney, and an Australian National Health and Medical Research Council (NHMRC)
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22 Principal Research Fellowship held by ISM.
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28 Competing Interests
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31 This study was supported by the Lambert Initiative for Cannabinoid Therapeutics, a
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philanthropically-funded centre for medicinal cannabis research at the University of Sydney.
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36 Iain McGregor is Academic Director of the Lambert Initiative and an NHMRC Principal Research
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Fellow and receives research funding from the ARC and NHMRC. He is involved in an NHMRC-
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41 funded clinical trial using the cannabis extract, Sativex. This survey was conducted at seminars
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43 run by HealthEd. Ramesh Manocha is the CEO of Healthed, and Iain McGregor received speaker
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46 fees from Healthed for lectures on conducted at these events. All other authors have no
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48 competing interests to declare.
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58 16
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3 Author contributions
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R.M., I.S.M., E.A.K., A.S., and N.E. conceived the study; I.S.M. collected the data; E.A.K. and
7
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9 I.S.M. conducted the data analysis and wrote the manuscript; All authors reviewed the
10
11 manuscript.
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18 Ethics approval
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20 Ethical approval for the survey was granted by The University of Sydney Human Research Ethics
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Committee.
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27 Data sharing statement

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No additional data are available.
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36 REFERENCES
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11 18. Australian and New Zealand College of Anaesthetists. 'Medicinal' cannabis: Where's the
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23 20. Nutt D, King LA, Saulsbury W, et al. Development of a rational scale to assess the harm
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35 findings/data (accessed Nov 2017).
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45 23. Ziemianski D, Capler R, Tekanoff R, et al. Cannabis in medicine: a national educational
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47 needs assessment among Canadian physicians. BMC Med Educ 2015;15:52.
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50 24. Bonevski B, Magin P, Horton G, et al. Response rates in GP surveys - trialling two
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52 recruitment strategies. Aust Fam Physician 2011;40(6):427-430.
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58 20
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3 25. Department of Health. GP Workforce Statistics – 2001-02 to 2016-17. Canberra:
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6 Commonwealth of Australia; 2017.
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8 http://www.health.gov.au/internet/main/publishing.nsf/content/General+Practice+Statistics-1
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14 26. Cull W, O’Conner K, Sharp S, et al. Respond rates and response bias for 50 survey for
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16 pediatricians. Health Services Research 2005; 40(1):213-226
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21 Figure legends
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23
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24 Figure 1. Attitudes and clinical experiences of general practitioners with respect to medicinal
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26
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27 cannabis, n = 632 – 637.

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30 Figure 2. Ratings of general practitioners on knowledge-related items, n = 636 – 640.

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32 RACGP=Royal Australian College of General Practitioners.
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Figure 3. Support for use of medicinal cannabis in different conditions, n = 627 – 632.
36
37
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38 CINV=Chemo-induced nausea and vomiting; MS=Multiple sclerosis; PTSD=Post-traumatic stress

39
40 disorder.
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Figure 4. Ratings of relative hazards of medicinal cannabis compared to other prescription
44
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46 medicines, n = 627 – 632.
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58 21
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Figure 3. Support for use of medicinal cannabis in different conditions, n = 627 - 632. CINV=Chemo-induced
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38 nausea and vomiting; MS=Multiple sclerosis; PTSD=Post-traumatic stress disorder.

39
40 145x137mm (300 x 300 DPI)
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0 20 40 60 80 100
% RESPONSES
1 MEDICINAL CANNABIS SURVEY FOR GPs

2
3
4
GP NURSE MIDWIFE PHYSIO PHARMACIST O&G OTHER
5 Profession
6
<35 35-44 45-54 55-64 65+
7 Age category
8
M F OTHER
9 Sex
10
<2 2-5 6-15 16-25 26+
11 Years in general practice
12
Y N
13 GP registrar?
14
<10 11-20 21-30 31-40 >40
15 Average hours spend in clinical practice per week
16
1 2-4 5-9 10-20 >20
17 Size of Practice (number of GPs)
18
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NSW VIC QLD SA TAS WA ACT

19 State/Territory of the Practice you work in
20
METRO REGIONAL REMOTE
21 Geographical area serviced
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22
Y N
23
Did you attend the Women and Children's Healthed event this year?
24
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27 0 1 2-5 6-10 >10
1 . In the past 3 months, how many of your patients have enquired about
28
medicinal cannabis products?
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29
30 STRONGLY SLIGHTLY NEUTRAL SLIGHTLY STRONGLY
31 DISAGREE DISAGREE AGREE AGREE
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32 2 . I have patients who may benefit from medicinal cannabis

33
3 . Medicinal cannabis products should be available on prescription now for certain indications
34
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35 4 . I feel comfortable discussing medicinal cannabis with my patients

36 5 . I have good knowledge around the effects of medicinal cannabis products
37
38 6 . I am aware of the different medicinal cannabis products and formulations currently available
39 7 . I would like the ability to prescribe medicinal cannabis products
40
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41 8 . Medicinal cannabis should only be prescribed by specialists

42 9 . Medicinal cannabis should be provided in "shared care" with a specialist
43
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44 10 . Only GPs who have undergone specific training and credentialing should be allowed to
prescribe medicinal cannabis
45
46 11 . I know how to help patients legally access medicinal cannabis
47
12 . I understand the current regulatory approach to medicinal cannabis
48
49 13 . I understand the current RACGP position on medicinal cannabis
50
14 . There is little difference between "street cannabis" and medicinal cannabis products
51
52 15 . I will not prescribe medicinal cannabis as the risk of abuse and dependence is too high
53
16 . I will not prescribe medicinal cannabis as the risk of side effects (other than abuse and
54 dependence) is too high.
55
56 17 . There is sufficient scientific evidence of the efficacy of medicinal cannabis
57
58
59
60

GP Survey on Medicinal Cannabis, 09/10/2017, version 6
STRONGLY SLIGHTLY NEUTRAL SLIGHTLY STRONGLY
DISAGREE DISAGREE AGREE AGREE
18 . I support the use of medicinal cannabis in patients with:
1 Chronic cancer pain
2 Chronic non-cancer pain
3
Neuropathic pain
4
5 Intractable epilepsy
6 Anti-tumour effects
7 Spasticity in Multiple Sclerosis
8
Dementia patients with agitation
9
10 Insomnia
11 PTSD
12
Anxiety
13
14 Depression
15 End of life/Palliative care
16 Chemotheraphy-induced nausea and vomiting
17
Cachexia associated with severe illness
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19 19 . The major side effects of medicinal cannabis consumption include:

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22 Cognitive impairment
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Driving impairment
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25 Weight gain
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26 Psychosis
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29 Interactions with other medications

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34 Prescription opioids
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36 Antipsychotics
37
Statins
38
39 Chemotherapy drugs
40
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41
42 21 . The right to prescribe medicinal cannabis should be available to: CHOOSE ONE RESPONSE ONLY
43 All GPs
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44
Only GPs with specific training and credentials
45
46 Only GPs in ‘shared care’ with a specialist
47 Only specialists
48
Medicinal cannabis should not be available on prescription
49
50 OPEN ENDED COMMENTS
51 Please use this space to offer any comments, opinions or observations about medicinal cannabis in Australia
52
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BMJ Open
Knowledge and attitudes of Australian general practitioners

towards medicinal cannabis: a cross-sectional survey
Journal: BMJ Open
Manuscript ID bmjopen-2018-022101.R1
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Article Type: Research
Date Submitted by the Author: 05-Apr-2018

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Complete List of Authors: Karanges, Emily; The University of Sydney, The Lambert Initiative for
Suraev, Anastasia; The University of Sydney, The Lambert Initiative for
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Elias, Natalie; The University of Sydney, The Lambert Initiative for

Manocha, Ramesh; Healthed
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McGregor, Iain; The University of Sydney, The Lambert Initiative for

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<b>Primary Subject
General practice / Family practice
Heading</b>:
Health services research, General practice / Family practice, Medical

Secondary Subject Heading:
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education and training
PRIMARY HEALTH CARE, MEDICINAL CANNABIS, THERAPEUTICS,

Keywords:
ATTITUDE
on
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1
2
3 Knowledge and attitudes of Australian general practitioners towards medicinal cannabis: a
4
5
6 cross-sectional survey
7
8
9 Iain McGregor
10
11 The Lambert Initiative for Cannabinoid Therapeutics
12
13 The University of Sydney
14
15 Level 6, Building M02F, Brain and Mind Centre,
16
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17 94 Mallet St, Camperdown, NSW, 2050
18
19 iain.mcgregor@sydney.edu.au
20
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21
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23 Emily A Karanges1
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24
25 Anastasia S Suraev1
26
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27 Natalie Elias1
28
29 Ramesh Manocha2
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30
31 Iain S McGregor1
32
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35 1
The Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney,
36
37 Australia
on
38 2
39 Healthed, Sydney, Australia
40
41
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43 Emily A Karanges and Anastasia S Suraev contributed equally to this paper.
44
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50 Word count: 3,681 (excl. tables, references and figure captions)
51
52
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58 1
59
1
2
3 Abstract
4
5 Objectives: To examine the knowledge and attitudes of Australian general practitioners (GPs)
6
7
8 towards medicinal cannabis, including patient demand, GP perceptions of therapeutic effects
9
10 and potential harms, perceived knowledge and willingness to prescribe.
11
12
13 Design, setting and participants: A cross-sectional survey completed by 640 GPs (response rate
14
15 = 37%) attending multiple topic educational seminars in five major Australian cities between
16
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17
18
August and November 2017.
19
20 Main outcome measures: Number of patients enquiring about medicinal cannabis, perceived
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21
22
knowledge of GPs, conditions where GPs perceived it to be beneficial, willingness to prescribe,
23
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25 preferred models of access, perceived adverse effects, and safety relative to other prescription
26
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27 drugs.
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29
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30 Results: The majority of GPs (61.5%) reported one or more patient enquiry about medicinal
31
32 cannabis in the last 3 months. Most felt that their own knowledge was inadequate and only
iew
33
34
35 28.8% felt comfortable discussing medicinal cannabis with patients. Over half (56.5%)
36
37 supported availability on prescription, with the preferred access model involving trained GPs
on
38
39
40
prescribing independently of specialists. Support for use of medicinal cannabis was condition-
41
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42 specific, with strong support for use in cancer pain, palliative care and epilepsy, and much lower
43
44
support for use in depression and anxiety.
45
46
47 Conclusions: The majority of GPs are supportive or neutral with regards to medicinal cannabis
48
49 use. Our results highlight the need for improved training of GPs around medicinal cannabis, and
50
51
52 the discrepancy between GP-preferred models of access and the current specialist-led models.
53
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58 2
59
1
2
3 Article Summary
4
5
6 Strengths and limitations of this study
7
8
9 • This is the first study to have examined the attitudes and knowledge of Australian
10
11
general practitioners (GPs) about medicinal cannabis.
12
13
14 • The study was performed across five major cities in Australia and included a relatively
15
16 large sample (n=640) of GPs.
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19 • Limitations include utilising a survey without established psychometric properties and
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21 exclusive recruitment of self-selected GPs from educational seminars who were

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24 motivated to complete a survey on medicinal cannabis.

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58 3
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1
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3 INTRODUCTION
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There is strong and increasing public support for the use of medicinal cannabis in Australia.[1]
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9 This support has been a driver of a number of legislative and policy changes enacted over the
10
11 last two years. These changes have allowed approved companies to cultivate cannabis plants
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14 and manufacture cannabis products, and have facilitated legal access to medicinal cannabis for
15
16 approved patients.[2]
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19 Despite this, patient access remains complex and highly restricted. Doctors wishing to
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22 prescribe medicinal cannabis products must either apply to become authorised prescribers for
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24 a class of patients, or apply for access for individual patients under the “Special Access Scheme
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Category B (SAS-B)”[3] via the Therapeutic Goods Administration (TGA), a regulatory body for
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29 therapeutic goods in Australia. Parallel approvals are also usually required from the relevant
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State or Territory Department of Health. Even with these approvals in place, patients often find
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34 available products prohibitively expensive. Moreover, no formal educational training programs
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for doctors on the topic of medicinal cannabis have been initiated since the recent legislative
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39 changes.
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42 Consequently, few doctors and patients are accessing medicinal cannabis in Australia.
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Currently, there are only about 31 authorised prescribers, servicing around 100 patients, with a
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47 further 386 patients granted access via SAS-B approvals (TGA, personal communication, March
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49 2018). This contrasts with the more mature access schemes of countries such as Canada, where
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52 approximately 200,000 patients are serviced.[4]
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58 4
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3 Under current schemes, Australian GPs are typically only permitted to prescribe medicinal
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6 cannabis if supported by a specialist.[3] Nonetheless, GPs are generally the first point of contact
7
8 for patients enquiring about, or seeking access to, medicinal cannabis. Australian medical
9
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11 bodies have forecasted that patient demand for medicinal cannabis is set to increase.[5] With
12
13 ongoing media coverage fuelling unrealistic patient expectations regarding therapeutic efficacy
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16 and cannabis access,[6] GPs may be forced into the role of gatekeepers despite having limited
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18 knowledge and training in the field.
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21 The attitudes of Australian GPs towards medicinal cannabis are unknown. Statements from
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peak medical bodies such as the Royal Australasian College of Physicians (RACP) [7], Australian
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26 Medical Association (AMA), and the Australian and New Zealand College of Anaesthetists’
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(ANZCA) Faculty of Pain Management generally advise caution on the basis of limited evidence
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31 for efficacy and safety.[5,8-10] Surveys from other countries suggest that clinicians are
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33 generally more reticent toward medicinal cannabis than the general public, particularly in the
34
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36 United States,[11,12] with concerns centred on limited evidence for efficacy and adverse
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38 effects, including abuse and dependence.[11-13] Nevertheless, recent analyses suggest that the
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41 majority of GPs and specialists internationally support the use of medicinal cannabis for specific
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43 conditions.[14]
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46 This article describes the results of a survey of Australian GPs around medicinal cannabis
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49 issues, including their clinical experiences, perceived knowledge, and beliefs about its
50
51 regulation, safety, indications for use, and the preferred role of GPs in its prescription.
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58 5
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1
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3 METHODS
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Printed surveys were distributed at one-day general practice educational seminars held in
7
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9 five major Australian cities (Sydney, Melbourne, Brisbane, Adelaide, and Perth) between August
10
11 and November 2017. All GPs and GP registrars were eligible to participate (n = 1728). Seminars
12
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14 covered a range of topics relevant to general practice with around 18 different topics covered
15
16 on the day in consecutive 20 - 30 minute presentations. GPs and GP registrars received
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19 professional education points for attending the seminars. One of the authors (ISM) spoke on
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21 the topic of medicinal cannabis at each event, but surveys were completed and collected prior
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to this presentation. During the opening of each Healthed seminar, participants were informed
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26 that the survey and its information and consent form were located in their conference satchel.
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Participants were instructed to turn in their surveys, before afternoon tea, into drop boxes at
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31 the conference.
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34 The survey was devised specifically for use in this study, and thus, had not been
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psychometrically validated. Questions were reviewed by an advisory group of GPs to ensure
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39 appropriate wording and clarity (see Supplementary Material online for copy of full survey).
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Participants first completed a series of closed questions on demographics, vocational

42
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44 experience (years in practice, registrar status, hours per week), and practice characteristics
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46 (size, state/territory, geographical classification). The survey proper consisted of 46 items on
47
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49 topics related to medicinal cannabis including clinical experience (4 items); perceived
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51 knowledge (5 items); concerns and awareness about safety and efficacy (18 items); appropriate
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indications for use (14 items); and views on the role of GPs, and specialists in its prescribing (5
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56 items).
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58 6
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1
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3 Participants rated the extent to which they agreed with 44 statements on a 5-point Likert
4
5
6 scale (1 = strongly disagree; 5 = strongly agree). There were also two multiple-choice questions
7
8 concerning patient demand and prescribing preferences (role of GPs/specialists). The latter
9
10
11 question was only introduced after the first seminar (included in 73% of completed surveys;
12
13 excludes respondents from the Sydney event). A space for open-ended comments was provided
14
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16 at the end of the survey. The study was approved by The University of Sydney Human Research
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18 Ethics Committee (2017/692).
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21 Results were summarised using descriptive statistics (frequency, percentage of valid

22
23
responses). Likert scale responses were generally collapsed into three categories: Agree,
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26 Neutral, and Disagree. Open-ended comments were reviewed for common themes. A
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composite score for Perceived Knowledge was created by summing scores from five
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31 knowledge-related questions. Age, sex, and perceived knowledge were tested as potential
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33 predictors of views on medicinal cannabis availability (‘medicinal cannabis should currently be

34
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36 available on prescription for certain indications’; 1 = strongly disagree to 5 = strongly agree)
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38 using separate ordinal logistic regression analyses. Chi-square tests were used to compare the
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41 demographic characteristics of our sample to the Australian population of GPs.[15]
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44 One section of the questionnaire asked whether GPs support the use of medicinal cannabis
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46 in 14 different medical conditions. To assess whether their support was consistent with current
47
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49 evidence for efficacy, each indication was categorised as having either “Good Evidence for
50
51 Efficacy” (spasticity in MS, intractable epilepsy, chronic cancer pain, chronic non-cancer pain,
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neuropathic pain, CINV, and insomnia) or “Poor Evidence for Efficacy” (anxiety, depression,
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56 PTSD, cachexia, cancer/ anti-tumour effects, agitation in dementia) based on two recent
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58 7
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1
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3 authoritative reviews,[16,17] and levels of support expressed compared to this evidence base.
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6 The evidence for ‘palliative care’ was not assessed in either review and was thus excluded for
7
8 the purposes of this analysis. Further, GP respondents were categorised as having either “Good
9
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11 Perceived Knowledge” or “Poor Perceived Knowledge” using a cut-off score of 15 on the
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13 composite score for Perceived Knowledge (the midpoint between the lowest (=5) and highest
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16 (=25) possible scores for the 5 questions relating to self-knowledge). Chi-square tests were used
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18 to assess whether GPs with Good Perceived Knowledge expressed greater support for specific
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indications than those with Poor Perceived Knowledge. Bonferroni correction were used to
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23 control for these multiple comparisons.
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26 Analyses were conducted using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp.,
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Armonk, N.Y., USA), and graphs were created using GraphPad Prism version 7.02 for Windows
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31 (GraphPad Software, La Jolla, California, USA).
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34 Patient and Public Involvement
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37 Patients were not involved in this study.
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RESULTS
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43 Demographic data
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46 Demographic and practice details of the 640 participants are shown in Table 1. The majority
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48 of participants were female (67.3%), aged between 35 and 64 years (77.5%), and residing in
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Victoria (30.3%) and New South Wales (27.5%). Over half of respondents had been practicing
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53 for >15 years (56.7%), worked >30 hours/week (63.4%), and serviced metropolitan areas
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55 (60.3%). Only 8.2% were in single-GP practices and 7.9% were registrars.
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58 8
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3 Table 1. Demographic and practice characteristics of GPs in this study, and all GPs in Australia.
4
5 GP survey (n = 640) Australia p (X2 test)
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7
(n = 34,606) [15]
8 n Valid % %
9 Age (n = 640) <0.001
10 <35 57 8.9 13.4
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35-44 134 20.9 24.9
13 45-54 177 27.7 24.9
14 55-64 185 28.9 23.1
15 65+ 87 13.6 13.7
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18 Sex (n = 636) <0.001
19 Female 428 67.3 44.7
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GP registrar (n = 611) 0.08
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23 Yes 48 7.9 10.0
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25 State/territory (n = 627) 0.001
26 New South Wales 175 27.9 30.6
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28 Victoria 193 30.8 24.1
29 Queensland 129 20.6 21.7
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30 South Australia 81 12.9 7.8

31 Western Australia 39 6.2 10.2
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34 Geographical area (n = 611)
35 Metropolitan 381 62.4 68.2 0.01
36 Regional 206 33.7 28.0
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Remote 24 3.9 3.9
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40 Years as GP (n = 637)
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<2 38 6.0
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2-5 90 14.1
44 6-15 148 23.2
45 16-25 136 21.4
46 26+ 225 35.3
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58 9
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3 Experience, practice and general attitudes
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6 A majority of GPs (61.5%) had experienced at least one patient enquiry regarding medicinal
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9 cannabis in the prior three months, with 7.5% reporting more than five enquiries. When
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11 considering GPs working >30 hours/week, the proportion with at least one enquiry increased to
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14 69.0% and 11.8% received more than five enquiries (Table 2).
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20 Table 2. Reported number of patient enquiries about medicinal cannabis in the prior three months,
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21 for all respondents and those working over 30 hours per week, on average.
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23 Number of patients All respondents (n = 615) Respondents >30 h/week (n = 391)
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24 enquiring
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N % N %
26 0 237 38.5 116 31.0
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28 1 159 25.9 90 24.1
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2-5 173 28.1 124 33.2

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31 6-10 33 5.4 32 8.6
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33 >10 13 2.1 12 3.2

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More than half of GPs agreed with the statement that medicinal cannabis should currently
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40 be available on prescription for certain indications (strongly agree: 19.6%, n = 125/637; slightly
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agree: 36.9%), while 14.9% disagreed (Figure 1). GPs were more likely to agree if they were
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45 older (χ2 (4) = 25.63, p < 0.001) and had greater perceived knowledge (χ2(2) = 5.54, p = 0.02),
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47 but there was no difference between sexes (χ2 (1) = 2.55, p = 0.11).
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More GPs agreed that they had patients who would benefit from medicinal cannabis
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53 (44.0%, n = 280/636) than disagreed (21.4%), with 34.6% expressing a neutral opinion (Figure
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55 1). Conversely, fewer respondents agreed that they would like to be able to prescribe medicinal
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58 10
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3 cannabis (28.9%, n = 183/633) than disagreed (33.8%), again with a high number of neutral
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6 responses. Approximately half of respondents (n = 51.9%; n = 328/632) did not feel comfortable
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8 discussing medicinal cannabis with their patients.
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11 Perceived knowledge
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GPs generally rated their knowledge of medicinal cannabis as poor (Figure 2). On all five
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17 knowledge-related items, over two-thirds of respondents disagreed that they had knowledge of
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19 the topic in question. Notably, 65.4% (n = 417/638) ‘strongly disagreed’ that they knew how to
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22 access medicinal cannabis for patients, and more than half ‘strongly disagreed’ that they knew
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24 about available products (55.5%, n = 354/638) or the current regulatory approach (57.8%, n =
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370/630). According to their own self-ratings, 543 (86%) GPs had Poor Perceived Knowledge
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29 (<15/25 composite score) while 88 (14%) GPs were categorised as having Good Perceived
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Knowledge (≥15/25 composite score).
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35 Respondents were more likely to endorse an access model permitting prescribing by
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37 trained and accredited GPs (78.6% agree, n = 503/640), or by GPs in a ‘shared care’
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arrangement with a specialist (63.2%, n = 401/634) than specialist-only prescribing (44.6%, n =
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42 283/634). When asked to choose one preferred model, 41.2% (n = 164/398; note this question
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was not included in the survey used at the first seminar in Sydney) indicated trained GPs as
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47 their preferred prescriber, followed by shared care (29.6%). Specialist-only prescribing was
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49 preferred by 14.6% of respondents, while only 12.1% preferred that all GPs have the right to
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52 prescribe, regardless of training.
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58 11
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3 Indications for use and evidence for efficacy
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Almost half of respondents (48.0%, n = 305/635) were neutral as to whether there was
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9 sufficient overall scientific evidence for the efficacy of medicinal cannabis, with 22.8%
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11 supporting the statement. Those who agreed that medicinal cannabis should be available on
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14 prescription had higher endorsement of the statement than those who disagreed (40.2% versus
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16 11.7%). GPs supported the use of medicinal cannabis in chronic cancer pain (80.2% agree, n =
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19 506/631), palliative care (78.8%, n = 494/627), and intractable epilepsy (70.3%, n = 441/627;
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21 Figure 3). Use in chronic non-cancer pain and neuropathic pain was endorsed by only 39.1% (n
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23
= 246/629), and 38.3% (n = 241/630) of respondents respectively, with a high degree of
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26 neutrality. Less than 15% of GPs supported use in anxiety, insomnia or depression with a
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majority of GPs declining to support use in these conditions (Figure 3).
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GPs with Good Perceived Knowledge of medicinal cannabis were more likely to support its
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34 use in neuropathic pain (52.9%) and chronic non-cancer pain (54%) than GPs with Poor
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36
Perceived Knowledge (35.6% and 36.4%, respectively) (neuropathic pain, X2 (2, N=620) = 9.9,
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39 p=0.007; chronic non-cancer pain, X2 (2, N=620) = 11.2, p=0.004). No other significant
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differences between GPs perceived knowledge level and their support for specific medical
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44 conditions were identified.
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47 Perceived features and adverse effects of medicinal cannabis
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50 Approximately two-thirds of respondents disagreed with the statement that medicinal
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cannabis was no different to street cannabis (43.9% strongly disagree; n = 271/640; 20.5%
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55 slightly disagree), while 14.4% agreed.
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58 12
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3 The side effects of medicinal cannabis endorsed by more than half of respondents included
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6 driving impairment (64.9% agree, n = 408/629), adverse effects on the developing brain (58.4%,
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8 n = 366/627), cognitive impairment (56.5%, n = 356/630), and addiction and dependence
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11 (56.3%, n = 353/627); psychosis was endorsed by 49.9% (n = 313/627).
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14 Overall, 27.7% of respondents (n = 177/637) agreed that they would not prescribe
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16 medicinal cannabis due to the risk of abuse and dependence, and 19.8% (n = 127/638) due to
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19 other side effects. These proportions were higher among GPs who disagreed with the
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21 availability of medicinal cannabis on prescription (58.1% and 44.2% respectively) and among
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those who disagreed that they would like to prescribe medicinal cannabis (47.6% and 34.6%
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26 respectively).
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29 A high proportion of GPs were neutral with respect to whether medicinal cannabis was
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more hazardous than other prescription medicines (range: 43.7% to 51.3%; Figure 4). Of the
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34 remaining responses, a majority believed that medicinal cannabis was safer than chemotherapy
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drugs (78.1%, n = 278/356), opioid analgesics (75.6%, n = 248/328), benzodiazepines (74.5%, n
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39 = 248/333) and antipsychotics (68.3%, n = 209/306), and over 50% for antidepressants and
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statins.
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Open-ended responses
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Of the 156 open-ended responses, 48.1% concerned the participant’s lack of knowledge
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50 about medicinal cannabis and/or the desire for training. Other common themes included the
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need for more evidence of efficacy (n = 18) and concerns about harms (n = 19), namely abuse
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58 13
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3 and dependence (n =10), cannabis-seeking for recreational use (n = 5), repeating mistakes
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6 made with opioids/benzodiazepines (n = 6) and other side effects (n = 4).
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9 DISCUSSION
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12 To our knowledge, this is the first study of the experiences, attitudes and knowledge of
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Australian GPs regarding medicinal cannabis. The survey demonstrates that many GPs have
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16
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17 fielded recent enquiries about medicinal cannabis from their patients, yet half were not
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19 comfortable dealing these enquiries and most felt poorly informed about medicinal cannabis
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22 and its current availability, regulation and uses. This perceived lack of knowledge was strongly
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24 conveyed in the open-ended comments, as well as broadly reflected in the large number of
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26
neutral responses to questions regarding therapeutic and adverse effects.
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29
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30 In agreement with clinician surveys in the United States,[11,12] Australian GPs were
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32 somewhat conservative in their attitudes about medicinal cannabis: only about half agreed that
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35 medicinal cannabis should be available on prescription compared to approximately 85% of the
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37 general Australian population.[1] This rate however has somewhat risen since previous surveys,
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with just under 30% of Australian GPs reporting that cannabis should be available for medicinal
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42 purposes in 2012.[18] This suggests a possible shift in attitudes over time as increasing
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community support has driven a number of legislative and policy changes for greater patient
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47 access and clinical trials in Australia. In the present survey, GPs were generally more supportive
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49 of use of medicinal cannabis in conditions with a stronger evidence-base (such as spasticity in
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52 multiple sclerosis, chemotherapy-induced nausea/vomiting) and/or where few effective
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54 alternatives exist (palliative care, cancer pain, intractable epilepsy).[16] This also aligns with the
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58 14
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3 indications for use suggested by various state governments.[19,20] By contrast, less than 40%
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6 of all GPs supported use of medicinal cannabis in chronic non-cancer pain. This may reflect the
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8 mixed findings regarding efficacy for this indication,[16,21] concerns about inappropriate use,
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11 particularly in light of the problems associated with prescription opioids,[22] and the lack of
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13 endorsement by Australian government and medical organisations.[10,19] Similarly, concerns
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16 about limited evidence for efficacy, risk of worsening illness, and inappropriate use may
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18 underlie the very low support for use in depression, anxiety and insomnia.[16,19] It is
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somewhat troubling that these latter indications were among the most common reasons for
21
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23 illegal use of cannabis for medicinal purposes in a survey of more than 1700 current users in the
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25 Australian community (Lintzeris et al, in press).
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Although GPs exhibited responses that suggested at least some familiarity with the
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31 scientific and clinical literature, perceived knowledge about the effects, products and process of
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33 accessing medicinal cannabis was generally very low. Less than 10% of GPs in our survey
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36 reported understanding the current regulations concerning medicinal cannabis or how it can be
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38 accessed for patients. It is well known that poor knowledge and low levels of comfort discussing
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41 issues with patients are barriers to optimal patient care.[12,23] Provision of continuing medical
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43 education and guidelines on the regulatory, pharmacological and clinical aspects of medicinal
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cannabis are vital for equipping GPs to manage patients effectively.
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49 One surprising aspect of this survey was how GPs rated medicinal cannabis relative to other
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51 common classes of prescription medicines. Of those expressing a non-neutral opinion
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(approximately 50%), about three-quarters rated medicinal cannabis as less harmful than
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56 opioids and benzodiazepines, and notably, just over half rated it less harmful than
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58 15
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1
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3 antidepressants and statins. This perception of the relative safety of medicinal cannabis
4
5
6 compared to opioids and benzodiazepines may reflect its negligible rate of mortality and
7
8 relatively mild dependence and withdrawal syndrome.[24] Nonetheless, cannabis can clearly
9
10
11 produce dependence; recent estimates suggest that there are over 45,000 treatment episodes
12
13 each year for Australians seeking control over their cannabis use.[25] Concerns about abuse,
14
15
16 misuse and dependence was an identified theme of the open-ended comments in our survey.
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18 Moreover, almost half of the GPs who did not want to be able to prescribe cannabis cited the
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risk of abuse and dependence as a primary concern.
21
22
23
Although there was a high degree of neutrality with respect to the desire of GPs to
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26 prescribe medicinal cannabis, the vast majority supported a model of prescribing in which GPs
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played a significant role. A model in which trained, accredited GPs could prescribe without
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31 specialist input received the strongest support, followed by GP prescribing in a ‘shared care’
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33 arrangement with a specialist. This contrasts with the current model in Australia, where
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36 prescribing is conducted by specialists, although shared care arrangements are theoretically
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38 possible.[3] Although specialist-only prescribing may provide greater restrictions on use, the
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41 extension of prescribing rights to appropriately trained GPs arguably enables more holistic
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43 patient care, more frequent monitoring, better detection of adverse effects, and more timely
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treatment.[26] It is notable that GPs are empowered to prescribe, or permit access to,
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48 medicinal cannabis products in countries such as Canada and the United States,[12,23,27] and
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the Royal Australian College of GPs (RACGP) recently updated their position statement to
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53 explicitly endorse a direct role for GPs in medicinal cannabis access.[28]
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58 16
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3 The strength of the study is the unique nature of the survey and the relatively large
4
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6 sample size enabled by accessing the GPs attending popular educational events. While our
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8 response rate of 37% appears relatively low, it exceeds typical published response rates of GP
9
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11 surveys.[29] Limitations include the sole recruitment of self-selected GPs from Healthed
12
13 seminars, reliance on self-report of service provision, and utilising a survey without established
14
15
16 psychometric properties. Furthermore, the survey respondents differed on a number of
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18 demographic and practice characteristics to the general population of GPs in Australia,
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suggestive of a non-representative sample. For instance, there was a disproportionate
21
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23 representation of female GPs in our study, which may be due to a tendency for greater survey
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25 response from females relative to males in general.[30] Finally, the findings cannot be
26
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28 generalised to other countries such as the United States and Canada, among others, where
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30 access to medicinal cannabis is not so strictly regulated.

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32
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33 In conclusion, our results demonstrate guarded support for medicinal cannabis

34
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36 availability among Australian GPs, but very low levels of perceived knowledge. Clearly, there is
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38 an urgent need for improved training of GPs around medicinal cannabis, and, in the future, a
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41 reconsideration of the role of GPs in its prescription.
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3 Acknowledgements
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6
The authors gratefully acknowledge the contribution of Healthed seminar organisers, who
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9 assisted with recruitment, printed and administered the questionnaires. We thank Dr Michael
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11 Bowen for assistance with statistical analysis.
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16 Funding statement
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19 This work was supported by The Lambert Initiative for Cannabinoid Therapeutics at The
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22 University of Sydney. ISM is a National Health and Medical Research Council (NHMRC) of
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24 Australia Principal Research Fellowship.

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Competing Interests
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This study was supported by the Lambert Initiative for Cannabinoid Therapeutics, a
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36 philanthropically-funded centre for medicinal cannabis research at the University of Sydney.
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Iain McGregor is Academic Director of the Lambert Initiative and an NHMRC Principal Research
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41 Fellow and receives research funding from the ARC and NHMRC. He is involved in an NHMRC-
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43 funded clinical trial using the cannabis extract, Nabiximols (Sativex). This survey was conducted
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46 at seminars run by HealthEd. Ramesh Manocha is the CEO of Healthed, and Iain McGregor
47
48 received honoraria and travel expenses from Healthed for lectures conducted at these events.
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51 All other authors have no competing interests to declare.
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3 Author contributions
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6
R.M., I.S.M., E.A.K., A.S., and N.E. conceived the study; I.S.M. collected the data; E.A.K., A.S., and
7
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9 I.S.M. conducted the data analysis and wrote the manuscript; All authors reviewed the
10
11 manuscript.
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18 Ethics approval
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20 Ethical approval for the survey was granted by The University of Sydney Human Research Ethics
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Committee [2017/692].
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27 Data sharing statement

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No additional data are available.
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3 References
4
5 1. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2016:
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7 Detailed findings. (Drug Statistics series no. 31. Cat. no. PHE 214.). Canberra: AIHW; 2017.
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9 https://www.aihw.gov.au/getmedia/15db8c15-7062-4cde-bfa4-
10 3c2079f30af3/21028.pdf.aspx?inline=true (accessed Nov 2017).
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12 2. Therapeutic Goods Administration. Medicinal cannabis products: overview of regulation.
13
14 Canberra: TGA; 2017. https://www.tga.gov.au/medicinal-cannabis-products-overview-regulation
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17 3. Therapeutic Goods Administration. Access to medicinal cannabis products: steps to using access
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19 schemes. Canberra: TGA; 2017. https://www.tga.gov.au/access-medicinal-cannabis-products-
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steps-using-access-schemes (accessed Dec 2017).
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22 4. Health Canada. Market Data. Cannabis for Medical Purposes (FY 2017-18) - Licensed Producers:
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canada/services/drugs-health-products/medical-use-marijuana/licensed-producers/market-
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29 5. Royal Australian College of General Practitioners. RACGP Position statement: Medicinal use of
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32 https://www.racgp.org.au/support/policies/clinical-and-practice-management/racgp-position-
iew
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34 statement-medicinal-use-of-cannabis-products/ (accessed Oct 2017).
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6. Gates P, Todd S, Copeland J. Survey of Australian’s knowledge, perception and use of cannabis
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37 for medicinal purposes. J Addict Prev 2017;5(1):10.
on
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39 7. Martin, J. H., Bonomo, Y., & Reynolds, A. D. (2018). Compassion and evidence in prescribing
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cannabinoids: a perspective from the Royal Australasian College of Physicians. MJA, 208(3), 107-
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44 8. Bartone T. Medicinal cannabis - still a lot of misinformation. Barton, ACT: Australian Medical
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47 misinformation (accessed Oct 26 2017).
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49 9. Johnson C. Green light for medicinal cannabis but AMA says proceed with caution. Aus Med
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51 2017;29(3):9.
52 10.Faculty of Pain Medicine. Statement on “Medicinal Cannabis” with particular reference to its use
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7 11.Charuvastra A, Friedmann PD, Stein MD. Physician attitudes regarding the prescription of medical
8 marijuana. J Addict Dis 2005;24(3):87-93.
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10 12.Kondrad E, Reid A. Colorado family physicians' attitudes toward medical marijuana. J Am Board
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12 Fam Med 2013;26(1):52-60.
13 13.Crowley D, Collins C, Delargy I, et al. Irish general practitioner attitudes toward decriminalisation
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15 and medical use of cannabis: results from a national survey. Harm Reduct J 2017;14(1):4.
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14.Adler JN, Colbert JA. Medicinal Use of Marijuana — Polling Results. N Engl J Med
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18 2013;368(22):e30.
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22 of Australia; 2017.
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35 17.Whiting, P. F., Wolff, R. F., Deshpande, S., et al (2015). Cannabinoids for medical use: a
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38 18.Norberg, M. M., Gates, P., Dillon, P., et al (2012). Screening and managing cannabis use:
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43 19.Queensland Health. Clinical Guidance: for the use of medicinal cannabis products in Queensland.
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45 Brisbane: Queensland Health; 2017.
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47 https://www.health.qld.gov.au/__data/assets/pdf_file/0023/634163/med-cannabis-clinical-
48 guide.pdf (accessed Nov 2017).
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50 20.Victorian Law Reform Commission. Medicinal cannabis: report. Melbourne: Victorian Law Reform
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52 Commission; 2015. http://lawreform.vic.gov.au/projects/medicinal-cannabis/medicinal-
53 cannabis-report-pdf (accessed Nov 2017).
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3 21.Nugent SM, Morasco BJ, O'Neil ME, et al. The Effects of Cannabis Among Adults With Chronic
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5 Pain and an Overview of General Harms: A Systematic Review. Ann Intern Med 2017;167(5):319-
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7 331.
8 22.Australian and New Zealand College of Anaesthetists. 'Medicinal' cannabis: Where's the
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10 evidence? ANZCA Bulletin, September 2016. Victoria: ANZCA; 2016.
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12 www.anzca.edu.au/documents/anzca-bulletin-september-2016.pdf (accessed Nov 2017).
13 23.Carlini BH, Garrett SB, Carter GT. Medicinal cannabis: a survey among health care providers in
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15 Washington state. Am J Hosp Palliat Care 2017;34(1):85-91.
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24.Nutt D, King LA, Saulsbury W, et al. Development of a rational scale to assess the harm of drugs
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18 of potential misuse. Lancet 2007;369(9566):1047-1053.
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25.Australian Institute of Health and Welfare. Alcohol and other drug treatment services in Australia
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22 2015–16: key findings, Table S2. Canberra: AIHW; 2017.
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https://www.aihw.gov.au/reports/alcohol-other-drug-treatment-services/aodts-2015-16-key-
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25 findings/data (accessed Nov 2017).
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27 26.Royal Australian College of General Practitioners. RACGP Submission: GP prescribing rights for
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Isotretinoin. Melbourne: RACGP; 2014.
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30 https://www.racgp.org.au/yourracgp/news/reports/201405isotretinoin (accessed Nov 2017).

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32 27.Ziemianski D, Capler R, Tekanoff R, et al. Cannabis in medicine: a national educational needs
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assessment among Canadian physicians. BMC Med Educ 2015;15:52.
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35 28.Royal Australian College of General Practitioners. The regulatory framework for medicinal use of
36
37 cannabis product: Position Statement – March 2018. Melbourne: RACGP; 2018.
on
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39
https://www.racgp.org.au/download/Documents/Policies/Health%20systems/Regulatory-
40 framework-for-medicinal-use-of-cannabis-products-.pdf
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42 29.Bonevski B, Magin P, Horton G, et al. Response rates in GP surveys - trialling two recruitment
43
44
strategies. Aust Fam Physician 2011;40(6):427-430.
45 30.Cull W, O’Conner K, Sharp S, et al. Respond rates and response bias for 50 survey for
46
47 pediatricians. Health Serv Res 2005; 40(1):213-226
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58 22
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1
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3 Figure legends
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6
Figure 1. Attitudes and clinical experiences of general practitioners with respect to medicinal
7
8
9 cannabis, n = 632 – 637, valid percentage.
10
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12 Figure 2. Ratings of general practitioners on knowledge-related items, n = 636 – 640, valid
13
14
percentage. RACGP=Royal Australian College of General Practitioners.
15
16
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18 Figure 3. Support for use of medicinal cannabis in different conditions, n = 627 – 632, valid
19
20 percentage. CINV=Chemotherapy-induced Nausea and Vomiting; MS=Multiple sclerosis;
rp
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22
PTSD=Post-Traumatic Stress Disorder.
23
ee
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26 Figure 4. Ratings of relative hazards of medicinal cannabis compared to other prescription
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28 medicines, n = 627 – 632, valid percentage.
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34 Figure 1. Attitudes and clinical experiences of general practitioners with respect to medicinal cannabis, n =
35 632 – 637, valid percentage.
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159x133mm (300 x 300 DPI)
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34 Figure 2. Ratings of general practitioners on knowledge-related items, n = 636 – 640, valid percentage.
35 RACGP=Royal Australian College of General Practitioners.
36 160x134mm (300 x 300 DPI)
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Figure 3. Support for use of medicinal cannabis in different conditions, n = 627 – 632, valid percentage.
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CINV=Chemotherapy-induced Nausea and Vomiting; MS=Multiple sclerosis; PTSD=Post-Traumatic Stress

42 Disorder.
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44 166x173mm (300 x 300 DPI)
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1 MEDICINAL CANNABIS SURVEY FOR GPs

2
3
4
GP NURSE MIDWIFE PHYSIO PHARMACIST O&G OTHER
5 Profession
6
<35 35-44 45-54 55-64 65+
7 Age category
8
M F OTHER
9 Sex
10
<2 2-5 6-15 16-25 26+
11 Years in general practice
12
Y N
13 GP registrar?
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<10 11-20 21-30 31-40 >40
15 Average hours spend in clinical practice per week
16
1 2-4 5-9 10-20 >20
17 Size of Practice (number of GPs)
18
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NSW VIC QLD SA TAS WA ACT

19 State/Territory of the Practice you work in
20
METRO REGIONAL REMOTE
21 Geographical area serviced
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Y N
23
Did you attend the Women and Children's Healthed event this year?
24
25
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27 0 1 2-5 6-10 >10
1 . In the past 3 months, how many of your patients have enquired about
28
medicinal cannabis products?
rr
29
30 STRONGLY SLIGHTLY NEUTRAL SLIGHTLY STRONGLY
31 DISAGREE DISAGREE AGREE AGREE
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32 2 . I have patients who may benefit from medicinal cannabis

33
3 . Medicinal cannabis products should be available on prescription now for certain indications
34
iew
35 4 . I feel comfortable discussing medicinal cannabis with my patients

36 5 . I have good knowledge around the effects of medicinal cannabis products
37
38 6 . I am aware of the different medicinal cannabis products and formulations currently available
39 7 . I would like the ability to prescribe medicinal cannabis products
40
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41 8 . Medicinal cannabis should only be prescribed by specialists

42 9 . Medicinal cannabis should be provided in "shared care" with a specialist
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44 10 . Only GPs who have undergone specific training and credentialing should be allowed to
prescribe medicinal cannabis
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46 11 . I know how to help patients legally access medicinal cannabis
47
12 . I understand the current regulatory approach to medicinal cannabis
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49 13 . I understand the current RACGP position on medicinal cannabis
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14 . There is little difference between "street cannabis" and medicinal cannabis products
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52 15 . I will not prescribe medicinal cannabis as the risk of abuse and dependence is too high
53
16 . I will not prescribe medicinal cannabis as the risk of side effects (other than abuse and
54 dependence) is too high.
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56 17 . There is sufficient scientific evidence of the efficacy of medicinal cannabis
57
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60

STRONGLY SLIGHTLY NEUTRAL SLIGHTLY STRONGLY
DISAGREE DISAGREE AGREE AGREE
18 . I support the use of medicinal cannabis in patients with:
1 Chronic cancer pain
2 Chronic non-cancer pain
3
Neuropathic pain
4
5 Intractable epilepsy
6 Anti-tumour effects
7 Spasticity in Multiple Sclerosis
8
Dementia patients with agitation
9
10 Insomnia
11 PTSD
12
Anxiety
13
14 Depression
15 End of life/Palliative care
16 Chemotheraphy-induced nausea and vomiting
17
Cachexia associated with severe illness
18
Fo
19 19 . The major side effects of medicinal cannabis consumption include:

20
21 Addiction and dependence
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22 Cognitive impairment
23
Driving impairment
24
25 Weight gain
ee
26 Psychosis
27 Other long-term mental health issues
28
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29 Interactions with other medications

30 Impact on the developing brain
31
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32
20 . Medicinal cannabis is generally more hazardous than:
33
34 Prescription opioids
iew
35 Benzodiazepines
36 Antipsychotics
37
Statins
38
39 Chemotherapy drugs
40
on
Antidepressants
41
42 21 . The right to prescribe medicinal cannabis should be available to: CHOOSE ONE RESPONSE ONLY
43 All GPs
ly
44
Only GPs with specific training and credentials
45
46 Only GPs in ‘shared care’ with a specialist
47 Only specialists
48
Medicinal cannabis should not be available on prescription
49
50 OPEN ENDED COMMENTS
51 Please use this space to offer any comments, opinions or observations about medicinal cannabis in Australia
52
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60

1
2
3
4 STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies
5
6
7 Section/Topic Item
Recommendation Reported on page #
#
8
9 Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract
Fo
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10 (b) Provide in the abstract an informative and balanced summary of what was done and what was found 2
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12 Introduction
13 Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 4-5
14
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15 Objectives 3 State specific objectives, including any prespecified hypotheses 5
16 Methods
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17 Study design 4 Present key elements of study design early in the paper 5-6
18
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Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and
19 6-7
20 data collection
iew
21 Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of participants
22 6
23
24 Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic
6-8
on
25 criteria, if applicable
26 Data sources/ 8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe
27 7-8
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measurement comparability of assessment methods if there is more than one group
28
29 Bias 9 Describe any efforts to address potential sources of bias 17
30 Study size 10 Explain how the study size was arrived at 6
31
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were
32 NA
33 chosen and why
34 Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 7-8
35
(b) Describe any methods used to examine subgroups and interactions 7-8
36
37 (c) Explain how missing data were addressed 7
38 (d) If applicable, describe analytical methods taking account of sampling strategy NA
39
40 (e) Describe any sensitivity analyses NA
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47
1
2
3
4 Results
5 Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,
6 6, 8
confirmed eligible, included in the study, completing follow-up, and analysed
7
8 (b) Give reasons for non-participation at each stage NA
9 (c) Consider use of a flow diagram NA
Fo
10 Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and
11 8-9
potential confounders
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12
(b) Indicate number of participants with missing data for each variable of interest Percentage of valid responses
13
14 stated for each categorical
ee
15 variable in tables/figures
16 Outcome data 15* Report numbers of outcome events or summary measures NA
rr
17 Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95%
18 NA
ev
confidence interval). Make clear which confounders were adjusted for and why they were included
19
20 (b) Report category boundaries when continuous variables were categorized NA
iew
21 (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period NA
22 Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses NA
23
Discussion
24
on
25 Key results 18 Summarise key results with reference to study objectives 14-15
26 Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both
17
27 direction and magnitude of any potential bias
ly
28 Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results
29 17
from similar studies, and other relevant evidence
30
31 Generalisability 21 Discuss the generalisability (external validity) of the study results 17
32 Other information
33
Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original
34 18
35 study on which the present article is based
36
37 *Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
38
39
40
41
42
43
44
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47
1
2
3
4 Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE
5 checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
6 http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
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BMJ Open is committed to open peer review.

As part of this commitment we make the peer review

Knowledge and attitudes of Australian general practitioners

Journal: BMJ Open

Date Submitted by the Author: 01-Feb-2018

Elias, Natalie; The University of Sydney, The Lambert Initiative for

McGregor, Iain; The University of Sydney, The Lambert Initiative for

MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, PRIMARY

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

24 motivated to complete a survey on the topic.

21 topics related to medicinal cannabis including clinical experience (4 items); perceived

27 New South Wales 175 27.9 30.6

30 Queensland 129 20.6 21.7

38 Regional 206 33.7 28.0

2-5 173 28.1 124 33.2

33 >10 13 2.1 12 3.2

30 Views on medicinal cannabis access models

33 Respondents were more likely to endorse an access model permitting prescribing by

38 arrangement with a specialist (63.2%, n = 401/634) than specialist-only prescribing (44.6%, n =

21 chemotherapy-induced nausea/vomiting) and/or where few effective alternatives exist

In conclusion, our results demonstrate guarded support for medicinal cannabis

27 Data sharing statement

30 6. Gates P, Todd S, Copeland J. Survey of Australian’s knowledge, perception and use of

33 cannabis for medicinal purposes. J Addict Prev 2017;5(1):10.

30 DC: National Academies Press; 2017. https://www.ncbi.nlm.nih.gov/books/NBK423845/

33 (accessed Nov 2017).

30 Australia 2015–16: key findings, Table S2. Canberra: AIHW; 2017.

27 cannabis, n = 632 – 637.

30 Figure 2. Ratings of general practitioners on knowledge-related items, n = 636 – 640.

38 CINV=Chemo-induced nausea and vomiting; MS=Multiple sclerosis; PTSD=Post-traumatic stress

38 nausea and vomiting; MS=Multiple sclerosis; PTSD=Post-traumatic stress disorder.

30 Medicinal cannabis is generally more hazardous than55.

1 MEDICINAL CANNABIS SURVEY FOR GPs

NSW VIC QLD SA TAS WA ACT

32 2 . I have patients who may benefit from medicinal cannabis

35 4 . I feel comfortable discussing medicinal cannabis with my patients

41 8 . Medicinal cannabis should only be prescribed by specialists

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

19 19 . The major side effects of medicinal cannabis consumption include:

29 Interactions with other medications

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Knowledge and attitudes of Australian general practitioners

Journal: BMJ Open

Date Submitted by the Author: 05-Apr-2018

Elias, Natalie; The University of Sydney, The Lambert Initiative for

McGregor, Iain; The University of Sydney, The Lambert Initiative for

Health services research, General practice / Family practice, Medical

education and training

PRIMARY HEALTH CARE, MEDICINAL CANNABIS, THERAPEUTICS,

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

21 exclusive recruitment of self-selected GPs from educational seminars who were

24 motivated to complete a survey on medicinal cannabis.

Participants first completed a series of closed questions on demographics, vocational

21 Results were summarised using descriptive statistics (frequency, percentage of valid

33 predictors of views on medicinal cannabis availability (‘medicinal cannabis should currently be

30 South Australia 81 12.9 7.8

2-5 173 28.1 124 33.2

33 >10 13 2.1 12 3.2

30 access to medicinal cannabis is not so strictly regulated.

33 In conclusion, our results demonstrate guarded support for medicinal cannabis

24 Australia Principal Research Fellowship.

27 Data sharing statement

24 Monthly Data Ontario: Health Canada; 2017. https://www.canada.ca/en/health-