Self-reported Practices of Frontline Cannabis Dispensary Workers and the Implications for Clinicians

Forty-seven percent of US adults who use cannabis report medical reasons for use,¹ and many obtain their information about medical cannabis from dispensaries. Merlin et al² report results of a study that surveyed 434 frontline cannabis dispensary workers, most of whom described themselves as a “budtender” (people who give advice to customers on marijuana) (40%) or manager (32%). Respondents reported that their recommendations to customers were frequently based on the customer’s medical conditions (74%), experiences of other customers (70%), the customer’s own prior experience with cannabis (67%), and the respondents personal experience (63%). Most respondents reported not basing their recommendations on clinician input and never or rarely talking to customers about potential risks of cannabis use, including cannabis use disorder or addiction, cannabis withdrawal, motor vehicle collisions, psychotic reactions, cannabis medication interactions, and potential adverse effects. Dispensary workers in states with full legal adult cannabis use as of July 2019 were more likely to discuss safe cannabis storage but no more likely to discuss other risks of cannabis use. Working in a state with cannabis regulations resembling those for prescription and over-the-counter medications was not associated with increased discussion of risks of cannabis use. The study experienced recruitment challenges that leave uncertainty about the representativeness of the sample; however, the findings raise questions about the quality of the information on which patients base decisions about medical cannabis use.

More than half of frontline dispensary workers report basing their cannabis recommendations on training provided by the dispensary. Cannabis dispensaries are businesses and discussion of the addictive potential of cannabis or offering shared decision-making about potential risks and benefits of cannabis use may be counter to the business model. That advice is frequently based on personal experiences raises further questions. Many frontline dispensary workers are managers (32%) or work on commission (15.2%), producing a potential conflict of interest. Patients want to learn more about medical cannabis from health care professionals, but without clinician-initiated discussions about cannabis use, which some clinicians are hesitant to initiate, patients rely instead on frontline dispensary workers as proxy clinicians for information on medical cannabis use.²

Ideally, patients could talk to clinicians about using cannabis for medical conditions, with clinicians informed about current evidence on risks and benefits of medical cannabis use. Although preventive counseling about cannabis use has not been shown to decrease its use,³ offering patients information on known risks and benefits of medical cannabis use may be considered an appropriate action for all clinicians. There is good evidence that cannabis can benefit chronic pain, chemotherapy-induced nausea and vomiting, and multiple sclerosis spasticity symptoms, and there is moderate evidence, based on observational studies, that cannabis use is associated with improved short-term sleep outcomes for some individuals with chronic conditions.⁴ However, other effective medications are available for most conditions as first-line options. Other conditions for which cannabis is used—depression, anxiety, posttraumatic stress disorder, cancer, glaucoma, irritable bowel syndrome—have limited or insufficient evidence.⁴ Despite limited research on safety and efficacy,⁴ there are known risks associated with frequent cannabis use that clinicians can discuss with their patients. Studies suggest that 25% to 50% of patients who use cannabis daily develop a cannabis use disorder⁵ and approximately 54% of outpatients who use cannabis regularly experience withdrawal,⁶ characterized by irritability, nervousness, and anxiety, which can lead patients to increase cannabis use thereby worsening these symptoms.

Although extensive research is needed on the benefits and risks of medical cannabis use, there are several steps that can be taken now to support clinicians in offering evidence-based patient-centered care for those using cannabis for medical reasons. Health systems can begin by routinely asking patients about their cannabis use, as recommended by the US Preventive Services Task Force.³ Routine screening has the potential to reduce stigma around cannabis use and normalize patient opportunities to discuss cannabis use with their clinician.⁷ Alongside brief screens to identify use, electronic health records can support documentation, consistent with practices for other over-the-counter medical products. Continuing medical education focused on potential risks as well as benefits is critical. Development of patient decision aids including current evidence on potential benefits and risks could support shared decision-making. Among patients who report frequent cannabis use, placing them at risk for addiction, substance use disorder symptom checklists can help patients and their clinicians to identify symptoms of a cannabis use disorder.⁷

Although most patients obtain their information on medical cannabis from cannabis dispensaries, the study by Merlin et al² suggests they may not be receiving balanced information and advice. This imbalance is an important gap in medical care that will widen as the prevalence of cannabis use continues to increase. Clinicians can meet this need by asking patients about their cannabis use and offering patients shared decision-making about the potential risks as well as the benefits of medical cannabis use.

Published: September 15, 2021. doi:10.1001/jamanetworkopen.2021.25262

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Matson TE et al. JAMA Network Open.

Corresponding Author: Theresa E. Matson, MPH, Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101 (tessa.e.matson@kp.org).

Conflict of Interest Disclosures: Drs Bradley and Lapham reported receiving grants from the National Institute on Drug Abuse, Clinical Trials Network outside the submitted work. No other disclosures were reported.