Pharmacy-based interventions for cannabis-use related difficulties

Last updated February 2015

John Howard, Jan Copeland, Peter Gates, Morag Millington, Denis Leahy and Carlene Smith
National Cannabis Prevention and Information Centre
The Pharmacy Guild of Australia (New South Wales Branch)

Potential harms associated with cannabis use

Cannabis is the most commonly used illicit drug in the Western world. Despite this, the effects of cannabis use and dependence on mental and physical health and psycho-social functioning are typically under-recognised and under-treated.¹ This represents missed opportunities for health promotion and brief and early interventions for those who are already experiencing cannabis use-related difficulties.

People s personal experience with cannabis use, including those in the health workforce, can influence opinions on the health impact of cannabis use. Opinions based on personal experience often ignore significant changes in the patterns of cannabis use over the past 30 to 40 years. These include differences in the frequency and quantity of cannabis use, a significant decline in the age of initiation of use, an increase in potency of the cannabis plant, and use of the more potent parts of the plant.^{1, 2, 3}

There is increasing evidence of an association between cannabis use and cognitive impairment in attention, memory, and the organisation and integration of complex information.³ As cannabis is usually smoked, there are risks for respiratory disease, such as chronic bronchitis. In addition, most smokers mix cannabis with tobacco and are also regular tobacco smokers. There is evidence that some of the negative respiratory effects of cannabis and tobacco may be additive. This concurrent cannabis and tobacco use may complicate the management of smoking cessation, particularly if the treatment seeker wishes to abstain from only one substance. That is, cannabis use may prompt relapse to tobacco use and vice versa.⁴

Early onset, frequent and heavy use of cannabis exacerbates mental health conditions, including schizophrenia, manifesting as increased symptoms and severity, non-compliance with treatment and more frequent hospitalisations.^{5, 6}

Role for Pharmacists

Pharmacists represent a unique position in healthcare, and are particularly relied on to provide healthcare where medical practitioner availability is limited. A study by Dhital⁷ has outlined how pharmacy reform aims to provide patients with better choices and access to healthcare through the utilization of pharmacists skills and expertise. She notes that this is most evident in areas such as self-care, management of long-term conditions, the delivery of public health messages and improving access to services. In particular, pharmacists can be trained to deliver brief interventions during medication reviews with cannabis users and provide advice to those recently diagnosed with a health condition where smoking cessation would be beneficial, and for pregnant customers. Early work suggests that typical pharmacist visitors are positive about brief interventions for alcohol use, and view pharmacies as informal places where no appointment is required.⁷ This was particularly the case where pharmacies have a consultation room.

Screening and brief intervention practices may have, on average, only small effects, however, they require minimal training and can be cost-effective.⁸ Pharmacists are in a position to deliver such interventions using an Ask, Advise, Refer approach. Notably, there is emerging evidence that pharmacists can be effective in providing information, screening, brief interventions and referrals in relation to tobacco smoking and problematic alcohol use. Although pharmacists support playing a role in addressing concerns in these two areas, a number of barriers prevent this from being enacted. That is, many believe they lack the required skills and resources, have negative attitudes towards people dependent on alcohol, tobacco and/or other drugs, lack confidence in the efficacy of pharmacy-based and brief interventions, and were concerned there would be no remuneration for their efforts.^{7, 9, 10} In addition, a study in New Zealand and England¹¹ revealed that pharmacists had concerns about offending or alienating customers and invading their privacy. Finally, as pharmacists may lack the knowledge and confidence to provide brief interventions, the importance of promoting role adequacy was noted in a study from Scotland.¹²

In relation to interventions focussed on tobacco use, a systematic review noted that individuals who work in pharmacies (including pharmacists, pharmacy technicians, dispensary assistants, and trained staff) have regular interactions with large numbers of people who may benefit from drug-related screening and intervention. This review supported the effectiveness of the delivery of non-pharmacological tobacco use cessation interventions (including offering behavioural counselling or support), as well as those combining non-pharmacological interventions with pharmacological approaches.³

While research to date has focussed on two licit drugs nicotine and alcohol, pharmacists are extensively involved in opioid substitution treatment, including the provision of methadone, buprenorphine, buprenorphine and naloxone in combination (Suboxone) and other medications, and have a role in extending needle and syringe availability. However, little is known about the potential role of pharmacists in relation to the use of cannabis.

The Project

The National Cannabis Prevention and Information Centre (NCPIC) and the Pharmacy Guild of Australia (NSW Branch), have been working together to explore the potential role of pharmacists in health promotion and delivering brief, opportunistic interventions in relation to the cannabis use of their customers.

It is not proposed that the pharmacist takes on a clinical counselling or therapy role, but rather one of a concerned healthcare provider, who can assist a customer s consideration of their use of cannabis and its health and broader implications, and provide them with evidence-based information and referral guidance where appropriate. Importantly, the brief, opportunistic interventions that are proposed meet the requirements under the 5th Community Pharmacy Agreement (2010-2015) with the Australian Government, in relation to the provision of health promotion and brief clinical interventions.

The project builds on a similar National Cannabis Prevention and Information Centre (NCPIC) project with general practitioners. It aims to expand the dissemination of evidence-informed information on cannabis and the potential risks associated with its use (particularly mental and physical health issues), teach appropriate interventions (brief or otherwise) and provide referral information. The project comprises both research and practice components.

The research component

The research component had two parts (i) qualitative and (ii) quantitative.

A qualitative study with 11 pharmacists explored their views and attitudes towards cannabis and cannabis users and any perceived barriers to providing brief intervention. There was broad support for the provision of information and brief interventions, and questions raised about engagement with customers who could benefit, in conjunction with realities of pharmacies. The results were used to develop the quantitative instrument and the process for recruiting pharmacists and pharmacy staff to complete the survey.

For the quantitative study, the online survey went live in mid February 2013. The survey used was modelled on the NCPIC survey of general practitioners and Sheridan s (2008) survey of pharmacists views on providing expanded services related to alcohol use-related difficulties. Specifically, this survey gathered information on the attitudes of pharmacists to cannabis and its use; their potential role in health promotion and provision of brief, opportunistic interventions (ie information provision, health promotion, clinical advice and referral) and their willingness to do them; any barriers to such provision; and resources that could assist. The invitation to complete the survey was circulated via email to NSW Pharmacy Guild members, and a wider pharmacy audience including pharmacy interns.

The online survey was completed by 129 pharmacists and the data from this sample is discussed. Despite widespread advertisement, the sample size is small, and this may reflect the contested views about the role of pharmacists in provision of screening and interventions addressing illicit substance use.

These participants were aged 22 to 71 years (M=45.6, SD=12.5), and almost two thirds were male (61%). Participants worked in metropolitan (49%), regional (24%), and rural and remote areas (27%), and had worked an average of 23 years (SD=13.4) as a pharmacist.

The majority (77%) of respondents believed pharmacists could be effective in providing brief, opportunistic interventions to cannabis users, and 60% believed that screening alone can lead to a positive change. However, over half (56%) rated their knowledge about cannabis as poor to very poor and only 39% rated it as acceptable to strong. Additionally, 73% rated their skill-level in screening for cannabis use-related difficulties as poor to very poor.

A scale representing the participants belief that treatment can help cannabis users comprised four items, each scored from one-to-five, where higher scores show stronger belief (5 = I can help ). This scale had adequate internal consistency for a four item scale ( =0.65).

Table 1: Pharmacists attitudes on cannabis treatment utility

A second scale was created to indicate a participants role importance in providing a treatment (12 items, each scored from one to five where higher scores show less perceived importance (5 = I am no help ). This scale had good internal consistency ( =0.80).

Table 2: Pharmacists attitudes to their role importance in cannabis-related screening or intervention*

(*higher score reflects stronger agreement)

The participants reported an average belief in treatment score of 14.0 out of 20 (SD=2.7), and an average role importance score of 33.9 out of 60 (SD=8.0).

Participant gender, age and location of their pharmacy were not significantly associated with these scale scores.

Pharmacy experience

The participants had worked up to 48 years as pharmacists (M=23.0, SD=13.4), and reported spending up to 82 hours per week in their pharmacy, with an average of 36.6 (SD=14.5) hours.

The vast majority (93%) of participants reported offering customers tobacco smoking cessation advice and had provided clinical interventions which met the requirements under the 5th Community Pharmacy Agreement (2010-2015). Despite this, the sample was not likely to have reported screening more than one customer for cannabis use in the past month (M=0.7, SD=4.6; 9.3% screened at least one), and were not likely to have provided any brief interventions (M=0.5, SD=2.0; 16.3% provided at least one), referred any cannabis-using customers to a drug and alcohol clinic (M=0.3, SD=1.3; 10.9% referred at least one) or mental health service (M=0.2, SD=0.5; 11.6% referred at least one).

No indicator of pharmacy experience was significantly associated with the belief in treatment or role importance scales.

Cannabis training, knowledge and beliefs

Just under half the participants (48.1%) reported at least a small amount of cannabis-related training and only one in ten (10.9%) reported having received a moderate or substantial amount of training. For those who did report at least a small amount of training (47%), under one third (29.5%) reported that this training had been delivered within the past two years.

More than half of the sample (55.5%) reported that their cannabis-related knowledge was poor or very poor and only one in twenty (5.2%) reported strong or very strong knowledge. An even greater proportion (72.6%) reported poor or very poor skills in screening for cannabis problems, with only 3.2% reporting strong or very strong screening skills. In addition, 100% of the sample agreed that they should receive education about cannabis. In order to feel more confident in screening for cannabis use, the participants suggested that they should receive more training (93.8%), access to up-to-date intervention guidelines (85.3%), more options for referral (73.6%), more resources (72.9%), and the belief that screening leads to positive outcomes (60.5%).

Some of the participants (44.2%) believed that cannabis should be available for medicinal purposes or available as a maintenance therapy in a pharmaceutical preparation (46.5%). This was more common than those who believed cannabis should remain illegal (34.9%), or be decriminalised (28.7%).

The variation in participant scores on the belief in treatment and role importance scales was not significantly associated with any variation in responses to these indicators of cannabis-related training, knowledge or beliefs.

Cannabis harms

The participants reported that an average of 6% (SD=8.0) of their customers would be at least weekly cannabis users, and believed that an average of 32.2% (SD=29.8) of those who try cannabis would someday develop cannabis dependence; three times greater than expected. This later belief was significantly associated with role importance (R2=0.12, B=0.09, t=3.72, p<0.001), such that the greater the percentage of cannabis users the pharmacist believed would one day be dependent, the greater the pharmacist s feelings of role importance.

The majority (89.9%) of participants commonly agreed that cannabis users were more likely to have a mental health concern than non-users and 83.6% disagreed that it is OK to smoke cannabis as long as it does not become a habit. In addition, 77.8% of the sample commonly agreed that cannabis withdrawal can act as a barrier when quitting cannabis. The sample was likely to indicate agreement that cannabis-related harms were similar to alcohol-related harms (59.1%) but responded with mixed agreement to the idea these harms were similar to tobacco-related harms (52.8% agreed, 41.8% disagreed, 5.5% neutral)

The variation in participant scores on the belief in treatment and role importance scales was not significantly associated with any variation in the proportion of participants who agreed or disagreed with these harm-related beliefs.

Beliefs regarding participant treatment seeking

The sample believed that, if someone was concerned about their cannabis use, they would first seek help from a general practitioner (GP) (M=5.7, SD=2.2) or counsellor (M=5.0, SD=1.9). Other common responses included: a pharmacist (M=4.9, SD=1.9), an alcohol or other drug treatment service (M=4.8, 2.5), online support (M=4.6, SD=2.4), or a friend (M=4.2, SD=2.5). The sample was less likely to believe that a cannabis user would seek help from a support group (M=3.6, SD=1.9) or from a self-help workbook (M=3.3, SD=2.0).

The variation in participant scores on the belief in treatment and role importance scales was not significantly associated with any variation in the proportion of the sample sharing each of these beliefs.

The views of pharmacists participating in this study are comparable to those of the general public. The National Survey of Mental Health and Wellbeing¹⁴ reported that among those with cannabis dependence seeking help, a GP is the most common form of treatment (12% of males and 25% of females) followed by a psychiatrist (4% of males and 6% of females) or psychologist (3% of males, 8% of females). In addition, according the National Minimum Data Set¹⁵ cannabis users most commonly receive counselling (43%) followed by withdrawal management (13%). Treatment settings are typically non-residential (70%). In an unpublished online survey of 500 regular cannabis users conducted by NCPIC, the order of treatment seeking was: GPs (43%), counsellors (24%), self-help books (12%), internet (10%), support groups (9%) and an alcohol or other drug facility (2%). Pharmacists were a little more likely to believe that more cannabis treatment seekers would go to a drug or alcohol treatment service than actually do.

Conclusions from the survey

Notwithstanding the small sample, the study indicates that there does exist a willingness among a section of pharmacists to become equipped to raise the awareness of customers of possible health concerns that could arise from cannabis use, and to provide screening, information, brief interventions and referrals to customers who may be experiencing cannabis use-related health concerns, or who are considering a reduction or cessation of their cannabis use. Essentially, the findings are identical to previous studies of pharmacists opinions regarding the screening and brief intervention for alcohol and tobacco use.^8-13 That is, they believed that they required more information on cannabis, its use, health impacts and broader implications, and capacity building to raise their skill level and confidence. The activities described below have been undertaken to address these concerns.

Practice component

In order to address the knowledge gaps identified in the study, NCPIC and the Pharmacy Guild of Australia (NSW Branch) have produced a Cannabis Kit for Pharmacists to use in community settings, which builds on a similar one for general practitioners. Selected NCPIC Factsheets were adapted for use by pharmacists and their customers. These, together with the Severity of Dependence Scale and various NCPIC resources, form the package for use by pharmacists in community settings. Some content from the package appears in the Appendices, and the kit is available to download at: https://cannabissupport.com.au/workforce/pharmacists/

Capacity building workshops have been provided at Pharmacy Guild conventions to demonstrate how pharmacists could engage with customers who may have cannabis use-related difficulties, in addition to evening workshops in selected areas of NSW. The NSW Branch is piloting the cannabis information package with pharmacists who have indicated a willingness to be involved.

The content of the Cannabis Kit for Pharmacists includes:

1. Screening and intervention flow chart (see Appendix 1)
2. Motivational enhancement for pharmacists with cannabis users: 5 key questions (see Appendix 2)
3. Referral information.
4. Factsheets for customers (5) and pharmacists (10) on: cannabis, potency, dependence, withdrawal, pregnancy, mental health, prescribed medications, driving, the law, synthetic cannabis and treatment.
5. NCPIC booklets: Fast facts series on: cannabis, how to help someone and mental health; What s the deal? series on: quitting, facts for young people, facts for parents and talking with a young person about cannabis.
6. Severity of Dependence Scale.
7. Treatment guidelines.
8. Clearing the smoke DVD.

Project Members

NCPIC: Dr John Howard, Professor Jan Copeland and Morag Millington.

Project Collaborators

Denis Leahy and Carlene Smith, Pharmacy Guild of Australia (NSW Branch); Associate Professor Timothy Chen, Faculty of Pharmacy, University of Sydney; Associate Professor Janie Sheridan, research director and deputy head of school, School of Pharmacy, University of Auckland; and Jennie Houseman, consultant pharmacist, Community GP & Pharmacy Liaison, Northern Sydney Area Drug and Alcohol Services, NSW Health.

References

1. Copeland, J. & Howard, J. (2012). Cannabis use disorder. In: Rosner, R. (eds) Clinical Handbook of Adolescent Addiction. Chichester: Wiley and Sons.

2. Copeland, J., Rooke, S., & Swift, W. (2013). Changes in cannabis use among young people: impact on mental health. Current Opinion in Psychiatry 26, 325-329.

3. McLaren, J. & Mattick, R. (2007). Cannabis in Australia: use, supply, harms and responses. Monograph Series No. 57. Australian Government Department of Health and Ageing. Sydney: National Drug and Alcohol Research Centre.

4. Budney, A.J., Vandrey, R. G., Hughes, J. R., Thostenson, J. D., & Bursac, Z. (2008). Comparison of cannabis and tobacco withdrawal: severity and contribution to relapse. Journal of Substance Abuse Treatment 35, 362-368.

5. Kuepper, R., van Os, J., Lieb, R., Wittchen, H., H fler, M., & Henquet, C. (2011). Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study. British Medical Journal 342, d738.

6. Large, M. (2011). Cannabis use and earlier onset of psychosis: a systematic meta-analysis. Archives of General Psychiatry 68, 555-561.

7. Dhital, R. (2007). Alcohol screening and brief intervention by community pharmacists: benefits and communication methods. Journal of Communication in Healthcare 1, 20-31.

8. Strang, J., Barbor, T., Caulkins, J., Fischer, B., Foxcroft, D., & Humphreys, K. (2012) Drug policy and the public good: evidence for effective interventions. Lancet 397, 71-83.

9. Dhital, R., Whittlesea, C., Norman, I., & Milligan, P. (2010). Community pharmacy service users views and perceptions of alcohol screening and brief interventions. Drug and Alcohol Review 29, 596-602.

10. Sheridan, J., Wheeler, A., Chen, L., Huang, A., Leung, I., & Tien, K. (2008). Screening and brief interventions for alcohol: attitudes, knowledge and experience of community pharmacists in Auckland, New Zealand. Drug and Alcohol Review 27, 380-387.

11. Horsfield, E., Sheridan, J., & Anderson, C. (2011). What do community pharmacists think about undertaking screening and brief intervention with problem drinkers? Results of a qualitative study in New Zealand and England. International Journal of Pharmacy Practice 19, 192-200.

12. McCraig, D., Fitzgerald, N., & Stewart, D. (2011). Provision of advice on alcohol use in community pharmacy: a cross-sectional survey of pharmacists practice, knowledge, views and confidence. International Journal of Pharmacy Practice 19, 171-178.

13. Mdege, N. & Chindove, S. (2014). Effectiveness of tobacco use cessation interventions delivered by pharmacy personnel: a systematic review. Research in Social and Administrative Pharmacy 10, 21-44.

14. Australian Bureau of Statistics. (2008). 2007 National Survey of Mental Health and Wellbeing: summary of results.

15. Australian Institute of Health and Welfare. (2013). Alcohol and other drug treatment services in Australia 2011-12. Drug treatment series 21. Cat No HSE 139. Canberra: AIHW.