To our knowledge, this is the first study to explore GPs’ experience with prescription of MC and their knowledge, and attitudes towards prescribing it in a Danish setting. One and a half years after the launch of the national test scheme, 37 GPs (8.7% of the respondents) answered that they had prescribed MC to one or more patients and most of the GPs were males. Almost half of the prescribing GPs had a negative attitude towards MC and nearly one third were neither positive nor negative. Four out of five of the 427 responding GPs stated that they only had low or no knowledge of MC and more than two thirds were negative towards MC and its prescription.
Residing in a singlehanded practice and perceiving oneself to have quite some knowledge of MC were factors associated with prescription of MC. The odds of stating to have quite some knowledge of MC and its prescription were higher for males, in the 60+ age group, and in the group who stated to be positive towards MC. Being male and perceiving oneself to have quite some knowledge of MC was associated with a positive attitude towards MC, and prescription of it.
Interpretation of the results
The finding from the regression analyses that GPs perceiving themselves to have quite some knowledge of MC was associated with a positive attitude towards MC and prescription of it was not surprising. Research has shown that physicians experienced in prescribing MC are more convinced of its benefits and less worried about adverse effects than physicians without these experiences [
12,
25]. Conversely, the negative attitude among most GPs may be partially explained by the fact that they are responsible for prescribing MC according to Danish law, where some might fear the possibility for negative side effects [
18].
Being a male GP was associated with a positive attitude towards MC as well. This finding is supported by previous studies in which being male was associated with early new drug prescription [
26,
27]. In addition, we found that being a GP in a singlehanded practice was associated with prescription of MC. This finding is in contrast with findings from a previous study of diffusion of new drugs, which showed that partnership practices adopted new drugs faster than single-handed practices [
28]. A possible explanation to our finding could be that the introduction of a new medicine in a partnership practice requires that everyone must agree on the use of it, before using that medicine in the practice. However, this study investigated medicine, which had been approved formally by authorities, and it may be different concerning non-approved medicine [
28]. Previous literature has also found that physicians’ interest in particular therapeutic areas, participation in clinical trials, and volume of prescribing either in total or within the therapeutic class of the new drug, increases the likelihood of early adoption of new drugs [
29].
The response rates were higher for GPs in the Central Denmark Region and the Region of Southern Denmark compared to The North Denmark Region, The Capital Region of Denmark and Region Zealand. This phenomenon is also observed in Danish GP surveys targeting other areas than medicinal cannabis [
30,
31].
The low prescription rate of MC could be caused by a general prudence among GPs when new medicines or tools are introduced. This is for example seen in the introduction of video consultations in general practice [
32]. The qualitative study on video consultations found three categories related to uncertainty about the new tool being 1) integrity, 2) setting, and 3) interaction. The uncertainties refer to 1) uncertainties related to how new technology may impede the provision of health care; 2) uncertainties related to the potentials of the technology; and 3) uncertainties related to how the technology affects interactions with patients. This can be transferred to uncertainties related to the prescription of MCs, namely the GPs' uncertainties about the potentials of cannabis as medicine [
13,
32]. Besides from uncertainties related to prescription, the time aspect could also be an issue, given that it takes time to become familiar with a new type of medicine and the official guidelines that follow, in terms of indications recommended for prescription and use of available products on the market [
19,
33].
The low prescription rate could, however, also be due to a perceived lack of training, as seen with the introduction of point-of-care ultrasound (POCUS) in family medicine [
34]. POCUS’ ability to aid and guide in diagnosis and procedures has been demonstrated by numerous studies and it has been used for years by various medical specialties as a result [
35,
36]. Many physicians working in family medicine did not feel they had the necessary training to begin with. They needed a training curriculum tailored to family medicine, which was later developed by colleagues within research. It lead to a significant improvement in confidence in their ability to perform and interpret a POCUS [
34]. Implementation of newly established MC curriculums in general practice could also be a mean to improve confidence in usage among GPs, that in the end might have an effect on the present prescription rate [
37,
38].
A recent systematic review that investigated physicians’ experiences, attitudes, and beliefs in MC found that a general lack of knowledge of clinical effects, both beneficial and adverse, affected their decision to prescribe [
13]. Physicians from various specialties frequently experienced patient demands for MC, but their willingness to prescribe varied considerably. Hospital physicians and GPs experienced in prescribing were more convinced of effects and less worried about adverse effects. One way to increase the GPs’ knowledge and willingness to prescribe could be through already existing educational courses, as found in the UK and Denmark, that are based on the most recent evidence about treatment guidelines and the endocannabinoid system [
39,
40].
Limitations and strengths of the study
The response rate of our survey reached a total of 38.4% of the invited GPs which is comparable to response rates in similar studies [
13]. Although, the proportion of GPs having prescribed MC and GPs with a positive attitude towards it is quite small, meaning that the results of the regression analyses, in which these variables are outcomes, only reveal tendencies along with actual associations.
The fact that the Danish Parliament has enacted a test scheme about MC prescription may have worried many physicians, as MC has not undergone the same rigorous clinical trial process as other new medications on the market and the physicians are responsible for prescribing it [
41]. It is possible, that the most worried GPs (having the most negative attitudes) are also the ones who took the time to fill in the questionnaire to express their discontent with the test scheme. If so, it may have resulted in an overrepresentation of respondents with a negative attitude towards MC. However, it is also a possibility that the GPs with the most positive attitudes towards research in general are the ones responding to the questionnaire, regardless of their attitudes towards MC. This has been found in earlier patient studies [
42,
43].
We did not perform a rigorous psychometric validation of the questionnaire. However, we carried out a thorough qualitative pilot test among five physicians in various relevant specialties focusing on content validity, relevance, acceptability, and feasibility. This led to some changes to the questionnaire. Hereafter, a small-scale quantitative pilot testing of the questionnaire was conducted among 12 physicians in relevant specialties with many GPs. Hence, we believe that the instrument and accordingly the results are reliable.
This cross-sectional study was conducted approximately one year after the four-year test scheme was enacted and provides knowledge of the factors influencing GPs’ decision to prescribe MC to patients, as well as their knowledge and attitudes towards it at this early point of time. We stress that prescribing patterns, knowledge, and attitudes may change throughout the remaining time of the test scheme, as they might have from the beginning to the end of our data collection. The long period of data collection was caused by a delay in data access from some regions.