All interviews were coded by J.E., and six interviews were independently coded by D.D. Throughout the analysis process, J.E. and D.D. discussed codes and coding structures. Findings were viewed through an HTA lens, and attention was paid to the impact of the technology on the participants and their interactions with end users . In the following section, some quantifying language is used to provide a sense of consistency within themes. For example, the term “most” indicates that a theme was present in at least 10 participant accounts, while the term “many” indicates that at least 6 accounts included the theme. The terms “some” or “several” indicate that less than half of participant accounts included a theme; however, the absence of a theme in a participant account does not indicate that a belief was not held, only that it was not raised during the interview.The medical cannabis field was perceived by participants to be rapidly evolving, and participants expressed a desire to learn more about cannabis, including about cannabis-based products and cannabinoids, noting that increased knowledge would allow them to better counsel patients . No participants had received formal training about medical cannabis, and several expressed the need for its addition to medical school curricula. Participants reported learning about medical cannabis by attending rounds, reading journal articles, viewing web seminars, and through discussions with colleagues . Several participants described a desire for guidelines from Canadian professional associations, stating that it would facilitate their practice by allowing them to better counsel patients.Most participants reported discussing costs with families, and some described working with parents to calculate costs based on the projected dose. Several participants noted that the cost of treatment sometimes limited their ability to reach a therapeutic dose because parents are typically paying out-of-pocket for the cannabis products. Neurologist 10 summarized the issue as follows: “Families sometimes don’t advance the treatment to a therapeutic dose because the cost is prohibitive and in that case, I think that’s all a kind of a waste.
It’s like going through the trouble of spending your money to take an aspirin a day when really you need eight aspirins a day. Wasting your money, one aspirin a day won’t do anything but you’ll never get up to eight because you can’t afford it.” Because of this issue, mobile grow system some participants described choosing between licensed producers based on the availability of compassionate discounts for pediatric patients. One neurologist reported that parents were sometimes surprised to learn that cannabisbased products are not typically covered by insurance, especially since the legalization of recreational cannabis in Canada in October 2018 . This was echoed by some neurologists who stated a belief that cannabis-based products should be covered by insurance programs, citing benefits to the health care system .Participants who had not previously authorized medical cannabis described a variety of reasons for not authorizing its use, including personal and institutional factors. Insufficient evidence or guidance: Some participants reported not authorizing medical cannabis because of a lack of evidence and/or guidance . Out of scope: Out of scope: Others described feeling that authorizing medical cannabis was outside their scope of practice, that they considered it a “regulatory hassle” , or that they could not do a “better job” than physicians at cannabis clinics. Restrictive policies: Some participants described policies at their hospital or within their department that prohibit authorization, while others reported not wanting to be seen as going against people in leadership positions . Several participants noted that consensus had been reached within their department or group to not authorize cannabis and that a unified position was felt to prevent any one neurologist from being given the most complex cases and/or “the most demanding families” .Participants who do not authorize medical cannabis described referring patients to other health care providers or to cannabis clinics, often in the patient’s community , or in one case, to in an adjacent province, stating that there was no closer alternative. Others described hospital or departmental policies that prevented them from referring patients, leaving it up to parents to find a cannabis clinic or care provider to provide authorization .
Of note, some neurologists were strongly against the practice of referring patients to non-neurologists for the purpose of obtaining cannabis authorization , citing patient safety as a key concern.Most participants reported that caring for children using medical cannabis does not affect their workflow, in terms of the number of patient visits or tests ordered. In one neurologist’s experience, the number of visits may be fewer, at least during the dose-optimization phase, for children who received authorization from another physician . In terms of testing, participants described treating cannabis “like another drug,” with no additional testing performed, while some order additional tests at baseline and while titrating the dose or if the child presented in a “sleepy state,” or being “a lot more cautious with the other medications” prescribed concurrently. Several neurologists described providing counselling and education to families about medical cannabis, which may add to the length of the clinical visit, and one neurologist described offering parents the opportunity to ask follow-up questions via telemedicine after an initial discussion about cannabis. One neurologist described difficulties entering nonformulary medicines into hospital electronic medical records and, for parents who receive authorization at a cannabis clinic, having to rely on parents to supply information about the treatment plan because of a lack of communication from some cannabis clinics .In this qualitative interview study, we explored the experiences and perceptions of neurologists in Canada about the use of medical cannabis for treatment of pediatric drug-resistant epilepsy. Most of the neurologists interviewed for this study viewed medical cannabis as a viable option, particularly after other options had been explored; however, important gaps in the evidence-base were identified, including limited knowledge about the medical properties of cannabinoids beyond CBD, the inability to predict which patients are most likely to benefit from cannabis treatment, and a lack of long-term safety data. Most neurologists reported having overall positive experiences with medical cannabis, although several commented that it’s not a magic pill and that the benefits are likely oversold by the media. In 2013, CNN aired a documentary about Charlotte Figi, a 5-yearold girl with Dravet syndrome. In an attempt to control her drug resistant seizures, Charlotte’s parents initiated a regimen of medical cannabis, reducing her seizures by more than 90 %. Charlotte’s case received considerable media attention and has led, at least in part, to increased interest among parents in the use of cannabis as an alternative or complementary treatment for epilepsy and to increased requests to physicians for cannabis authorization.
Participants in our study also identified the legalization of recreational cannabis in Canada in 2018 as a potential driver of additional interest in medical cannabis. Compared with the public, the medical community has been more slow to adopt cannabis as a treatment for pediatric epilepsy, owing largely to a lack of published clinical studies. Although our study was not intended to quantify support for medical cannabis, we observed that most participants were supportive of a trial of medical cannabis for children whose epilepsy had not responded to other treatments. This is consistent with the findings of a 2019 systematic review, which reported that medical practitioners were largely supportive of the use of medical cannabis across multiple indications, with higher levels of support when other options had been “exhausted.”The Canadian League Against Epilepsy recently published recommendations regarding the use of medical cannabis in the treatment of epilepsy. First, CLAE recommends that patients should make the decision to use cannabis “in consultation with their health care provider to ensure their safety.” Neurologists echoed this, voicing concerns that some parents may be administering cannabis to their children without oversight of a health care professional, which could lead to unsafe situations for the child. The use of complementary and alternative medicine is common among children with epilepsy, and parents may not disclose its use . This further supports the need to establish open communication between parents and health care providers. Second, CLAE “encourages clinicians and researchers to continue to seek further knowledge and education” about medical cannabis.Several neurologists in our study also expressed a desire for additional and ongoing education, in order to better counsel their patients. In a 2015 educational needs assessment of Canadian physicians, 64 % of respondents perceived a strong need for cannabis education, and 70 % felt that receiving cannabis education would better allow them to care for their patients using cannabis. Similarly, a recent systematic review highlighted a lack of self-perceived knowledge among clinicians about medical cannabis, and several groups have called for increased cannabis education. However, there are also several notable differences between our findings and CLAE’s recommendations. First, CLAE acknowledges the differences between purified CBD oil and the CBD:THC cannabis oils available in Canada, stating that “evidence is lacking” for products containing both CBD and THC. In contrast, some participants in this study described inferring the safety and effectiveness of CBD:THC cannabis oils based on studies of Epidiolex, which further highlights the need for additional education about the differences between cannabis-based products. Notably, Epidiolex is not available in Canada at this time, mobile vertical rack and there are important differences between Epidiolex and the products available in Canada. The Canadian CBD:THC oils are whole plant isolates, containing CBD as well as THC in various ratios, as well as other phytocannabinoids , flavonoids, and terpenes. There is also considerable variation in terms of the CBD-THC oils available within Canada.
Most licensed producers in Canada offer multiple products with various ratios and concentrations of CBD and THC, including those high in THC , balanced oils , and those high in CBD . The concentration of cannabinoids is variable across preparations, such that a cannabinoid oil with a 20:1 ratio of CBD to THC from one producer does not necessarily contain the same concentration of CBD as a 20:1 oil from a different producer. There is also potential for variability in cannabinoid concentration between batches of the same product, leading to uncertainty that may affect dosing, cost, adverse effects, and therapeutic efficacy. These complex issues related to the use CBD:THC oils further reinforce the CLAE’s recommendation that clinicians continue to seek additional education about medical cannabis. Second, some participants described referring patients and their families to cannabis clinics or to health care providers who may not be experienced in caring for patients with epilepsy. However, CLAE recommends that “treatment with CBD:THC cannabis oil be managed by a physician knowledgeable and experienced with epilepsy care and anti-seizure medications, preferably with experience in CBD:THC cannabis oil.” Some participants noted departmental policies that prevented them from authorizing cannabis or that neurologists in their group had reached consensus that none would authorize cannabis, instead referring patients to cannabis clinics or leaving families to find other health care providers to authorize use. One participant was particularly critical of the practice of referring complex neurology patients to non-neurology health care professionals, stating that “they owe it to the patient” to find an appropriate neurology referral if the family wishes to pursue medical cannabis.Cannabis sativa L., Cannabaceae, has a long history of exploitation as a medicine, in pain relief and epilepsy, and also in food, textile, and paper industries. The scientific research of Cannabis sativa demonstrates an exponential increase in the past 30 years, as most of its ingredients were isolated and characterized, but the breakthrough was achieved in the discovery of the endogenous cannabinoids and the endocannabinoid system. Also, many study results, personal and anecdotal testimonies changed the public perception, asserting pressure for legislation changes in the definition of Cannabis as a Schedule 1 substance resulting in passing laws that legalize its use for medical purposes. Even though each country/state that passed such law brought specific provisions that vary considerably , the common feature of these laws is that they permit the legal use of cannabis for medical treatment if the patient has obtained appropriate medical authorization.