Pharmacy Students ’ Knowledge and Attitudes Regarding Cannabis for Medical Purposes

Pharmacy Students’ Knowledge and Attitudes Regarding Cannabis for Medical Purposes A Marina S. Stojanović1, Ana D. Tomas2, Milica M. Paut-Kusturica1, Aleksandar L. Rašković1, Milan B. Ubavić2, Zdenko S. Tomić1, Ana J. Sabo1, Olga J. Horvat1 A 1 Department of Pharmacology Toxicology and Clinical Pharmacology, Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia 2 Institute for Laboratory Diagnostics, Medlab, Novi Sad, Serbia


INTRODUCTION
Th roughout history, cannabis has been used to treat a variety of diseases and illnesses.In ancient Greece, Rome, China and India, it was used to ameliorate muscle spasms, cramps and pain [1].At the end of the 19th century in Europe, cannabis was most commonly used for the treatment of pain, asthma, sleep disorders, depression, and loss of appetite [2].Its medicinal use continued until the fi rst half of the 20th century, when cannabis became subject to legal restrictions due to its psychoactive potential.Th e possession, use, and sale of cannabis became illegal in most countries of the world [3].
However, there has been a cultural change regarding the perception and use of marijuana medicinally and recreationally over the past 20 years throughout the world.Th e term "medical marijuana" is generally associated with the use and consumption of the Cannabis plant.Although cannabis contains numerous bioactive constituents, cannabinoids (such as delta-9-tetrahydrocannabinol (THC) -responsible also for marijuana's psychoactive eff ects and cannabidiol (CBD)) are the most potent components of the plant.Research studies demonstrate some benefi ts for the use of medical marijuana for conditions such as severe nausea and vomiting, glaucoma, anorexia, chronic pain, and spasticity related to diseases such as multiple sclerosis [4][5][6][7][8].
Smoking marijuana is the main form of consumption of the cannabis in research studies.A dried (cured) cannabis fl ower can be packed into a pipe, water pipe (bong) or rolling paper ("joint") [9].Tobacco is oft en added to assist burning.A few drops of hash oil may be applied to a cigarette or a joint, or the oil may be heated and the vapors inhaled.
Cannabis can also be consumed orally (e.g.desserts, candies, sodas).When swallowed the onset of the psychoactive eff ects of THC is delayed by about an hour and the 'high' is of lesser intensity although it may last several hours longer [10].
As for the topical application, salves, ointments, lotions, and sprays can be used for the treatment of arthritis, chapped skin, eczema, minor burns, muscle soreness, sunburns, swellings, joint pain, and tendonitis, to name just a few.Th ere are, also, medical cannabis transdermal patches that come in a mild dosages [9].
Nowadays medical cannabis can be prepared also as a sublingual spray [11].
When it comes to Serbia, in the 1700s, Italian farmers and hempseed strains were brought here, making hemp an important crop until the 1900s [12].Th e fi rst law to sanction drug abuse was the Criminal Code of the Kingdom of Serbs, Croats and Slovenes which entered into force in 1930 [13].Th e consumption of the Cannabis plant, which is classifi ed under narcotic drugs in Serbia, meaning it has a high potential for abuse, has no recognized medical uses, and is illegal to prescribe in Serbia (Law on Psychoactive Controlled Substances).
However, the fact that cannabis is the drug most oft en mentioned in reports of drug law off ences in Europe as well as Europe's most commonly used illicit drug has hampered the medicinal use of marijuana.Th is has prompted patients and physicians to lobby governments to approve its use for medical purposes [14].
In recent years, a number of nations have introduced specifi c laws and programs to allow patients to use cannabis preparations in various forms to relieve the symptoms of a range of severe, disabling diseases.In Europe, the member states are free to set their own national drug laws, although all of them are parties of the UN Single Convention.For example, the country with longest experience of cannabis use-both medicinal and recreational-is the Netherlands, where physicians have been able to prescribe cannabis preparations for patients for more than 10 years.Aft er Netherlands, many countries in Europe have allowed the use of cannabis in medical purposes, Macedonian and Poland are the most recent [15].In Serbia the use of cannabis and its derivatives in medical purposes is still not legal, but in the recent years there is an increased interest of society in legalization.
With the growing trend in fi ght for legalization in Serbia, pharmacists are likely to be consulted on the safety, effi cacy, and drugdrug or drug-disease interactions of medical cannabis.Also if medical cannabis will be legalized in future, pharmacists will be the ones who will dispense it and answer to patients' questions about its use, benefi ts or side effects.
Th us, the aim of our study was to assess pharmacy students' knowledge and attitude toward medical marijuana use in Serbia to determine if additional education is needed.

Setting
Students from the fi nal year of the study program of integrated academic studies of pharmacy at the Faculty of Medicine, University of Novi Sad were asked to complete an anonymous questionnaire regarding their knowledge and attitudes on the use of cannabis and its derivatives in medical purposes.Aft er giving their written informed consent, they were instructed by the researchers on how to complete the questionnaire.All questionnaires were administered between August 1, 2017 and August 15, 2017.Th e study was approved by the Ethical Committee of the Faculty of Medicine in Novi Sad; a total of 80 questionnaires were distributed.

Th e questionnaire
Th e questionnaire used in this study is based on the questionnaire of Helena Neziri (2015) [16].Necessary modifi cations were made to enable correct answers to questions and statements.
Aft er the question about gender, students were given 15 statements about the use of cannabinoids in therapeutical purposes.Th ey were asked to mark one number from one (I completely disagree) to fi ve (I completely agree), according to the level of their agreement with the specifi c statement.Th e questionnaire consisted of 3 groups of statements.Th e fi rst group was related to students' knowledge about the use of cannabis and its derivatives in therapeutical purposes, like their familiarity with the current legalization process, possible therapeutical eff ects and pharmaceutical forms of cannabis.Th e second group was related to potential negative eff ects of using cannabis and its derivatives in therapeutical purposes such as side eff ects, abuse and other risks.In the third group, students could fi nd the statements about what should or should not be required when it comes to dispensing cannabis in a pharmacy and legalization of cannabis and its derivatives in medical purposes.Th rough the last statement in this group, students are asked to declare themselves about the issue of legalization specifi cally in Serbia.

RESULTS
One third of the respondents (31.2%) were familiar with the current legalization process of cannabis in therapeutical purposes in Serbia.Although 91.2% of the respondents agreed that cannabis and its derivatives could potentially have therapeutical eff ects, much lower percentage of respondents (51.3%) were familiar with possible therapeutical eff ects of cannabis.About 39% thought of themselves as familiar with the farmaceutical forms of cannabis such as pills, oil, etc.More than a half of respondents (51.3%) learned about therapeutical eff ects of cannabis from sources other than school.
On the question if the use of cannabis and its derivatives in therapeutical purposes could cause addiction as a side eff ect the same number of the respondents (31) gave the positive and the negative answer, but more than a half of the respondents (55%) did not think that the use of cannabis and its derivatives in therapeutical purposes could lead to the consumption of more serious drugs such as heroin or cocaine.About third (31.3%) of our respondents thought that the use of cannabis and its derivatives in therapeutical purposes could cause their abuse and the similar percentage of respondents (33.8%) thought that issuing cannabis and its derivatives in the pharmacy could expose a pharmacist to the certain dangers such as insisting on the issuing without the prescription or robbery.
More than a three quarters (76.3%) of the respondents thought that doctor's prescription is necessary for dispensing cannabis and its derivatives and 71.3% thought that cannabis and its derivatives should not be grouped under OTC medications.Little less than 90% of the respondents agreed it is necessary to create clear guidelines for the use of cannabis and its derivatives in therapeutical purposes, while none of the respondents thought it is not the case.Only one respondent did not think that dispensing cannabis and its derivatives in the pharmacy requires additional education and scientifi c knowledge of the pharmacist about therapeutical eff ect of cannabis.Majority of the respondents (86.2%) thought that the use of cannabis and its derivatives was justifi ed in the case of terminal patients and also, most of the respondents (75%) agreed that, based on the experiences of the countries which have approved the use of cannabis and its derivatives in therapeutical purposes, its use in those purposes should be approved in Serbia.

DISCUSSION
In our study 31.2% of students were familiar with the current legalization process of cannabis in therapeutical purposes in Serbia.
Although almost all the students agreed that cannabis and its derivatives could potentially have therapeutical eff ects, only half of the respondents (51.3%) were famil- additional education and scientifi c knowledge of the pharmacist about therapeutical eff ect of cannabis.
One third of the respondents in our study thought that the use of cannabis and its derivatives for therapeutical purposes could cause addiction as a side eff ect.Dependence is unlikely to present a problem with clinically prescribed doses for patients in therapeutic settings, but withdrawal eff ects may be undesirable.As well as psychological eff ects (restlessness, anxiety and insomnia, tremor), there may be a rebound increase in, nausea, diarrhea and other physical symptoms [26].Withdrawal symptoms are usually short-lived in experimental subjects but they may be more severe in recreational users.When it comes to other side eff ects, although the acute toxicity of cannabinoids is very low and no deaths have been directly attributable to their recreational or therapeutic use, there are some of the adverse eff ects commonly observed during the clinical setting.Th ose include sedation, some psychological eff ects such as euphoria, dysphoria, anxiety, impaired memory, depersonalization, hallucinations and depression and physical symptoms and signs such as dry mouth, ataxia, blurred vision, tremor, palpitations, tachycardia and hypotension [27].iar with possible therapeutical eff ects of cannabis which is similar percentage recorded in the study which was carried out among pharmacy students in USA, Kansas, where cannabis is also not legal for medical purposes [17].Namely, the only approved medical indications correctly identifi ed by more than 50% of pharmacy students were for the treatment of cancer and glaucoma (91% and 57%, respectively).Beside this two, therapeutic uses of medical marijuana are shown in many other diseases and conditions such as spastic disorders, pain, bronchial asthma, nausea and vomiting caused by anticancer drugs, mood disorders, anorexia, epilepsy and glaucoma [18][19][20][21][22][23][24][25].
More than a half (51.3%) of the pharmacy students in Novi Sad learned about therapeutical eff ects of cannabis from sources other than school.In the above mentioned study at the University of Kansas pharmacy students also indicated they had received little to no education regarding the use of medical marijuana in the pharmacy curriculum [17].Th is lack of formal education can be refl ected in the low confi dence and comfort levels in students' ability to answer patients' marijuana questions.What is more, almost every respondent in our study thought that dispensing cannabis and its derivatives in the pharmacy requires About third of our respondents thought that the use of cannabis and its derivatives in therapeutical purposes could cause their abuse.Th e reason for that attitude of those respondents could be the fact that cannabis abuse is increasing and continues to be high in Europe.Th ere are indications that the number of people requiring treatment for cannabis use is increasing.Th e evidence suggests that more drug users are suff ering from cannabis use disorders, and there is growing evidence that cannabis may be becoming more harmful.Th is is refl ected in the high proportion of persons entering treatment for the fi rst time for cannabis use disorders in Europe.Also of note is the important role of international traffi cking in cannabis herb cultivation in the region.Serbia, Bulgaria and Romania report that seeds or saplings are oft en grown in the Netherlands or Belgium and then shipped to South-Eastern Europe for cultivation [28].
Majority of the respondents thought that doctor's prescription is necessary for dispensing cannabis and its derivatives and they should not be grouped under OTC medications.In countries nearby Serbia, where the use of cannabinoids for therapeutical purposes is legal, situation is correlating to our respondents' answers.For example, in Croatia following the recommendation of certain neurology, infectious diseases or cancer specialists, medicines containing THC, dronabinol or nabilone can be prescribed, on non-repeatable prescription, by physicians working in general and family practice, health protection of preschool children and women's healthcare [29].In Czech Republic currently only 16 specially qualifi ed doctors, such as oncologists and psychologists, are authorized to prescribe cannabis, and only 26 pharmacies can dispense it.No country permits the supply or possession of medical cannabis without a doctor's prescription and the cannabis that is provided for medical use is cultivated under government supervision [30].
Little less than 90% of the respondents agreed it is necessary to create clear guidelines for the use of cannabis and its derivatives for therapeutical purposes such as indications, pharmaceutical form, dose and longevity of treatment.In Croatia the doctor's prescription should state the amount of THC in a single dose, the number of individual doses, drug form, dosage and method of use.Medicines containing THC can be prescribed in the quantity necessary for treatment up to 30 days.Th e total amount of prescribed THC in 30 days of treatment must not be greater than 7.5 grams.Th ese medicines may be prescribed to relieve the symptoms of multiple sclerosis, cancer, epilepsy and AIDS.In Czech Republic THC level that can be prescribed is up to 21%.Initially patient limits were 30 grams per month, but these were raised to 180 grams per month in October 2015 [30].
Most of the our respondents (75%) agreed that, based on the experiences of the countries which have approved the use of cannabis and its derivatives for therapeutical purposes, its use in those purposes should be approved in Serbia as well.Also high percentage of the medical students in Belgrade (63.4) was for medical cannabis legalization according to the study which was carried out among medical students in Belgrade, Serbia [31].Th e same attitude was among pharmacy students in Kansas where also majority of the students favored legalizing cannabis for medical purposes.Th ese three results contrast markedly from student attitudes described by Burke and Marx in a study conducted more than 40 years ago.In that study, only a small percentage of pharmacy students (16%) supported the use of medical marijuana [32].

CONCLUSION
Most pharmacy students supported medical cannabis legalization in our study.From the results, it can also be concluded that strict legal regulations concerning control of selling cannabis and its derivates as well as clear guidelines for their use should be implemented.Further education of the pharmacist about therapeutical eff ect of cannabis is necessary.Th erefore, pharmacy schools need to evaluate the adequacy of medical marijuana education in their courses and consider revising curriculum accordingly.

Table 1 .
Students Except from knowledge obtained at school, I learned about therapeutical eff ects of cannabis from other sources (congresses, seminars, workshops, internet, formal literature) ' knowledge about the use of cannabis and its derivatives in therapetucal purposes 1-Completely disagree; 2-Mostly disagree; 3-Neighter agree nor disagree; 4-Mostly agree; 5-Completely agree Data analysis Descriptive statistical data analysis was performed with the statistical program Microsoft Excel 2016.

Table 3 .
Dispensing in a pharmacy and legalization of cannabis and its derivatives in medi- cal purposes 1-Completely disagree; 2-Mostly disagree; 3-Neighter agree nor disagree; 4-Mostly agree; 5-Completely agree OTC medications -Over the counter medications