An Evidence-Based Intervention to Enhance the Readiness of Providers to Discuss Medical Cannabis With Patients Who Have Chronic Neurological Conditions

In 2018, Utah voters approved Proposition 2, which will allow patients to use cannabis when recommended by a licensed provider. Availability and legal implications have left providers with significant knowledge deficits in prescribing cannabis. The purpose of this project was to develop an evidence-based intervention to prepare neurology providers for the legalization of medical cannabis in Utah. The specific aims were to (a) determine a baseline knowledge of medical cannabis among neurology providers; (b) identify gaps in knowledge; (c) disseminate an evidence-based educational intervention that outlines the pharmacology and current evidence available on medical cannabis; and (d) at 2 weeks postintervention, reassess provider knowledge. A short survey about cannabis was sent to 32 providers who care for patients with neurological conditions in outpatient and inpatient settings within the University of Utah Hospital and Clinics. An evidence-based module that reviewed the Utah Medical Cannabis Act, University of Utah guidelines for providers regarding cannabis recommendations, pharmacology, and clinical-trial data, was provided to the 18 providers who responded to the survey. Fourteen days after the module was distributed, a postintervention survey was sent by email. Eighteen providers responded to the preintervention survey, and 11 of those 18 (61%) responded to the postintervention survey. Median survey scores increased significantly from pre- to postintervention in the following areas: increased confidence in discussing cannabis with patients who have epilepsy improved from neither confident or unconfident to somewhat confident (W = 3.5, p = .04); the measure of agreeability on whether or not providers should be recommending cannabis improved from neither agree or disagree to somewhat agree (W = 0, p = .03); side-effects profile of cannabidiol versus tetrahydrocannabinol remained strongly agreeable (W = 15, p = .05); cannabis administration for diminishing motor symptoms in patients with Parkinson's disease declined from neither agree or disagree to somewhat disagree (W = 28, p = .01); and cannabinoid administration to prevent seizure-induced neurotoxicity improved from somewhat agree to strongly agree (W = 0, p = .05). After completing the evidence-based module, providers indicated that (a) cannabis does have a role in medicine, (b) cannabis can improve and/or prevent some symptoms from occurring in patients with chronic neurological conditions, (c) they have a better understanding of the Utah Medical Cannabis Act and University of Utah Health Sciences policy as it relates to writing recommendations, and (d) it is imperative to reschedule cannabis within the Controlled Substance Act in order to conduct further randomized controlled clinical trials. The evidence-based module improved both knowledge and provider comfort in discussing cannabis with their patients. Current federal law remains a barrier to providers recommending cannabis for their patients, as evidenced by variability in provider responses regarding cannabis and federal law. This project can be reproduced for other specialties and has the potential to benefit patients by clarifying questions and concerns of providers.

An Evidence-Based Intervention to Enhance the Readiness of Providers to Discuss Medical Cannabis With Patients Who Have Chronic Neurological Conditions Christopher G. Taylor The University of Utah College of Nursing Abstract Background: In 2018, Utah voters approved Proposition 2, which will allow patients to use cannabis when recommended by a licensed provider. Availability and legal implications have left providers with significant knowledge deficits in prescribing cannabis. The purpose of this project was to develop an evidence-based intervention to prepare neurology providers for the legalization of medical cannabis in Utah. The specific aims were to (a) determine a baseline knowledge of medical cannabis among neurology providers; (b) identify gaps in knowledge; (c) disseminate an evidence-based educational intervention that outlines the pharmacology and current evidence available on medical cannabis; and (d) at 2 weeks postintervention, reassess provider knowledge. Methods: A short survey about cannabis was sent to 32 providers who care for patients 1 with neurological conditions in outpatient and inpatient settings within the University of Utah Hospital and Clinics. An evidence-based module that reviewed the Utah Medical Cannabis Act, University of Utah guidelines for providers regarding cannabis recommendations, pharmacology, and clinical-trial data, was provided to the 18 providers who responded to the survey. Fourteen days after the module was distributed, a postintervention survey was sent by email. Results: Eighteen providers responded to the preintervention survey, and 11 of those 18 (61%) responded to the postintervention survey. Median survey scores increased significantly from pre- to postintervention in the following areas: increased confidence in discussing cannabis with patients who have epilepsy improved from neither confident or unconfident to somewhat confident (W = 3.5, p = .04); the measure of agreeability on whether or not providers should be recommending cannabis improved from neither agree or disagree to somewhat agree (W = 0, p = .03); side-effects profile of cannabidiol versus tetrahydrocannabinol remained strongly agreeable (W = 15, p = .05); cannabis administration for diminishing motor symptoms in patients with Parkinson's disease declined from neither agree or disagree to somewhat disagree (W = 28, p = .01); and cannabinoid administration to prevent seizure-induced neurotoxicity improved from somewhat agree to strongly agree (W = 0, p = .05). After completing the evidence-based module, providers indicated that (a) cannabis does have a role in medicine, (b) cannabis can improve and/or prevent some symptoms from occurring in patients with chronic neurological conditions, (c) they have a better understanding of the Utah Medical Cannabis Act and University of Utah Health Sciences policy as it relates to writing 2 recommendations, and (d) it is imperative to reschedule cannabis within the Controlled Substance Act in order to conduct further randomized controlled clinical trials. Conclusions: The evidence-based module improved both knowledge and provider comfort in discussing cannabis with their patients. Current federal law remains a barrier to providers recommending cannabis for their patients, as evidenced by variability in provider responses regarding cannabis and federal law. This project can be reproduced for other specialties and has the potential to benefit patients by clarifying questions and concerns of providers. Problem Description Cannabis has been used as a medicinal modality for thousands of years. Current records reflect that the Chinese were the first to do this, in the year 2737 BCE (Aggarwal 3 et al., 2009). In the United States, the Controlled Substances Act classifies cannabis as a Schedule I drug, which implies no medical use (United States, 1970). Evidence from clinical trials is therefore limited. The most current evidence available was gathered from small observational studies (Bruce, Brady, Foster, & Shattell, 2018). Congressional inaction has hampered the initiation of substantial clinical trials, ultimately preventing medical providers and patients from accessing a potentially useful medication. An aggregate of studies has shown that providers want more in-depth training on cannabis in order to competently discuss it and feel more comfortable answering patient questions (Brooks, Gundersen, Flynn, Brooks-Russell, & Bull, 2017). Because of the legal issues, medical providers in Utah have a significant knowledge deficit related to prescribing medical cannabis to treat patients with neurological conditions. In 2018, Utah voters approved Proposition 2, which will allow patients to use medical cannabis to treat symptoms of select medical conditions (H.B.3001, 2018). Medical cannabis will be available by prescription to patients in Utah beginning in March 2020. It is critical to ensure that providers are prepared to safely care for patients treated with medical cannabis. Available Knowledge Pharmacokinetics and Pharmacodynamics The bioavailability of orally ingested cannabis is approximately 5% to 10% due to the first-pass metabolism in the liver and the patient's metabolism, whereas the bioavailability of smoked or vaporized cannabis is 15% to 30%, with considerable variation between individuals (McGilveray, 2005). Cannabinoids are metabolized by 4 isoenzymes CYP3A4 and CYP2C9. CYP3A4 inhibitors increase serum tetrahydrocannabinol (THC) concentration and duration of action. The endocannabinoid system has prominent roles in regulating various functions of the central/peripheral nervous system, endocrine system, and immune system. CB1 and CB2 receptors are found in the previously mentioned areas of the human body and play a direct role in modulating pain, inflammation, and feelings of anxiety. The majority of cannabinoids, including THC, interact with cannabinoid receptors within the body; cannabidiol (CBD), however, has a low affinity for these receptors but does have effects on other receptors, such as serotonin receptors, opioid receptors, and nonendocannabinoid G protein-coupled receptors (Silvestro, Mammana, Cavalli, Bramanti, & Mazzon, 2019). Applications in Chronic Brain Disease Subjective data regarding the use of medical cannabis instead of opiates or diseasemodifying drugs for Multiple Sclerosis (MS)-related symptoms include the following: "Topical cannabis has a faster onset and fewer side effects than the opiates I took before." "The effects last longer." "Relieve the fear of severe liver damage from taking opiates over long periods" (Bruce, Brady, Foster, & Shattell, 2018). A 2012 study showed that smoked cannabis was superior to placebo for pain relief and other related MS symptoms in patients with treatment-resistant spasticity (CoreyBloom et al., 2012). Treatment with a CBD/THC combination oral spray was found to subjectively relieve symptoms of pain, spasticity, and bladder dysfunction in patients who were refractory to traditional treatment (Patti et al., 2016. The Ashworth Scale is the most 5 often used and validated scale currently established to measure spasticity in patients with MS. A multicenter, randomized, placebo-controlled trial utilized the Ashworth Scale to assess whether there is spasticity relief related to cannabis for patients with MS. The trial found that treatment with cannabinoids did not improve spasticity in these patients when measured by the Ashworth Scale, but did show a benefit in two secondary measures, including improvement in mobility and the patient's perception of spasticity (Zajicek et al., 2003). In 2015, a meta-analysis identified 11 studies assessing spasticity associated with MS in 2,138 participants. Cannabinoids showed more average improvement on the Ashworth Scale for spasticity compared with a placebo, but there was no statistical significance observed (Whiting et al., 2015). In Parkinson's patients treated with 300 mg of CBD per day, there were significant improvements in functioning and in overall well-being compared with another group treated with a placebo (Chagas et al., 2014). Although these subjective data reflect an improvement in well-being, the study found no statistically significant differences in the Unified Parkinson's Disease Rating Scale, which assesses motor and general symptoms and is scored by a neurology provider (Chagas et al., 2014). In an anonymous questionnaire sent to all patients who attended the Prague Movement Disorder Center, 25% of 339 respondents had used cannabis for symptom relief, with approximately half stating that they felt an improvement in symptoms. These patients took cannabis leaves orally and reported improvement of Parkinson's symptoms, including less rigidity, bradykinesia, resting tremor, and levodopa-induced dyskinesia (Venderová, Růžička, Voříšek, & Višňovský, 2014). 6 Contraindications Absolute contraindications include acute psychosis and psychiatric syndromes that are in an unstable phase. Relative contraindications include heart arrhythmias and other cardiac syndromes; use resulting in cannabis hyperemesis syndrome; and use of cannabinoids in conjunction with anticholinergics, which can amplify tachycardia and hypertension (Fugh-Berman et.al, 2015). Rationale A study that surveyed physicians in training reported that a significant proportion (89.5%) of residents and fellows felt they were unprepared to discuss medical marijuana with their patients. In addition, 84.9% said they had received no education about medical marijuana during medical school or residency (Evanoff, 2017). Physicians who are leaders in their field feel unprepared, as well. In expressing his support for reclassifying cannabis within the Controlled Substances Act (United States, 1970), the president of the American Academy of Neurology, James C. Stevens, stated, "Many conditions that are the focus of potential medical cannabis treatments are neurologic in nature (Stevens, 2019; American Academy of Neurology (AAN), 2019). However, neurologists are left with little scientific research on which to base appropriate prescribing decisions for their patients (AAN, 2019). Recent research studies that explored the utility of treating patients who suffer from chronic neurological diseases with medical cannabis share some commonalities: expressed need by physicians for further research, citing the need to reclassify cannabis within the Controlled Substance Act (United States, 1970); a significant amount of 7 subjective evidence from patients advocating its efficacy; and a vast number of medical providers who feel they are unprepared from a knowledge perspective to prescribe or recommend cannabis to their patients (Evanoff, 2017; Stevens, 2019). Change in healthcare is accelerated by innovation and curiosity. For change to fundamentally alter a healthcare process, the forces that relish the familiarity of stagnation must be opposed by an opposite and more potent force. Lewin's theoretical change framework can assist in conceptualizing the transformation cannabis has had on the medical community and how organizational change can maximize efficiency, effectiveness, and sustainability (Batras, Duff, & Smith, 2014). The framework outlines three stages: unfreezing, change, and refreezing. The unfreezing stage took place with the neurology providers' willingness to complete the presurvey, then subsequently review the evidence-based module and consider it within the framework of making progressive changes to their practice. The refreezing stage will be fluid through the preintervention survey and will begin to solidify on exposure to the evidence-based intervention. The vicissitudes of cannabis policy and the deep roots it has in individual morality ensure passionate consideration among providers of this newly available treatment modality. Specific Aims The purpose of this project was to develop an evidence-based intervention to prepare neurology providers for the legalization of medical cannabis in Utah. The specific aims are (a) to determine a baseline knowledge of medical cannabis among neurology providers, (b) to identify gaps in knowledge, (c) to disseminate an evidence- 8 based educational intervention that outlines the pharmacology and current evidence available on medical cannabis, and (d) after 2 weeks, to subsequently reassess provider knowledge postintervention. The intent of this project was not to convince neurology providers that they should be prescribing cannabis to their patients. Instead, it was to prepare providers to competently discuss cannabis with their patients and determine if cannabis is an appropriate treatment modality. Methods Context The Imaging and Neurosciences Center (INC) was located in the foothills of the Wasatch Mountains 10 minutes from downtown Salt Lake City. INC was a satellite clinic of the University of Utah Hospital & Clinics (UUHC). The INC consisted of four different outpatient clinics, including the Surgical Specialty Clinic, the Radiology Clinic, the Chronic Cough Clinic, and the Neurology Clinic. The Neurology Clinic was one site where the evidence-based intervention took place. Providers at this clinic cared for patients with a wide range of neurological disorders, including but not limited to chronic headache, migraine, Parkinson's disease, Tourette's syndrome, Huntington's disease, postural orthostatic tachycardia syndrome, multiple sclerosis, Alzheimer's disease, Guillain-Barré syndrome, myasthenia gravis, unspecified cognitive disorders, and neuroautoimmune diseases. The INC was inherently a teaching clinic. The team at INC consisted of two administrators who checked in the patients, five medical assistants, two registered nurses (RNs), a clinic manager, a patient customer service representative, two medical students, 9 two neurology residents, a pharmacist, and 14 providers. Providers at INC were independent in their roles, but teamwork was highly valued. Patient cases were discussed daily, and referrals within the clinic were frequent during the diagnostic process. The other intervention site was the Neuro Critical Care Unit (NCCU) at University of Utah Hospital. The NCCU was a 23-bed neurology intensive care unit that provided postoperative care for patients who had undergone brain surgery and medical care for patients who had traumatic brain injuries, strokes, encephalitis, and other neurological disorders. Unit staff consisted of three health care assistants, a health unit coordinator, a nurse manager, two clinical nurse coordinators, 14 bedside RNs, 3 neurology/neurosurgery residents, three nurse practitioners/physician assistants, two respiratory therapists, a social worker/case manager, and a critical care intensivist physician. At the time of the intervention, the providers on NCCU were not prescribing cannabis to patients in the ICU; however, some of the providers also worked in an outpatient setting, and their experiential knowledge was valuable to the project. Intervention The intervention, entitled "An Evidence Based Intervention to Enhance the Readiness of Providers to Discuss Medical Cannabis with Patients Who Have Chronic Neurological Conditions," consisted of an initial anonymous survey sent to providers to assess baseline knowledge and preconceptions about medical cannabis for their patient population. Each provider was assigned a unique 4-digit identifier that would allow for anonymity and for comparative analysis pre- and postintervention. After the surveys were completed, data were analyzed to identify gaps in 10 knowledge; clarify questions, concerns, or misconceptions; and gain an understanding of whether providers currently felt cannabis was a legitimate medical therapy for their patients. These data assisted in molding the evidence-based educational intervention specifically to this provider population. The module consisted of cannabis pharmacology, the available clinical-trial evidence and observational data from patients, and a section that addressed specific provider questions or concerns collected from the initial survey assessment. After the educational module was delivered by way of a PowerPoint presentation, a post survey was sent 14 days later to every respondent who completed the initial survey. The purpose of the post survey was to determine if the evidence-based module created a change in how they would practice in terms of preparing them to discuss cannabis as a medical modality with their patients. The evidence-based intervention was created by utilizing the most current research available on medical cannabis. Research and clinical-trial data were identified primarily using the following databases: PubMed, EBSCO, and Google Scholar. Current evidence related to the pharmacokinetics and pharmacodynamics of cannabis and available clinical-trial data were the core aspects of the module. Additional information was integrated from questions asked by providers on the initial survey. This project is generalizable in states where medical cannabis is legal and may be replicated in another outpatient clinic that treats patients with chronic neurological conditions. The data were specific to neurology patients; therefore, it may not be transferrable to other outpatient clinics, such as family practice or a cardiac clinic. The 11 pharmacodynamic and pharmacokinetic data are generalizable and can be used across the spectrum of healthcare. The project team consisted of a DNP-FNP student, a neurology-subject-matter expert, a teaching expert who was then the manager of the University of Utah Stroke Center and was previously the nursing educator on NCCU for 6 years, and a project faculty member. Study of the Intervention The approach used to assess the impact of the intervention was a survey delivered to providers after the evidence-based module was provided to them. A period of 14 days was given to ensure that providers had adequate time to review the module, to allow a lag between the module and the posttest to ensure that providers codified and remembered the information, and to allow respondents to contact the creator of the module if questions arose. Data collected from the questions asked on the postintervention survey assisted in determining if the module increased the preparedness of neurology providers to discuss medical cannabis with their patients. Comparison of responses related to the pharmacodynamics and pharmacokinetics of cannabis included questions that asked providers to identify if they strongly agreed, somewhat agreed, were neutral, somewhat disagreed, or strongly disagreed with specific statements. For example: "Cannabidiol is less psychoactive than tetrahydrocannabinol and commonly used for an analgesic, sedative, anti-emetic, and as an appetite stimulant." "Cannabis may be used in the prevention of the initial mechanisms triggering a migraine aura and the subsequent pain." Utilizing a numerical scale from 1 (not prepared at all) to 5 (very prepared), providers 12 were asked to rate their confidence in discussing medical cannabis with their patients after learning from the evidence-based module. Participants were also provided with a free-text section to allow them to elaborate their responses to that question if they chose to do so. Based on a search done at the time this project was implemented and on provider responses to direct questions, there was no other similar project currently being implemented. To our knowledge, no published survey aimed at assessing the readiness of neurology providers to discuss and prescribe cannabis to their patients currently exists. In early 2019, a survey of the attitudes toward, beliefs about, and knowledge about medical cannabis was conducted among primary care providers and was used as a template to create a survey specific for providers who cared for patients with chronic neurological conditions (Philpot, Ebber, & Hurt, 2019). Measures The surveys were created based on a Likert-type-scale framework with free-text questions included at the end of the surveys. Free-text questions were included to identify supplementary provider needs and gaps in knowledge that could be addressed in the evidence-based module. Providers were sent an email containing a link to the preintervention survey and a unique 4-digit identifier for each participant that allowed for anonymity and enabled comparative statistics with the post survey. The preintervention survey included questions pertaining to the pharmacology, benefits, and side effects of medical cannabis; contraindications; provider preference for how the evidence-based educational module would be disseminated; provider perception of a need for evidence- 13 based recommendations for medical cannabis; questions providers currently had; openended questions about preconceived notions of cannabis used for medicinal purposes; and provider willingness to prescribe medical cannabis based on current evidence. The preintervention survey was created by incorporating general survey questions from Philpot, Ebber, and Hurt's (2019) research on primary care providers and medical cannabis and by creating additional questions in relation to patients with neurology sequelae. Survey data were analyzed to identify (a) measurable perceived benefits of the module; (b) personal narratives from the providers, to assist in identifying future needs for medical cannabis as a therapeutic modality; and (c) the utility and usability of the module in improving providers' competence in discussing and utilizing medical cannabis in their practice. Survey Monkey was used to collect data for both the pre- and postintervention survey. This specific software was selected for ease of use for both the creator and the person taking the survey. In addition to ease of use, the software is available at no cost. Neither survey contained any protected healthcare information requiring HIPAA compliance. As a critical care nurse, the project lead worked with each provider from the NCCU weekly and spent 2 or 3 days per week at INC as a DNP-FNP student, which allowed for ongoing input from stakeholders. Continued follow up was pertinent for these provider groups, and this working relationship enabled the sustainability of this project. Analysis Demographic (Table 1) and outcome variables (Tables 2, 3, 4) were described 14 using frequency distributions and appropriate summary statistics for central tendency and variability. The Wilcoxon signed-rank test was used to measure the change between preintervention and postintervention scores. A content analysis was conducted on the open-ended survey questions. The words were read word for word and then coded. Next, the coded data were categorized, organized, and summarized. Ethical Considerations The University of Utah Institutional Review Board determined this study to be exempt from human-subject review. The creator of this project had no conflicts of interest concerning this study. Results Process Measures and Outcomes Eighteen providers completed the preintervention survey and 11 completed the postintervention survey (see Appendix A). The 11 participants who completed both surveys consisted of nurse practitioners (n = 5), physician assistants (n = 2), and physicians (n = 4). The average time needed to complete each survey was 5 minutes. Critical conceptual data related to enhancing provider readiness to discuss cannabis with their patients are listed in Tables 3 and 4. A Wilcoxon signed-rank test indicated that the median posttest confidence levels in answering questions from patients with epilepsy about medical cannabis was statistically significantly higher than pretest, W = 3.5, p = .04 (Table 3). The test reflected the median posttest degree of agreeability that medical providers should be recommending cannabis for managing medical conditions was statistically significantly higher than pretest, W = 0, p = .03 (Table 3). The test also 15 showed that the median posttest degree of agreeability on the statement that cannabidiol (CBD) is less psychoactive than tetrahydrocannabinol (THC), and is commonly used for an analgesic, sedative, anti-emetic, and/or as an appetite stimulant was statistically significantly higher than pretest, W = 15, p = .05 (Table 3). Results showed the median posttest measure of agreeability on the statement that cannabis (CBD, THC, or both) may diminish motor symptoms and pain associated with Parkinson's disease was statistically significantly lower than pretest, W = 28, p = .01 (Table 3). Lastly, statistics indicated that the median posttest measure of agreeability on whether phytocannabinoid administration may prevent seizure-induced neurotoxicity and can reduce seizure severity was statistically significantly higher than pretest, W = 0, p = .05 (Table 4). After completing the evidence-based module, 10 participants (91%) indicated that even if they chose not to recommend cannabis for their patients, they strongly agreed or somewhat agreed that they were better prepared to discuss medical cannabis with their patients. All participants (N = 11) reported that the module improved their knowledge of the Utah Medical Cannabis Act (H.B.3001, 2018), 10 participants (91%) felt the module improved their knowledge on the University of Utah Health Sciences policy on recommending cannabis, 8 participants (73%) felt the module improved their knowledge on cannabis pharmacology, and 10 (91%) felt the module improved their knowledge of potential clinical benefits. Slightly more than half (63.6%, n = 6) of the respondents strongly agreed or somewhat agreed that for patients who can independently care for themselves and are free from baseline cognitive impairment, they would feel comfortable recommending medical cannabis based on their subjective report of 16 symptom improvement (with a qualifying diagnosis outlined in the Utah Cannabis Act). After analyzing the participants' responses, a presumed barrier appeared between the Controlled Substance Act (United States, 1970) and providers being comfortable recommending cannabis to their patients, as the data reflected that 3 participants (27%) strongly agreed or somewhat agreed that they were not comfortable recommending medical cannabis due to federal law, 3 (27%) neither agreed nor disagreed that federal law was a barrier to them recommending medical cannabis, and 5 (46%) somewhat disagreed or strongly disagreed that federal law was a barrier to them recommending cannabis. Common themes from the pretest assessment of barriers to prescribing cannabis to patients were the need for more randomized controlled trials and changing the schedule of cannabis within the Controlled Substance Act (United States, 1970) (Table 2). Contextual Elements Contextual elements that might have affected responses include lack of motivation for change, objections related to moral beliefs, and the two practice settings participants were selected from, inpatient Neuro Critical Care and the outpatient Imaging & Neurosciences Center. A technical problem that occurred and was corrected in the pretest was related to providers being asked to enter a unique 4-digit identifier in response to Question 1; this was originally coded as being optional. Nine initial respondents did not enter their unique identifier; therefore, follow-up emails were sent to appropriately identify the participants. Unintended Consequences 17 Three measures of agreeability were developed with evidence taken from peerreviewed clinical trials (Table 4). Results did not reflect statistically significant median data between pre-and posttests on statements related to the neuroprotective effects of cannabinoids on Alzheimer's disease and the preventive efficacy of cannabis in the pathophysiologic mechanism of migraine. The posttest was delivered 1 week prior to Thanksgiving. The attrition of participants could have been a result of people leaving on holiday and not checking their email. Participants who did not respond to the initial delivery of the posttest were contacted a second and third time. After the third contact, additional follow up was not attempted. Discussion Summary Key findings from this quality-improvement project confirmed previous findings: that providers want more in-depth training on the utility of cannabis in medicine. The knowledge deficit with regard to the pharmacology of cannabis and discussing cannabis with patients were subjectively improved after the implementation of the evidence-based intervention. All participants reported improved knowledge of the Utah Medical Cannabis Act (H.B.3001, 2018), and approximately two thirds of the participants indicated that they would feel comfortable recommending medical cannabis for patients with a qualifying diagnosis under the Utah Cannabis Act who could independently care for themselves and were free from baseline cognitive impairment. Hesitation in recommending cannabis to patients remained because of legal implications related to 18 federal law classifying cannabis as a Schedule I drug. Surprisingly, the results did not reflect any statistically significant median data with regard to the providers' understanding of the neuroprotective effects cannabis exhibits in migraines and Alzheimer's disease that was reported in peer-reviewed clinical trials. This identifies both a failure and an opportunity in that there is recent evidence available that should be presented to providers to ensure that they have information that could positively impact their practice (Lochte, Beletsky, Samuel, & Grant, 2017). Interpretation Preintervention survey results assessing how prepared providers felt to discuss cannabis with their patients were congruent with findings from Evanoff (2017) and Stevens (2019) in that providers overwhelmingly felt unprepared (Stevens, 2019). A common trend among providers surveyed, when asked what concerns they had about recommending cannabis to patients, was the lack of quality randomized controlled trials. This concern from the neurology providers who participated in this survey was consistent with the concern expressed by James C. Stevens, president of the American Academy of Neurology (Stevens, 2019). Overall, observed and anticipated outcomes were congruent with each other. Baseline knowledge and gaps in knowledge about medical cannabis were identified. Challenges and obstacles providers must navigate were established. Current evidence and clinical-trial data on cannabis were presented. Provider confidence in discussing cannabis with patients was increased. Attitudes toward a willingness to recommend cannabis were improved. Future needs in order to recommend cannabis to patients were identified. An 19 unexpected outcome was subjective improvement on knowledge of the Utah Medical Cannabis Act (H.B.3001, 2018) and the University of Utah Hospitals & Clinics position on recommending cannabis to patients. The timing of the intervention, 3 months prior to the enactment of the Utah Medical Cannabis Act (H.B.3001, 2018), was ideal for safely preparing providers to make clinical decisions in recommending cannabis to their patients based on the evidence currently available. There was a consensus among respondents that their knowledge of the pharmacology and utility of cannabis, their knowledge of related federal law, and their confidence in discussing cannabis within their practice were positively augmented in comparison with their knowledge and confidence before completing the module. The impact of this project on providers was positive. Incremental value to providers was added by means of knowledge and confidence in discussing cannabis with patients. Additional impact will become realized over time, following the enactment of the Utah Medical Cannabis Act (H.B.3001, 2018) on March 1, 2020. The results were promising with respect to providers becoming aware of an additional modality to treat symptoms of chronic neurological conditions, such as spasticity associated with multiple sclerosis, and an additional pharmacological option that interrupts the pathological process of disease while preventing potential permanent neurological damage in epilepsy. The Utah Medical Cannabis Act (H.B.3001, 2018) was not enacted until March 1, 2020. Because of the time requirements of this project, the evidence-based intervention was distributed 3 months before the law was enacted. Therefore, it was not possible to determine if the intervention resulted in a change of 20 practice among the providers surveyed. Limitations Results are from one medical center in Utah and therefore may not be generalizable to medical centers in states where cannabis is legal, or to other types of practices (e.g., small community-based practices). One factor that could have contributed to bias was the professional relationship that existed between the project lead and participants. The pre and post surveys were anonymous, but because the participants knew the creator of the project, a potential for bias did exist. Efforts were made to minimize limitations, including incorporating questions from another survey about medical cannabis sent to primary care providers and creating the surveys in such a way that a short time commitment from providers could be achieved. Conclusions Federal law remains a barrier to providers recommending cannabis for their patients, as evidenced by variable responses regarding cannabis and federal law. The evidence-based module improved both knowledge and provider comfort in discussing cannabis with patients. This project can be reproduced for other specialties and has the potential to benefit patients by clarifying questions/concerns of providers. Recommending cannabis for symptom relief is in its infancy, as is the medical community's understanding of cannabis as a medical modality. There are three primary implications of this project for clinical practice and further study. First, in order for more extensive randomized clinical trials to take place in the United States and in order to alleviate provider fear when recommending cannabis to 21 their patients, cannabis needs to be rescheduled within the Controlled Substance Act (United States, 1970). Second, there was consensus among this group of 11 medical providers that cannabis has a legitimate use in medicine. Third, further research is needed, specifically on dosing of cannabis among patients with chronic neurological conditions. The most crucial next step is for Congress to remove cannabis as a Schedule I drug and reschedule it in a category that would allow for a more significant number of randomized clinical trials to take place in the United States. Author Note I give everlasting gratitude and thanks to the project chair, Jenny Alderden, and neurology content expert, Jeanette Sherman. 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The Lancet,362(9395), 1517-1526. doi:10.1016/s0140-6736(03)14738-1 Table 1 Demographics of Presurvey 26 n % 4 2 1 3 1 36.3% 18.2% 9.10% 27.3% 9.10% Type of Provider Nurse practitioner Physician assistant Physician 5 2 4 45.5% 18.2% 36.3% Years of Experience 0-5 years 6-10 years 11-15 years 16-20 years 21+ years 5 2 1 1 2 45.5% 18.2% 9.10% 9.10% 18.2% Primary Practice Setting Inpatient critical care Outpatient clinic 4 7 36.3% 63.6% Characteristic Age Range 25-34 years 35-44 years 45-54 years 55-64 years 65+ years 27 Table 2 Presurvey Themes and Subthemes Theme Anticipated Benefits of Medical Cannabis Subthemes Relief of spasticity in patients with multiple sclerosis Seizure prevention No benefits Relief of chronic pain Relief of neuropathy Pain relief with fewer side effects than opiates and over-the-counter pain medications Appetite stimulation Easing anxiety Relief of nausea Concerns About Cannabis as an Adjunct Medication Poorer cognitive function Lack of randomized controlled trials; little reproducible quality evidence currently available Medication interactions Legal implications Being pressured by patients to prescribe cannabis Cannabis becoming the new opiate Patients will start with Cannabidiol and then want tetrahydrocannabinol Cannabis can cause depression Monitoring for elevated transaminase, drug-to-drug interactions; no regulatory oversight on various products and fillers; limited time spent with providers 28 Table 3 Measuring Change in Provider Confidence Alzheimer's Disease Somewhat confident in answering questions from patients with Alzheimer's disease about medical cannabis Median Confidence 2 Weeks Postintervention Somewhat confident in answering questions from patients with Parkinson's disease about medical cannabis Somewhat confident in answering questions from patients with Alzheimer's disease about medical cannabis Multiple Sclerosis Somewhat confident in answering questions from patients with multiple sclerosis about medical cannabis Somewhat confident in answering questions from patients with multiple sclerosis about medical cannabis Epilepsy Somewhat confident in answering questions from patients with epilepsy about medical cannabis Confident in answering questions from patients with epilepsy about medical cannabis 3.5 .04 Migraine and Headache Somewhat confident in answering questions from patients with migraines/ headaches about medical cannabis Somewhat confident in answering questions from patients with migraines/ headaches about medical cannabis 14.5 .66 Measure Parkinson's Disease Median Confidence Preintervention Little confidence to answer questions from patients with Parkinson's disease about medical cannabis 29 W p 1.5 .13 6 .19 6 .19 Essential Tremor Little confidence to answer questions from patients with essential tremor about medical cannabis Peripheral Somewhat confident in Neuropathy answering questions from patients with peripheral neuropathy about medical cannabis Somewhat confident in answering questions from patients with essential tremor about medical cannabis 2 .17 Somewhat confident in answering questions from patients with peripheral neuropathy about medical cannabis 3 .12 W p 0 .17 0 .03* 18.5 1 Table 4 Measuring Change in Perceptions About Cannabis Postintervention Measure Median Reported Agreement Preintervention Median Reported Agreement 2 Weeks Postintervention Somewhat agree Cannabis is a legitimate medical therapy Neither agree or disagree Medical providers should be recommending cannabis for managing medical conditions Neither agree or disagree Somewhat agree Medical cannabis can have significant drug-drug interactions with other prescribed medications Somewhat agree Strongly agree Side effects of cannabis outweigh the benefits for its use as a medical modality Neither agree or disagree Neither agree or disagree 9 .78 Cannabidiol (CBD) is less psychoactive than tetrahydrocannabinol (THC) and is commonly used for an analgesic, sedative, anti-emetic, and/or as an appetite stimulant Strongly agree Strongly agree 15 .05* Cannabis (CBD, THC, or both) use may diminish spasticity and pain associated with multiple sclerosis Somewhat agree Somewhat agree 7 .58 30 Cannabis (CBD, THC, or both) may diminish motor symptoms and pain associated with Parkinson's disease Neither agree or disagree Somewhat disagree 28 .01* Cannabis (CBD, THC, or both) may reduce the mean pain intensity in patients who suffer from neuropathic pain Somewhat agree Somewhat agree 7.5 1 Cannabis (CBD, THC, or both) may diminish motor symptoms associated with essential tremor Neither agree or disagree Somewhat agree 12 .82 Cannabinoids are hypothesized to have antioxidant, anti-inflammatory, and neuroprotective effects, which may diminish the effects of beta-amyloid toxicity in patients with Alzheimer's disease Neither agree or disagree Somewhat agree 9 .82 Cannabis may be used in the prevention of the initial mechanisms triggering a migraine aura and the subsequent pain Neither agree or disagree Somewhat agree 6 .37 Phytocannabinoid administration may prevent seizure-induced neurotoxicity and can reduce seizure severity Somewhat agree Strongly agree 0 .05* Note. * = statistically significant. 31 Appendix A Preintervention Survey 32 33 34 35 36 37 38 39 Appendix B Postintervention Survey 40 41 42 43 44 45 Appendix C Evidence-Based Intervention Distributed to Providers 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61