Abstract
Background:
Since cannabis has been legalized in Canada for medicinal and recreational use, there has been an increased demand on pharmacists for cannabis counselling. The aim of the study was to examine typical questions posed by consumers to managers and budtenders working at licensed recreational cannabis stores in Canada and to assess how often consumers seek unlicensed medical advice to treat various conditions using cannabis.
Methods:
An online survey was synthesized, consisting of 22 questions capturing demographics and Likert scale responses to survey questions, and was distributed online across Canada from January to June 2021.
Results:
There were 211 survey respondents: 91 budtenders and 120 managers. A total of 87.7% (n = 185) of respondents indicated that they receive questions related to cannabis use for medical purposes and/or perceived medical benefit, with the same number indicating that they have been told by a customer that their physician sent them to obtain a cannabis-containing product for medical purposes. The most common cannabis component asked about in an average day was THC (42% of responses).
Conclusion:
An alarming proportion of budtenders and managers in Canada report that they are fielding medical cannabis questions. This situation has the potential to put individuals at risk for drug-drug interactions and drug-disease interactions and to increase unnecessary hospitalizations due to adverse effects.
Introduction
The landscape of legal cannabis use in Canada has evolved significantly over the past several years. On October 17, 2018, cannabis was legalized for recreational use in Canada via the approval of Bill C-45. On this date, the Cannabis Act (2018) replaced the Access to Cannabis for Medical Purposes Regulations (ACMPR).1,2 The legalization and implementation of the Cannabis Act significantly changed the process by which consumers are able to access cannabis products in Canada. The methods by which cannabis can be legally obtained are regulated at both a federal and a provincial level, with management of recreational distribution processes mainly falling under the mandate of the individual provinces. 2 Initially, cannabis was available only through online purchases from stores such as the Ontario Cannabis Store. Subsequently, recreational cannabis retailers were authorized to open brick-and-mortar stores and sell cannabis products to consumers.
Knowledge into Practice.
Provincial organizations that oversee the sale of cannabis require that all store managers, employees and retail authorization holders complete an approved cannabis education program.
Under the directives of this training, recreational store employees, also called budtenders, and managers are prohibited from providing medical or therapeutic advice to customers looking to treat their conditions with medical cannabis.
An alarming proportion of budtenders and managers in Canada reported that they field medical cannabis questions, mainly related to the use of cannabis to help with anxiety, depression and insomnia-related disorders, and that Canadians are frequently told by their family doctors to pick up their medication from recreational retail stores.
These results highlight the need to investigate whether patients prescribed medical cannabis experience adverse effects differently if they are followed by an approved health care professional such as a pharmacist.
Mise En Pratique Des Connaissances.
Les organismes provinciaux qui supervisent la vente du cannabis exigent que tous les directeurs de magasin, employés et titulaires d’un permis de vente au détail suivent un programme de formation approuvé sur le cannabis.
Sous les directives de ces formations, les employés des magasins de vente au détail de cannabis récréatif, également appelés conseillers en cannabis, et les directeurs ne sont pas en mesure de fournir des conseils médicaux ou thérapeutiques aux clients qui souhaitent traiter leur maladie à l’aide de cannabis médical.
Un taux alarmant de conseillers en cannabis et de directeurs au Canada ont déclaré qu’ils répondent à des questions sur le cannabis médical, principalement liées à son utilisation pour lutter contre l’anxiété, la dépression et les troubles liés à l’insomnie, et que les Canadiens se font souvent dire par leur médecin de famille d’aller chercher leurs médicaments dans des magasins de vente au détail de cannabis récréatif.
Ces résultats soulignent la nécessité de vérifier si les patients à qui l’on a prescrit du cannabis médical présentent des effets indésirables différents s’ils sont suivis par un professionnel de la santé agréé, comme un pharmacien.
Provincial organizations that oversee the sale of cannabis (e.g., Alcohol and Gaming Commission of Ontario) require that all store managers, employees and retail authorization holders complete an approved cannabis education program (e.g., CannSell in Ontario) before starting to work in a cannabis retail store.3-5 Under the directives of this training, recreational store employees, also called budtenders, and managers are prohibited from providing medical or therapeutic advice to customers looking to treat their conditions with medical cannabis. However, with the recent legalization of cannabis for recreational purposes, the ease of access to cannabis has significantly increased, especially with the presence of local brick-and-mortar storefronts. Thus, patients wishing or needing to use cannabis for medical purposes might be inclined to obtain cannabis from one of these stores even though these stores are not licensed to provide medical advice. 6
In a recreational cannabis store, a patient who wants to obtain cannabis products to treat a medical condition and seeks information regarding the therapeutic use of cannabis will likely require the assistance of the store employees.6,7 Since these employees are nonmedical staff, the patient cannot receive reliable and appropriate information.8-10 This has been observed in countries where recreational cannabis has been legalized for longer than in Canada, especially in the United States.7-9 A survey conducted by Haug et al. 9 showed that 94% of the budtenders questioned gave advice to patients about cannabis strains, dosage, disease-specific information, benefits for specific symptoms and suggested administration methods, despite their lack of formalized medical training. The recommendations and counselling made by the budtenders were based on empirical but also nonempirical sources, and some of the advice given was not consistent with the existing literature. 8 Indeed, this identifies a gap in health care in Canada, a gap that is further complicated with the emerging trend of Canadian cannabis dispensaries serving pregnant and breastfeeding women.11,12
Taken together, the available evidence indicates that the current purchasing landscape for cannabis may lead Canadians to potentially receive therapeutically inappropriate products (i.e., incorrect dosage forms or ratios) as well as lead to a lack of information pertaining to specific medical conditions, side effects or interactions with other prescription medications.8,9 This situation could put individuals at a significant disadvantage compared with those who have access to cannabis-experienced health care professionals guiding treatment, potentially unnecessarily exposing Canadians to potential risks. 8 With the increase in cannabis use as well as the methods used to acquire cannabis products, the aim of this survey was to examine typical questions posed by consumers to managers and budtenders working at licensed recreational retail cannabis stores in Canada and to assess how often consumers seek medical advice to treat various conditions using cannabis.
Methods
Study design and participants
A review of the literature regarding cannabis dispensaries and employee knowledge was conducted through PubMed and Google Scholar. A survey was then developed that focused on (1) sociodemographics of employees and managers; (2) customer questions regarding cannabis use; (3) the frequency of these questions; and (4) demographics of customers. The survey was built and administered using the Research Electronic Data Capture (REDCap) platform.
This study was approved by the Children’s Hospital of Eastern Ontario Research Ethics Board. There was no budget associated with this study, and it was conducted without any additional funding. The invitation letter, which served as the consent form, provided a link for the survey.
Employees and managers of licensed cannabis retail stores in Canada were recruited to participate in the survey by means of targeted social media advertisements on Facebook, Twitter, Instagram and community platforms as well shared social media posts. Advertisements contained the links directing participants to the web-based survey administered. To incentivize the completion of the survey, respondents were offered a chance to win a $50 gift card upon completion. The survey was open from January 2021 to June 2021.
For the purposes of this survey, “medical cannabis” or “cannabis use for perceived medical benefit” was defined as the use of cannabis with the intention to treat any kind of illness or ailment (i.e., not including recreational cannabis use).
Sociodemographics of cannabis retail workers
Participants were screened using the question “Are you an employee of a licensed cannabis store?” (yes or no). Their position in the cannabis store was investigated with the statement “Describe your position at the licensed cannabis store,” with the suggested answers being “manager” or “budtender.” The participants’ completion of training was assessed with the question “Have you completed the CannSell course?” (yes or no) (results not shown). The survey also included some questions about demographics (i.e., age, sex), organization of work (i.e., working time, seniority in the company) and cannabis retailer characteristics (i.e., location, daily number of customers, number of employees).
Questions regarding medical cannabis use
Participants were asked, “Do you get questions related to cannabis use for medical purposes/perceived medical benefit?” (yes or no). Participants were also asked, “Have you been told by a customer that their doctor sent them to you to obtain a cannabis-containing product for medical purposes?” (yes or no).
Frequency of questions regarding medical cannabis use
To assess how often customers of the recreational retail stores seek cannabis products for medicinal purposes, we asked the question “How frequently does this occur?” for each “yes” answer to the questions regarding medical cannabis use. The responses were once per week, several times per week, 1 to 5 times per day, 6 to 10 times per day and more than 10 times per day.
Typical questions regarding medical cannabis use
To determine the types of questions related to medicinal cannabis use that are commonly asked, for respondents who answered “yes” to the question “Do you get questions related to cannabis use for medical purposes/perceived medical benefit?” the following 6 questions (yes or no) were put forward: “Can I use cannabis to help with sleep?” “Can I use cannabis to help with pain?” “Can I use cannabis to help with anxiety, depression, or mood?” “What are the side effects of cannabis?” “Should I use CBD or THC for my condition? “Will this product interact with my other medications?” To determine the most frequent type of question regarding medical cannabis use, respondents were asked the following open-ended question: “What is the most common question you receive?” to which they had to respond in a textbox.
Questions regarding general cannabis use
To evaluate general questions about cannabis use, we asked, “What is the most common cannabis component you are asked about on an average day?” Respondents could choose between CBD, THC, terpenes, strains (indica/sativa), cannabinoid percentages or cost. They were also asked, “What is the most common cannabis format you are asked about on an average day?” The possible answers were inhalation (flower/vape/concen trates), oil, topical, edible (including beverages) or capsules.
Analytic plan
Data were pooled and summarized where appropriate as frequencies and percentages or as means and standard deviations.
Results
Sociodemographics of cannabis retail workers
The current study represents data collected from 211 valid survey respondents; of these, there were 91 budtenders (45 male; 46 female) and 120 managers (76 male; 44 female). On survey questions that captured details about demographics of the retail locations, the most frequent responses indicated that most respondents had worked at their current store location for 2 to 3 years (~23%), worked for 31 to 40 hours per week (~35%) and worked with an average of 5 or 6 other budtenders (~33%) (Table 1). Overall, the most frequently cited number of customers served per day was between 26 and 30 (24.2%) (data not shown).
Table 1.
Survey responses from Canadian budtenders and managers
| Variable | n | % |
|---|---|---|
| How long working at current location (n = 211) | ||
| Less than 1 month | 11 | 5.2 |
| 1-5 months | 29 | 13.7 |
| 6-11 months | 45 | 21.3 |
| 1-2 years | 33 | 15.6 |
| 2-3 years | 48 | 22.7 |
| More than 3 years | 45 | 21.3 |
| How many hours per week worked at current location (n = 211) | ||
| Less than 10 hours | 7 | 3.3 |
| 11-20 hours | 31 | 14.7 |
| 21-30 hours | 72 | 34.1 |
| 31-40 hours | 73 | 34.6 |
| More than 40 hours | 28 | 13.3 |
| How many front store budtenders directly serving customers on typical day at current location (n = 211) | ||
| 1 or 2 | 20 | 9.5 |
| 3 or 4 | 56 | 26.5 |
| 5 or 6 | 69 | 32.7 |
| 7 or 8 | 31 | 14.7 |
| 9 or 10 | 21 | 10.0 |
| 11 or more | 14 | 6.6 |
| How many customers served in an average day (n = 211) | ||
| 0-10 | 14 | 6.6 |
| 11-20 | 46 | 21.8 |
| 21-30 | 75 | 35.6 |
| 31-40 | 33 | 15.7 |
| 41 or more | 43 | 20.4 |
| Province where store is located (n = 211) | ||
| British Columbia | 57 | 27.0 |
| Manitoba | 13 | 6.2 |
| Alberta | 9 | 4.3 |
| New Brunswick | 15 | 7.1 |
| Newfoundland and Labrador | 17 | 8.1 |
| Northwest Territories | 11 | 5.2 |
| Nova Scotia | 12 | 5.7 |
| Nunavut | 7 | 3.3 |
| Ontario | 57 | 27.0 |
| Prince Edward Island | 5 | 2.4 |
| Quebec | 5 | 2.4 |
| Saskatchewan | 2 | 0.9 |
| Yukon | 1 | 0.5 |
Questions regarding medical cannabis use and physician referral
A total of 87.7% (n = 185) of respondents indicated that they receive questions related to cannabis use for medical purposes and/or perceived medical benefit, with the same amount indicating that they have been told by a customer that their physician sent them to obtain a cannabis-containing product for medical purposes. As shown in Figure 1, on average, most respondents indicated they fielded questions related to cannabis use for medical purposes and/or perceived medical benefit between 6 and 10 times per day (45% of respondents, Figure 1A); similarly, the most respondents indicated they were told by a customer that their physician sent them to obtain a cannabis-containing product for medical purposes between 1 and 5 times per day (34% of respondents, Figure 1B).
Figure 1.
Responses from budtenders and managers to the survey questions (A) How often do you get questions related to cannabis use for medical purposes/perceived medical benefit? and (B) How often have you been told by a customer that their doctor sent them to you to obtain a cannabis-containing product for medical purposes?
Typical questions regarding general cannabis use
In evaluating general questions about cannabis use, we found for the overall sample (n = 211) that the most common cannabis component asked about in an average day was THC (42% of responses) and the most common cannabis format asked about in an average day was “inhalation” (49% of responses) (Figure 2). The most common questions that respondents fielded from customers are shown in Table 2.
Figure 2.
Responses from budtenders and managers to the survey questions (A) What is the most common cannabis component you are asked about on an average day? and (B) What is the most common cannabis format you are asked about on an average day?
Table 2.
Most common consumer questions posed to managers and budtenders about cannabis products
| Product characteristics |
| What purity can be achieved? |
| What ingredients are in this product? |
| What has the highest THC? |
| What has the highest THC for the lowest price? |
| Will CBD get me high? |
| What purity can be achieved? |
| Medical evidence |
| Can this product help with x ailment? |
| Will cannabis help me sleep? |
| What is the time for addiction? |
| Can I use marijuana to relieve my pain? |
| Does marijuana affect the brain? |
| What is the relationship between marijuana and mental illness? |
| What can you recommend for sleep or pain relief? |
| Adverse effects |
| What are the side effects? |
| How much marijuana at a time won’t hurt me? |
| What happens when marijuana is mixed with other drugs? |
| Will long-term use affect organ failure? |
| General comments |
| Why aren’t there more CBD flower options available? |
| How does it taste? |
| What is the price? |
| Is marijuana the same for both sexes? |
| What gummie will put me to sleep? |
| What days are your shipments on? |
| Why are the edibles only 10 mg of THC? |
A total of 90% of respondents indicated that they were asked questions about using cannabis to help with sleep, with most saying this occurred between 1 and 5 times per day (43% of responses) (Table 3). A total of 92% of respondents indicated that they fielded questions about using cannabis to help with pain, with 35% saying this occurred between 1 and 5 times per day (Table 3). A total of 90% of respondents indicated that they were asked questions about using cannabis to help with anxiety, mood or depression, with 37% saying this happened between 1 and 5 times per day (Table 3).
Table 3.
Managers’ and budtenders’ responses (expressed as percentages) regarding frequency of cannabis-related health questions encountered
| Survey question | Once a week | Several times a week | 1-5 times a day | 6-10 times a day | >10 times a day |
|---|---|---|---|---|---|
| What are the side effects of cannabis? (n = 155) | 6.6 | 15.2 | 25.6 | 19.4 | 6.6 |
| Will this product interact with my other medications? (n = 151) | 3.8 | 18.0 | 24.2 | 19.4 | 6.2 |
| Can I use cannabis to help with sleep? (n = 168) | 3.8 | 24.6 | 34.1 | 11.4 | 5.7 |
| Can I use cannabis to help with pain? (n = 162) | 6.2 | 20.4 | 28.0 | 22.3 | 3.8 |
| Can I use cannabis to help with anxiety, depression or mood? (n = 167) | 10.9 | 18.5 | 28.9 | 14.7 | 6.2 |
| Should I use CBD or THC for my condition? (n = 149) | 4.7 | 26.1 | 23.7 | 16.1 | 7.1 |
Discussion
The overall number of patients in Canada accessing cannabis for medical purposes has increased in the past 2 decades to 270,000 patients, 13 and this dynamic change represents a major challenge to the safe dispensing of cannabis. More Canadians than ever have questions about the safe use of cannabis. Thus, the overall aim of the current cross-sectional survey was to examine the typical questions posed to managers and budtenders working at brick-and-mortar recreational cannabis stores in Canada and to assess how often customers seek medical advice to treat medical conditions using cannabis. In the current survey, 88% of respondents indicated that they fielded questions on perceived medical use or benefit of cannabis and 87% indicated that they have been told by a customer that their physician sent them to obtain a cannabis-containing product for medical purposes. Our findings indicate that a high percentage of managers and budtenders across Canada face medical questions from consumers.
Sociodemographics of cannabis retail workers
When examining potential differences in survey responses across Canada, it is important to note a recent analysis of the cannabis retail market, which found that 1183 legal cannabis stores were open across Canada (3.7 stores per 100,000 individuals), but there was wide variation between jurisdictions in access to retail stores, with the lowest number of stores per capita in Quebec and Ontario (0.6 and 1.6 per 100,000, respectively) and the highest in Alberta and Yukon (14.3 per 100,000 in both). 14 Our findings highlight nearly homogeneous responses across provinces, where 75% of respondents in Quebec, 92.7% in Ontario, 88.9% in Alberta and 100% in Yukon stated that they are asked questions about perceived medical use or benefit of cannabis (data not shown). Furthermore, it is expected that the legal cannabis market will continue to grow as new product formulations are released and stigma continues to decrease. There is also an increasing trend for older Canadians to explore cannabis for persistent symptoms, including pain, insomnia and mental health disorders. 15 This patient population may have higher risks of adverse reactions due to comorbid illnesses and multiple prescription medications that could cause interactions. 16
Differences between traditional medication labels and labels on cannabis
Traditional medication labels have been improved to optimize content and format in order to improve readability, understanding and medication use. 17 This is in stark contrast to the packaging for cannabis, where the consumer is provided with only 3 pieces of information: the brand name and logo, the levels of THC and CBD and the health effects associated with cannabis consumption. The label does not provide information about the brand itself, how the strain varies from other products on the shelf, what the different levels of THC or CBD mean or the chemicals used in the production process. In the current study, 79.7% of budtenders indicated that they receive questions related to cannabis use for medical purposes and 79.2% indicated that they had been asked by a consumer if they should use THC or CBD for their condition. Ostensibly, this could point to a threat to public health in that budtenders are not qualified to answer such questions under the current Canadian Cannabis Act, such that consumers who want to purchase cannabis for medical purposes are left in the dark regarding information on efficacy or safety of medical cannabis when they approach a typical brick-and-mortar licensed store. A recent study of a group of Canadian university students 18 found that Canadians desire spokespeople with authenticity and expertise, further highlighting the potential role of pharmacists to safely dispense these drugs to Canadians.
Current cannabis climate in Canada: Anxiety, depression and sleep
Findings from the current study demonstrated that the majority of budtenders and managers in Canada (>90%) field questions related to the use of cannabis to help with anxiety, depression and insomnia-related disorders. These results are not surprising, considering that a recent national survey in Canada of 1803 participants showed that since the onset of COVID-19, the percentage of respondents who indicated that their anxiety was high to extremely high quadrupled (from 5% to 20%) and the number of participants with high self-reported depression more than doubled (from 4% to 10%). 19 Furthermore, a recent systematic review showed similar warning signs, where the prevalence of sleep problems was 40% of those surveyed. 20
On the need for pharmacists to dispense medical cannabis
Retail stores as well as pharmacies sell over-the-counter herbal, homeopathic and health food products. Although retail stores can be useful and convenient sources of health information, this type of advice comes without the expertise of a professional who has benefitted from years of pharmacy training in order to recognize possible contraindications or advice that can cause harm (e.g., by delaying treatment that has known benefit) if their recommendations were inaccurate or inappropriate. 21 According to the most recent Canadian Cannabis Survey in 2021, 14% of Canadians over the age of 16 years report having used cannabis for medical purposes (unchanged from the year before), although less than 3% of Canadians have an active medical cannabis prescription. 22 Since cannabis retail managers and budtenders are not regulated health professionals and are not legally authorized to provide medical advice, this shows the need for trained health care professionals, such as community pharmacists, to provide evidence-based advice to patients seeking cannabis for medicinal purposes. Moving forward with the safe dispensing of medical cannabis, it will be important to develop evidence-based tools for pharmacists to be able to efficiently assess specific patient needs and safely dispense medical cannabis products.
In the current study, our conclusions are restricted by limitations in the data, as well as the study design and statistical analysis. Given that the data were self-reported, various biases associated with administration of surveys cannot be ruled out, including the cross-sectional and observational survey design. Thus, although the current study highlights the potential for risk due to unlicensed medical advice, we cannot make any assertive conclusions without further study.
The Canadian Pharmacists Association (CPhA) recently issued a position statement on improving the regulation of medical cannabis and highlighted that pharmacists are best suited to advise patients and oversee the safe storage and dispensing of medical cannabis. 23 Furthermore, given that pharmacists are trained to assess drug-drug interactions and adverse effects and as prescribers often initiate cannabis as third- or fourth-line adjunctive therapy on top of other medications, 24 we support the CPhA position statement on medical cannabis and argue that this is a crucial element of governmental efforts to shape demand around the principle of responsible consumption.
Conclusion
The current cross-sectional survey was conducted to examine typical questions posed to managers and budtenders working at recreational cannabis stores in Canada and to assess how often consumers seek medical advice to treat medical conditions using cannabis. A majority of respondents indicated that they had fielded questions on perceived medical use or benefit of cannabis and that they had been told by a customer that their physician sent them to obtain a cannabis-containing product for medical purposes. This situation has the potential to put individuals at risk of drug-drug interactions, drug-disease interactions and increases in unnecessary hospitalizations due to adverse effects. Indeed, cannabis used for medical purposes should be treated the same as all other drugs and should be dispensed by a pharmacist. The results from the current study indicate that there is a need for specialized expertise when discussing the use of cannabis for medical purposes. ■
Acknowledgments
The authors thank Ashwin Juneja, Meghan Hayes and Damien Roux.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Author Contributions: All authors approved the final version of the article.
Funding: The authors received no financial support for the research, authorship and/or publication of this article.
ORCID iD: Jameason D. Cameron 
https://orcid.org/0000-0002-5210-6195
Contributor Information
Jameason Cameron, Department of Pharmacy, Children’s Hospital of Eastern Ontario, Ottawa.
Rahim Dhalla, Department of Pharmacy, Children’s Hospital of Eastern Ontario, Ottawa; Hybrid Pharm, Ottawa.
Taylor Lougheed, Department of Family Medicine, University of Ottawa Faculty of Medicine, Ottawa; Section of Emergency Medicine, Northern Ontario School of Medicine, Sudbury.
Ariane Blanc, Department of Pharmacy, Children’s Hospital of Eastern Ontario, Ottawa.
Régis Vaillancourt, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario.
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