Doctors’ and pharmacists’ perspectives on the clinical use of medicinal Cannabis: a cross-sectional study

Abstract

Background

As the first EU country to enact laws regulating the non-medical use of cannabis and with established legislation for the cultivation and production of cannabis for medical purposes and scientific research, Malta is at the forefront of cannabis regulation and research initiatives. Despite this context, healthcare professionals’ attitudes, beliefs, and knowledge regarding medicinal cannabis remain variable. We assess these constructs and examine perceived barriers to clinical integration.

Methods

A cross-sectional survey was distributed to doctors and pharmacists across Malta (n = 198). Data analysis included independent samples t-tests, Pearson correlation analyses, and hierarchical regression to examine demographic influences, professional comparisons, and predictors of prescription attitudes.

Results

Most professionals acknowledged medicinal cannabis’s therapeutic benefits but exhibited notable hesitancy in clinical practice, largely due to insufficient formal guidelines and inadequate education. No significant gender differences were observed, and only a weak correlation emerged between age and attitudes among male doctors. The strongest predictor of willingness to prescribe medicinal cannabis was doctors’ attitudes, outweighing formal education or knowledge.

Conclusions

Despite broad acknowledgment of potential therapeutic benefits, Maltese healthcare professionals remain cautious due to insufficient training and unclear guidelines. Enhancing evidence-based education and providing clear prescribing frameworks may significantly boost clinicians’ confidence and willingness to integrate medicinal cannabis into clinical practice.

Background

The global landscape surrounding medicinal cannabis is rapidly evolving, characterized by an increasing number of jurisdictions adopting legislative frameworks that facilitate patient access to cannabis-based medicinal products [1]. This shifting paradigm, reflective of changing social attitudes, is occurring within a context where, despite promising anecdotal and preliminary clinical observations indicating clinical benefits, scientific evidence remains insufficiently robust to conclusively support clinical application in many suggested therapeutic areas [2]. Concomitantly, there is evidence supporting clinical use for specific conditions such as multiple sclerosis spasticity, chronic neuropathic pain [3], some forms of epilepsy [4, 5], HIV/AIDS-related cachexia and chemotherapy-induced nausea and vomiting [6].

Medicinal cannabis refers to the therapeutic use of cannabis and cannabis-derived products under medical supervision. It encompasses the flower of the Cannabis genus plant, its preparations, or its active compounds, known as cannabinoids, which interact with the body’s endocannabinoid system to produce therapeutic effects [7].

Significant variability persists internationally in both the clinical integration and regulatory approaches to medicinal cannabis [8]. The present study was carried out among registered doctors and pharmacists in Malta. Malta was the first European Union country to adopt comprehensive legislation for the non-medical use of cannabis, in 2021 [9]. In 2018, Malta had already introduced the Production of Cannabis for Medicinal and Research Purposes Act, establishing the legal framework that allows cannabis to be grown and produced for both medical applications and scientific study [10].

Historically, sociocultural norms and the legal status of cannabis have significantly influenced healthcare professionals’ perceptions and willingness to incorporate medicinal cannabis into patient care [11]. Given that many current healthcare providers were trained during periods characterized by stricter cannabis regulations and pronounced societal stigma, these factors may continue to impact their attitudes and clinical decisions today [12]. Additionally, the absence of formalized educational frameworks addressing medicinal cannabis in traditional medical training could further contribute to hesitancy among professionals [13]. Recognizing and addressing this sociocultural and educational background is thus essential for fostering a more informed and open clinical environment toward medicinal cannabis use.

Given this evolving landscape and the relative novelty of recent legislative changes, this study aims to understand healthcare providers’ knowledge, attitudes, and beliefs, and to identify perceived barriers to clinical integration. Their viewpoints are critical, as doctors and pharmacists are integral to clinical decision-making, patient guidance, and the broader integration of medicinal cannabis into therapeutic regimes [11, 14]. By exploring healthcare professionals’ perspectives, knowledge, and experiences this research seeks to provide insights that could inform education, policy, and clinical practice, thereby supporting an evidence-based and patient-centred implementation of medicinal cannabis within the healthcare setting [15].

Materials and methods

Study design and participants

A 25-item questionnaire was developed with the intent of tapping into the attitudes, beliefs and knowledge of healthcare professionals with regards to the clinical use of medicinal cannabis. The questionnaire was developed in English, an official language of the Maltese islands. It was designed to focus on the following key areas: attitude towards clinical use of medicinal cannabis, knowledge, education received and interest in educational initiatives, safety, and prescription attitude.

We situate our measures within the Knowledge-Attitude-Behaviour (KAB) framework, which conceptualizes how what people know (knowledge), how they evaluate or feel about a topic (attitudes), and what they do (practice) are interrelated domains relevant to learning and decision-making. In line with the ABC model of attitudes, we treat beliefs as the cognitive basis of attitudes, alongside affective evaluations and behavioural predispositions. Our study focuses on knowledge, attitudes, and beliefs regarding the clinical use of medicinal cannabis among doctors and pharmacists. We did not directly measure behaviours, but KAB provides a rationale for examining these antecedent constructs and their relationships.

The questionnaire underwent a multi-step development process. Initially, a preliminary set of items was created based on an extensive review of the existing literature on medicinal cannabis attitudes among healthcare providers. To ensure the relevance and validity of the questionnaire, it was submitted to an expert panel consisting of healthcare educators, researchers, and practicing clinicians familiar with the field of medicinal cannabis. The panel reviewed the questionnaire for clarity, accuracy, and comprehensiveness, ensuring the questions were free from ambiguity and appropriately aligned with the study objectives. Feedback provided by the expert panel was incorporated, leading to minor revisions in phrasing and structure.

Four items were dedicated to collecting demographic information, including gender, age, profession, and specialization. Seventeen of the remaining 21 questions utilized a 7-point Likert scale. The scale ranged from 1 (Strongly agree) to 7 (Strongly disagree), allowing respondents to express the degree to which they agreed with statements regarding medicinal cannabis. This approach provided a detailed understanding of participants’ perceptions while ensuring a straightforward response format that facilitated analysis. The cross-sectional study data was collected between April and June 2024. All registered doctors, comprising dentists, and pharmacists in Malta were invited to take part in the study via e-mail, distributed through official regulatory bodies with which doctors and pharmacists are required to be registered for provision of a legal licence to practice their profession in the Maltese islands. No restrictions of age, gender or nationality were imposed. Participation was voluntary and anonymous. An information statement accompanied the invitation and appeared on the survey’s first page, outlining study purpose, data handling, and other study details. In line with ethics approval, completion and submission of the questionnaire constituted informed consent.

Data collection and analysis

Data was collected systematically and depicted using clustered and simple bar charts to enhance visual clarity and facilitate interpretation. Results are presented as percentages in most cases. Demographic data was collected, including age, gender and area of employment. Responses to the questionnaire were recorded using rating scales, multiple choice questions and open-ended questions.

The collected data was subjected to rigorous statistical analysis to identify significant trends and relationships among key variables. This exercise excluded four questionnaire items that were open-ended or restricted open-ended questions that impeded adequate conversion to numerical fields that could be utilized for analysis. Independent samples t-tests were conducted separately for doctors and pharmacists to compare variations across different data categories. The impact of gender on responses was also assessed to determine whether perceptions and attitudes differed significantly between male and female healthcare professionals. Pearson correlation analysis was performed for both doctors and pharmacists to examine potential relationships between various data categories. This analysis further investigated the influence of gender and age on responses, offering insights into demographic factors that may shape attitudes and beliefs regarding medicinal cannabis use in clinical practice. A hierarchical regression analysis was conducted exclusively for doctors to predict prescription attitude toward medicinal cannabis. This approach allowed for the identification of key predictors influencing doctors’ willingness or reluctance to prescribe medicinal cannabis, accounting for demographic and attitudinal variables in a structured manner. Data analysis was conducted using SPSS statistical software (version 25.0).

Results

Population demographics and area of profession practice

Respondents (n = 198) consisted of 108 physicians and 90 pharmacists. 54% were female and 46% male. The median age of the sample was 45. The mean age was 45.4. Of the 108 doctors 46.3% were female and 53.7% male. The median age was 48.5 and the mean was 48.7. 63.33% of the 90 pharmacist participants were female and 36.66% male. The cohort’s median age was 43 and the mean age 41.5.

Among doctors, work settings included hospital-based (45.7%), primary care (24.8%), and community care (15.2%). Among pharmacists, the majority were community pharmacists (39.4%). 18.1% were employed in the regulatory sector. Participant demographic data and practice settings are summarized in Table 1.

Table 1.

Demographic characteristics and practice area of respondents

Healthcare professionals’ attitudes and knowledge

The majority of participants (85.9%) signalled some level of agreement, ranging from ‘strong’ to ‘somewhat’ on the Likert scale provided, with the fact that there are patients who could benefit from use of medicinal cannabis. A small minority of the sample population (7%) indicating disagreement. A total of 63.6% stated that they would feel comfortable discussing the subject with patients, with only 14.6% of those expressing strong agreement with the statement. 28.4% said that they would not feel comfortable discussing medicinal cannabis with patients (Fig. 1).

Fig. 1.

Attitudes and knowledge of medicinal cannabis among doctors and pharmacists

69.2% and 65.6% of respondents said they have at least an acceptable knowledge of medicinal cannabis’ therapeutic effects and side effects, respectively. In both cases, the majority answered by choosing ‘somewhat agree’, the lowest level of agreement with the statement (40.4% and 31.3% respectively). With regards to knowledge about which patients can derive beneficial effects from medicinal cannabis the numbers were similar, with 64.6% claiming knowledge and 27.3% stating that, to some degree, they did not have such insight (Fig. 1).

A high number of participants admitted to reduced confidence levels in dealing with patients exhibiting side effects due to use of medicinal cannabis – 48% in contrast to 45% who claimed some degree of confidence in their abilities to deal with such situations. 52.1% of respondents claimed positive confidence levels in their ability to answer patient questions about the use of medicinal cannabis while 51% stated they were knowledgeable, to a degree, about prescription modalities for medicinal cannabis (Fig. 1).

Formal education, training and perceptions of safety

The data states that there is high agreement among questionnaire respondents in acknowledging there is little understanding of medicinal cannabis among the general population. 39.4% have indicated strong agreement on this. In total, 91.4% of participants expressed a form of agreement, compared to 3.5% who disagreed. Concomitantly, respondents have also indicated that as professionals they believe they received poor formal education on medicinal cannabis (71.3%) and that current students of medicine and pharmacy should have their curriculum boosted with more knowledge on the subject (93.4%). For both statements the highest level of conviction was the most frequent answer chosen by the participants – 39.9% and 60.1% respectively (Fig. 2).

Fig. 2.

Education, training and safety perceptions of medicinal cannabis among doctors & pharmacists

86.9% of participants said that they would be interested in attending educational activities to learn more about medicinal cannabis, with most preferring webinars and expert-driven online lectures as delivery methods. When asked about which medical conditions medicinal cannabis should be used for the most popular responses were, in descending order, cancer pain, palliative care, neuropathic pain and multiple sclerosis spasticity. Responses to the item “Medicinal cannabis is less dangerous than:” indicated no clear consensus, with a substantial proportion of clinicians selecting “I don’t know” as a response, underscoring uncertainty about relative safety compared with the medication classes listed (Fig. 2).

Doctors’ prescription attitude

This set of questions was targeted at doctors given they have the possibility of medicine prescription. 53.7% of doctors agree that medicinal cannabis is an ethical form of therapy. The most popular response on the 7-point Likert scale for this statement, however, was a neutral answer (27.8%). This pattern was also noted for questions probing doctors on whether they believe that medicinal cannabis causes more harm than benefit, and whether they think that risks of medicinal cannabis are higher than for conservative therapy. 50% of doctors disagree that medicinal cannabis causes more harm than it induces benefits but 25% registered a neutral response. 48.1% of doctors also disagreed that medicinal cannabis risks of side effects are higher than for conservative therapy, with 27.8% of them staying neutral in their answer. When asked about whether they would not prescribe medicinal cannabis because they consider that the risk of abuse and dependence is higher than for conservative therapy 51.8% of them disagreed. 19.4% had a neutral response, the second most popular answer for that question. The hesitancy is further highlighted in the total of 60.1% claiming they do not feel comfortable prescribing medicinal cannabis (Fig. 3).

Fig. 3.

Medicinal cannabis prescription attitude among doctors

Statistical analysis

Data collected from surveyed doctors and pharmacists was analysed using a range of statistical techniques. Independent samples t-tests were performed to examine differences between doctors and pharmacists, as well as differences between male and female participants within these professional groups, concerning their attitudes, beliefs, and knowledge of medicinal cannabis. Additionally, Pearson product moment correlation analyses were conducted to assess relationships among key survey categories: ‘age’, ‘attitude,’ ‘knowledge,’ ‘formal education,’ and ‘prescription attitude.’

In analysing the attitudes of professionals towards use of medicinal cannabis the values for doctors (M = 6.20, SD = 2.88) were higher in comparison to those of pharmacists (M = 5.19, SD = 2.26), t(195.78) = – 2.71, p = 0.006, Cohen’s d = – 0.4, indicating a moderate effect size (Table 2). This indicated a slightly more negative stance from doctors towards medicinal cannabis. No similar statistically significant difference was observed in assessing knowledge of medicinal cannabis for doctors (M = 23.21, SD = 9.78) and pharmacists (M = 24.28, SD = 9.06), t(196) = 0.79, p = 0.431, Cohen’s d = 0.1.

Table 2.

Independent sample t-test: doctors’ & pharmacists’ attitude to medical cannabis

Among pharmacists, significant gender differences emerged in attitudes (Female: M = 5.63, SD = 2.21; Male: M = 4.42, SD = 2.15; t(88) = 2.51, p = 0.014, Cohen’s d = 0.5) and knowledge (Female: M = 25.70, SD = 8.73; Male: M = 21.82, SD = 9.22; t(88) = 1.99, p = 0.049, Cohen’s d = 0.4), both indicating moderate effect sizes. Males reported significantly more positive attitudes towards the use of medicinal cannabis and also claimed higher knowledge levels. There were no significant differences in formal education. Among doctors, no significant gender differences emerged.

A Pearson product moment correlation analysis for doctors revealed that prescription attitude showed strong significant positive correlations with attitude (r = 0.68, p < 0.001), formal education (r = 0.30, p < 0.01), and knowledge (r = 0.31, p < 0.01), indicating these are key factors influencing doctors’ willingness to prescribe medicinal cannabis. Age had a weaker positive correlation with prescription attitude (r = 0.20, p < 0.05) (Table 3). Another Pearson product moment correlation analysis sought to unveil gender differences among doctors. Among male doctors, prescription attitude correlated positively with attitude towards medicinal cannabis (r = 0.67, p < 0.01) and moderately with knowledge (r = 0.32, p < 0.05) and formal education (r = 0.29, p < 0.05). Age also correlated significantly with prescription attitude (r = 0.34, p < 0.01). For female doctors, prescription attitude had a strong correlation with attitude (r = 0.71, p < 0.001), knowledge (r = 0.30, p < 0.05), and formal education (r = 0.32, p < 0.05).

Table 3.

Product moment correlation analysis for the doctor population

A hierarchical regression analysis was carried out specifically to identify significant predictors influencing ‘prescription attitude’ in doctors. Predictor variables included demographic factors, general attitude on the use of medicinal cannabis, formal education, and knowledge about medicinal cannabis. The hierarchical model was structured to evaluate incremental variance explained by each set of predictors, thus highlighting the relative contribution of individual predictors to prescription attitudes towards medicinal cannabis. In the first step of the analysis, demographic control variables (gender and age) were entered, which accounted for a modest 4% of variance in prescription attitudes (R² = 0.04). Gender was not a statistically significant predictor (β = – 0.06, p > 0.05), while age emerged as a statistically significant predictor, albeit weak (β = 0.22, p < 0.05), indicating that older doctors had slightly more negative attitudes to prescribing medicinal cannabis. In the second step, the addition of ‘attitude’, ‘knowledge’ and ‘education’ significantly improved the explanatory power of the model, increasing R² to 0.46, thus explaining approximately 46% of the variance in prescription attitudes. ‘Attitude’ was found to be a strong and statistically significant positive predictor (β = 0.71, p < 0.001). Conversely, ‘Knowledge’ (β = – 0.06, p > 0.05) and ‘Education’ (β = 0.03, p > 0.05) did not significantly predict prescription attitudes (Table 2).

Discussion

Therapeutic potential vs. clinical hesitancy

Our study found that both Maltese doctors and pharmacists have broadly positive attitudes toward medicinal cannabis, with most acknowledging its therapeutic potential. This mirrors findings in many Western contexts where a majority of healthcare professionals support medicinal cannabis use for certain conditions. For example, 58.6% of Irish general practitioners supported legalizing cannabis for medical purposes and more than 60% agreed it has a role in pain management, multiple sclerosis, and palliative care [16]. A survey among Californian pharmacists likewise overwhelmingly believed in the medical efficacy of cannabis, albeit lamenting having little information on the subject and were not able to state where they could get relevant guidelines [17].

Across psychiatrist samples, support for medical cannabis is generally favourable but qualified. French psychiatrists expressed support (84.4%) for medicinal cannabis, particularly highlighting its potential psychiatric benefits. 73% expressed interest in prescribing CBD, but most highlighted psychosis risks associated with THC [18]. Likewise, Swiss psychiatrists also expressed agreement (49%) regarding therapeutic applications of cannabis for mental disorders, yet 50% of the sample did emphasize that the evidence base remains insufficient [19]. Colombian psychiatrists supported non-psychiatric indications at high rates (87.6% for cancer-related pain), but approval was low for psychiatric indications (35.2% for insomnia; 29% for anxiety disorders), even though 73.1% wanted to be able to prescribe. Dermatologists in the US have recommended cannabinoids primarily for inflammatory and pruritic conditions such as psoriasis and atopic dermatitis, indicating growing acceptance across medical specializations [21].

Despite this widespread acknowledgment of benefits, a cautious hesitancy was evident in Malta, likely driven by uncertainty and lack of clear clinical guidance. Participants expressed uncertainty about how to prescribe or advise on medicinal cannabis, echoing a concern seen in many other countries. Australian general practitioners, despite strong patient demand, expressed significant discomfort discussing medicinal cannabis with patients [22]. Pharmacists similarly echoed uncertainty due to limited formal training, with most feeling underprepared to provide proper patient guidance [23, 24]. In the US, oncology trainees frequently discussed cannabis with patients yet only a minority (13%) felt sufficiently informed to make confident recommendations, highlighting a significant gap between clinical demand and provider confidence [25]. Likewise, orthopaedic surgeons acknowledged CBD’s analgesic benefits but reported a notable lack of formal education and pervasive stigma affecting prescription behaviours [26].

Absence of clear guidelines

A prominent theme in our study was the reluctance among clinicians to engage with medicinal cannabis in practice due to the lack of formal guidelines, echoing a concern noted in previous studies. In Poland, where medical cannabis was legalized in 2017, over 93% of physicians surveyed called for clear clinical guidelines on cannabinoid use, and 71% felt their knowledge was insufficient to counsel patients [27]​. Similarly, physicians in Norway highlighted significant knowledge gaps and uncertainty regarding prescribing medical cannabis due to the absence of specific guidelines [28]. A study of Italian oncologists and palliative care physicians revealed widespread uncertainty about legal frameworks and dosing strategies, significantly impacting their prescribing confidence [29]. Without official treatment protocols or dosing recommendations, even well-disposed doctors may feel unsupported when considering cannabis therapy. This was evident in our cohort’s cautious approach, and it parallels other doctors’ experiences in Europe. A systematic review noted that across the continent many providers are unsure of the legal status and regulations around medical cannabis, underscoring widespread confusion about prescribing protocols [30].

In Canada, pain management specialists expressed considerable uncertainty about medicinal cannabis due to insufficient research evidence and unclear clinical practice guidelines [31]. A survey of paediatric oncology providers in the United States identified the lack of clear standards for formulations, potency, and dosing as the primary barrier to recommending medicinal cannabis, despite recognizing its potential therapeutic benefits [32]. Thus, even in settings where therapeutic potential is recognized, many providers hesitate to actively recommend or prescribe cannabis without stronger institutional backing or evidence-based guidelines.

The absence of clear guidelines contributes directly to clinical inertia. In the UK, medicinal cannabis was rescheduled in 2018, yet formal prescribing guidelines remain restrictive. Consequently, very few National Health Service prescriptions have been issued, as physicians remain hesitant without strong guidance or endorsement from specialty colleges [33]. Such uncertainty can delay patient access despite provider willingness. Our findings from Malta align with these international observations. Without clear protocols from health authorities, clinicians err on the side of caution. Enthusiasm alone does not translate into prescriptions when doctors and pharmacists lack a framework to guide dosing, indications, and product sourcing. Establishing evidence-based clinical guidelines is critical in converting the generally positive mindset into confident practice.

Knowledge gaps and educational needs

Consistent with many studies worldwide, Maltese doctors and pharmacists reported poor formal education on medicinal cannabis and a strong desire for additional training. This finding is hardly unique. A global concern is that healthcare curricula have not kept pace with the rising medicinal cannabis use. Surveys in North America and Europe repeatedly show most providers feel ill-prepared. In Israel, 63% of primary care physicians reported having little knowledge about medicinal cannabis, with 75% interested in deepening their knowledge [34]. Similarly, a 2017 survey of US medical schools revealed that less than 10% included medicinal cannabis in their curriculum, leaving graduating students largely unprepared to counsel patients [35]. This educational gap is reflected in other studies. In Washington State, the majority of healthcare providers had insufficient knowledge and expressed a need for targeted training to confidently recommend cannabis [36].

Over 90% of Maltese professionals in our survey expressed interest in formal training on medicinal cannabis, a sentiment echoed internationally. Pharmacists in Illinois and Alabama demonstrated significant knowledge gaps regarding CBD and indicated high demand for continued professional education on cannabis-related pharmacotherapy [37, 38]. Australian healthcare providers, including psychiatrists and oncology professionals, expressed similar knowledge deficits, with only a small fraction feeling adequately prepared to discuss medicinal cannabis with patients [39, 40]. Educational shortcomings in medicinal cannabis extend to professional training programs globally. Canadian hospital pharmacists reported receiving virtually no formal training on cannabis despite recognizing its therapeutic potential [41]. Danish general practitioners displayed substantial uncertainty and knowledge gaps about medicinal cannabis, significantly limiting their willingness to prescribe despite legal provisions allowing it [42]. Orthopaedic sports medicine providers in the US demonstrated notable knowledge deficits about CBD, highlighting the need for robust, targeted education initiatives to bridge this gap [43].

Several studies explicitly underscore that inadequate educational content on medicinal cannabis within medical and pharmacy curricula perpetuates these knowledge gaps. Meyers et al. (2024) found significant improvement in provider knowledge following targeted education sessions, emphasizing the critical role of incorporating cannabis pharmacotherapy into medical training [44]. Likewise, Mitchell et al. (2016) and Shulman et al. (2022) highlight that existing healthcare curricula rarely include comprehensive education on medicinal cannabis, reinforcing the importance of structured, evidence-based training [41, 45].

Demographic factors and profession comparisons

Our study revealed no significant gender differences in attitudes or knowledge, and only a weak age-related effect observed among male doctors. This suggests that support for medicinal cannabis, and the associated knowledge deficits, cut across demographic lines in our sample. Other recent studies largely concur, finding that factors like gender and age are at most minor influences compared to the dominant effects of education and legal context. A systematic review of European healthcare workers did not identify any consistent gender-based attitude gaps in the included surveys [30].

A recent 16-country survey probing doctors, pharmacists and nurses registered cross-professional consensus, noting few significant differences between professions, specialties or regions in the healthcare providers’ generally favourable interest in cannabis-based products [46]. Similarly, Australian surveys found strong agreement among general practitioners and pharmacists regarding medicinal cannabis, highlighting that both professions generally share similar perspectives on its clinical use, with minimal differences noted between these healthcare providers [47, 48].

Our research detected no major discrepancies between doctors and pharmacists, suggesting that the acceptance of medicinal cannabis transcends professional roles. Data summarized in Figs. 1 and 2 presents results for the two professions grouped together as well as separately. As can be noted from the bar graphs and the adjunctive trend lines for each, even when results for the two groups are considered distinctly, the patterns that emerge are quite similar. The only two instances which recorded a minor discrepancy concerned the knowledge category, noting differing trend line trajectories. The first was with regards to answering questions put forward by patients on the use of medicinal cannabis, where pharmacists claimed higher confidence levels in relation to doctors (57.7% vs. 47.2%). Doctors claiming poor confidence levels in answering patient questions on medicinal cannabis were in equal numbers (47.2%) while pharmacists who claimed low confidence levels amounted to 32.3%. The second instance concerned the knowledge about the modalities of medicinal cannabis prescription, with pharmacists being more knowledgeable than doctors (58.8% vs. 44.4%). The majority of doctors (49%) admitted to being less knowledgeable on this matter, whilst only 21% of pharmacists stated this. Szaflarski et al. (2020) had also noted a similar streak in their study, with pharmacists indicating they felt better informed about cannabis therapies than neurologists and nurses, suggesting profession-specific educational and experiential differences might influence knowledge levels [49].

A more granular dissection of our data through statistical analysis does highlight another minor difference. An independent samples t-test noted that doctors exhibited a slightly more negative attitude towards the use of clinical cannabis when compared to pharmacists (M = 6.20, SD = 2.88 vs. M = 5.19, SD = 2.26, t(195.78) = – 2.71, p = 0.006, Cohen’s d = – 0.4). Similar results were reported in a recent Croatian study where pharmacists demonstrated slightly more favourable attitudes towards CBD than physicians, reflecting a greater optimism regarding its therapeutic potential and role in reducing opioid use for chronic pain [50]. As in our study, the divergence was minimal and, in essence, both groups of professionals in our research exhibited very similar patterns on variables analysed, demonstrating largely homogenous attitudes, beliefs and knowledge with regards to medicinal cannabis and its clinical use.

Predictor for doctors prescribing medicinal cannabis

While age emerged as a weak yet statistically significant predictor of prescription attitude (β = 0.22, p < 0.05), the strongest predictor was attitude towards the clinical use of medicinal cannabis, which demonstrated a robust and highly significant positive relationship with prescription attitude (β = 0.71, p < 0.001) (Table 4). This suggests that doctors’ general attitudes toward medicinal cannabis play a more substantial role in shaping their willingness to prescribe it than demographic factors such as age, or their formal education or knowledge on the subject. Assessment through Pearson product moment correlation analyses suggested similar correlational structures in both male and female doctors, with attitude towards medicinal cannabis consistently emerging as the strongest correlate of prescription attitude for both genders. Conversely, those who were ambivalent were unlikely to prescribe, regardless of knowledge. This trend is mirrored in multiple international studies, such as that by Adler et al. [34] which found that Israeli physicians who believed in the efficacy of medicinal cannabis were over 20 times more likely to prescribe it, whereas knowledge alone was a comparatively weaker predictor. Rosenbæk et al. [42] similarly reported that Danish GPs’ willingness to prescribe was closely tied to positive attitudes and self-reported knowledge levels.

Table 4.

Hierarchical regression analysis predicting doctor’s prescription attitude

The strength of attitude as a driver of clinical behaviour is also evidenced in research by Syed et al. [51], who noted that even when controlling for knowledge levels, positive attitudes about the utility of medicinal cannabis predicted greater readiness to recommend and prescribe it. This supports the hypothesis that in the context of therapeutic uncertainty, clinicians often default to heuristic reasoning shaped by values and anecdotal experiences. An international survey found that physicians who had seen positive patient outcomes with cannabis were significantly more likely to continue recommending it [52].

While attitude was the dominant predictor in our multivariate analysis, knowledge still played a role. Numerous studies have shown that greater knowledge about medicinal cannabis correlates with more favourable clinical attitudes. German doctors who reported greater familiarity with cannabis-related treatment options were significantly more likely to support its medical use, particularly in pain and palliative settings [53] and so were primary care providers in Washington State who presented higher knowledge scores [36]. Australian, Saudi and Thai physicians and pharmacists with greater self-rated knowledge were also significantly more open to the clinical use of medicinal cannabis [23, 47, 54]. Canadian and US pharmacists aligned with this trend in separate studies, with more education on cannabis translating in higher confidence and favourable attitudes towards its clinical use [41, 49]. However, Zolotov et al. (2019) presented an interesting counterpoint. Doctors who are more inclined to recommend medicinal cannabis sometimes reported lower confidence in their own knowledge, possibly indicating that positive attitude can precede or even substitute for formal learning in certain clinical decisions [55].

Study limitations

Several limitations should be considered when interpreting the findings of this study. Firstly, doctors’ attitudes toward medicinal cannabis may vary significantly depending on their medical specialty. For example, neurologists and pain management physicians typically exhibit more positive attitudes due to direct observations of patient improvements in clinical practice. Our study did not specifically investigate specialty-specific attitudes, which represents a missed opportunity to explore potentially influential variables affecting healthcare professionals’ perspectives. In a small jurisdiction such as Malta, protecting respondent anonymity was a priority. To minimise re-identification risk and reduce respondent burden, we did not collect potentially identifying variables such as medical specialty. This design choice precluded specialty-stratified analyses and limits the granularity of some inferences. Secondly, our measure of knowledge about medicinal cannabis relied on self-assessment, a common approach in similar research. It is important to recognize that self-assessed knowledge should not be conflated with actual competence. Previous research has demonstrated that healthcare professionals, including doctors, frequently underestimate or overestimate their true level of knowledge [56]. Therefore, self-evaluation in our study should be regarded primarily as a reflection of confidence rather than an objective measure of factual knowledge. Because participation in this registry-wide survey was voluntary, self-selection bias is possible. Healthcare professionals with stronger views or greater interest in medicinal cannabis may have been more likely to respond. While our census-style invitation to all licence registrants reduces coverage error and the observed distribution of neutral and uncertain responses suggests that participation was not limited to advocates, we cannot exclude differential non-response. The absence of non-respondent characteristics precludes formal adjustment. Future work could compare respondent demographics to registry benchmarks and use tailored follow-ups to assess non-response. Additionally, as noted in previous literature, attitudes toward medicinal cannabis are likely influenced by broader socio-cultural, legal, and policy contexts, which were not deeply explored in this study. Understanding these contextual factors in greater depth could provide more comprehensive insights into the barriers and facilitators affecting healthcare professionals’ prescribing behaviours. Finally, the cross-sectional design employed in this study precludes causal interpretations of the observed relationships. Longitudinal or experimental designs could offer stronger evidence for causation and potentially capture changes in attitudes, knowledge, and prescribing behaviours over time as regulatory frameworks and educational opportunities evolve.

Conclusion

Our findings indicate that improving healthcare professionals’ capacity to make informed, patient-centred decisions about cannabis-based medicines depends on addressing the underlying needs that shape their knowledge, attitudes, and beliefs. Namely evidence-based education, clear clinical guidance, and practical decision-support resources. Strengthening these elements can support the appropriate integration of cannabis as a treatment option where supported by evidence and regulation, while maintaining clinical caution in areas of uncertainty. Consistent with prior observations, the continued accumulation of well-controlled clinical trial data is likely to enhance both patient safety and professional confidence [46].

Author contributions

Conceptualization, David Zammit Dimech; Data curation, David Zammit Dimech; Formal analysis, David Zammit Dimech; Investigation, David Zammit Dimech; Methodology, David Zammit Dimech; Project administration, David Zammit Dimech; Resources, David Zammit Dimech; Supervision, Louise Grech and Anthony Serracino Inglott; Validation, David Zammit Dimech; Visualization, David Zammit Dimech; Writing – original draft, David Zammit Dimech; Writing – review & editing, David Zammit Dimech.

Funding

This research received no external funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.

Informed consent

All participants provided electronic implied consent. Participation was voluntary and anonymous.

Ethics approval and consent to participate

University Research Ethics Committee, University of Malta.