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Medical cannabis attitudes and beliefs among pain physicians
  1. Samer Narouze1,
  2. Sameh M Hakim2,
  3. Lynn Kohan3,
  4. Daniel Adams1 and
  5. Dmitri Souza1
  1. 1 Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
  2. 2 Department of Anesthesiology and Pain Management, Ain Shams University Faculty of Medicine, Cairo, Egypt
  3. 3 Divsion of Pain Medicine/Dept of Anesthesia, University of Virginia, Charlottesville, Virginia, USA
  1. Correspondence to Dr Samer Narouze, Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, OH 44223, USA; narouzs{at}

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Medical use of cannabinoids for pain management is gaining rapid popularity; however, little is known regarding physicians’ perceptions regarding its potential value.1 We conducted a survey for pain physicians with the aim to characterize their advocacy and concerns regarding medical cannabis (MC).


A previously employed questionnaire2 was adapted after consulting a group of pain experts. The modified questionnaire was fed into the Qualtrics software, Copyright 2019 (Qualtrics, Provo, UT), available at, and was tested and confirmed for internal consistency on a sample of 30 participants. The questionnaire was then distributed by the American Society of Regional Anesthesia and Pain Medicine to all active members by email with the web link. Participants were asked to score each item from 0 to 100 by sliding a pointer on a continuous scale. The scaling was intended to make a higher score on any item denote more favorable attitude regarding use of MC. So, scores of items denoting negative trend regarding MC were reversed by subtracting the actual score from 100. We conducted principal components analysis3 based on Eigenvalue >1.0 and rotated factor loading (r) of >0.5 which revealed that only 16 out of 19 items actually loaded on at least one of three principal components (factors). We named the components: ‘Legitimacy and physical benefits of MC’ (six items), ‘Psychological benefits of MC’ (seven items) and ‘Worries/Concerns over recommending MC to patients’ (three items). We calculated an average score for each of the three principal components by summing up the scores of the items comprizing the component and dividing it by the number of these items. Besides, we calculated an overall score for the questionnaire by averaging the scores of all three components comprizing the questionnaire. Scores are presented as median and IQR as they did not fulfill the assumption of normal distribution. Categorical variables are presented as percentages. Internal consistency was tested for each principal component using Cronbach’s alpha (α) coefficient. We screened for a relationship between demographic variables and component scores using Kendall’s tau-b (τb ) rank correlation (for continuous-ordinal associations) or point biserial (rpb) correlation (for continuous-nominal associations). Data were analyzed using IBM SPSS Statistics V.22 (IBM) and JMP V.14.3.0 (SAS). All statistical tests are two sided and p<0.05 is considered statistically significant.


Between 10 October 2019 and 1 March, 2020, 334 participants accessed the survey website with response rate of 21.7%; 67% were males, 62% were ≤50 years of age and 66% had been graduated for >10 years. Thirteen per cent of participants were registered in an MC program, 31% recommended MC to patients and 76% cared for patients on MC. The internal consistency for all three principal components was acceptable (Cronbach’s α, 0.892, 0.927 and 0.755, respectively). The participants’ scores were highest regarding legitimacy and physical benefits of MC, where 50% of participants scored 64 or higher and 25% scored 77 or higher. The scores were lower for concern over recommending MC (median (IQR), 49 (30–72)) and for psychological benefits of MC (median (IQR), 43 (27–59)). Seventy-five per cent of participants scored 38 or higher, while 50% scored 50 or higher and only 25% scored 65 or higher on the 101-point overall scale (table 1 and figure 1). There was no statistically significant association between the participants’ scores and their age, gender or years since graduation (all p>0.05).

Figure 1

Box plot illustrating the participants’ scores on the three principal components of the questionnaire and the averaged (overall) score of all three components. Box represents the IQR. Line inside the box represents the median. whiskers represent minimum and maximum values excluding outliers (red markers). MC, medical cannabis.

Table 1

Participants’ scores on the three principal components of the questionnaire and the averaged (overall) score of all three components


Pain physicians were most favorable regarding the legitimacy and benefits of MC for physical symptoms. The trend was less favorable for psychological benefits and for the worries associated with recommending MC. Thus, as more scientific evidence emerges supporting the use of MC, educational efforts targeting pain physician would be of great value.

To the best of our knowledge, this is the first attempt to explore this area among pain physicians. However, our report had few limitations. The target sample was rather selective and the results cannot be confidently extrapolated to other communities of pain practitioners. The response rate was lower than recommended.4 This may be relevant since subjects with more negative attitudes are less likely to participate in a survey.5 Nonetheless, the observed response rate is practically close to that reported by a similar survey.2 We used a continuous-type scale to quantify responses which we believed could have some advantages over conventional Likert-type scales in terms of enhanced precision and reliability of measures and convenience for statistical methods.6

In conclusion, our results suggest a mismatch between the pain physicians’ favorable attitude regarding the legitimacy of using MC and their willingness to recommend it. Such a discrepancy should be the focus of quality improvement activities as the possible medicinal benefits of cannabinoid therapy for chronic pain are better characterized.



  • Twitter @NarouzeMD, @kohanlynn

  • Contributors All authors contributed to the work, have read the final submission, and approved it.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was awarded Institutional Review Board (IRB) Review Exempt status by the Lake Erie College of Osteopathic Medicine (LECOM).

  • Provenance and peer review Not commissioned; externally peer reviewed.