While a number of studies have examined the characteristics of patients seeking cannabis recommendations from a physician,^3,8 and those obtaining cannabis from a dispensary,^2,9 the present study serves as the first examination of characteristics and practices of dispensary staff. Findings indicate that the vast majority of staff provide specific counseling to patients regarding cannabis that may be most helpful for their individual conditions, and that these recommendations are based on a number of sources, both empirically and nonempirically based. Despite the vast number of staff members offering recommendations to patients, only 20% of our sample reported prior medical and/or scientific training.

In terms of plant strain recommendations, very little work has documented patient preference or the specific efficacy of certain cannabis strains as a function of clinical condition. Staff recommendation of indica strains for chronic pain in the current study was consistent with individual patient preference observed in other work.¹⁰ The recommendation of indica primarily for insomnia and nightmares is consistent with one patient survey,¹¹ but differs from another empirical study that highlighted patient preference for sativa strains for sleep difficulties.¹² While observations related to strain recommendations are interesting, due to extensive hybridization and variations in growing conditions, the differences between cannabis strains do not seem to play as large a role in determining subjective effects as cannabinoid concentrations.¹³ This has led some to argue that distinctions among cannabis chemovars labeled as “Sativa” or “Indica” are relatively meaningless unless accompanied by detailed accurate assays of cannabinoid and terpenoid content.¹⁴

Dispensary staff recommendations of cannabinoid concentrations (e.g., THC, CBD) for particular patient symptoms and conditions were also frequently incongruent with the existing empirical literature. For instance, the existing empirical literature would suggest that cannabis high in CBD could be particularly helpful for individuals with anxiety disorders, while cannabis high in THC could actually lead to acute and long-term anxiety reactions.^6,15,16 Early pre-clinical work has also highlighted CBD as a potential antidepressant,¹⁵ anticonvulsant,^16,17 and therapeutic for PTSD.¹⁵ On the other end of the spectrum, the literature would suggest that THC may be an antiemetic, and particularly beneficial for appetite stimulation and pain.¹⁸ Finally, a number of reviews have documented that a combination of THC and CBD (e.g., nabiximols) can have therapeutic value for individuals with spasticity due to multiple sclerosis,^16,19 neuropathic pain,^16,20 as well as sleep disturbances.¹⁵ Based on the above literature, it appears that a meaningful number of dispensary staff are providing recommendations for cannabinoids that have either not been shown to be effective for a given condition (e.g., 33% recommending THC for depression, 10% recommending CBD for appetite, 78% recommending either high THC or high CBD for multiple sclerosis), or could actually worsen a patient's condition (e.g., 13% recommending THC for anxiety, 7% recommending THC for epilepsy).

Aside from the present study's contribution to the literature in terms of describing the characteristics of cannabis dispensary staff, findings highlight the importance of consistent, evidence-based training of those providing specific recommendations of cannabis strains or cannabinoid concentrations for a given patient condition (e.g., physicians, dispensary staff). Indeed, while one might expect the most qualified individuals to provide specific recommendations of cannabis product to be trained physicians who are aware of a patient's medical history and other prescription medications that could interact with certain cannabinoids,^21–23 it is dispensary staff who are the most likely to provide cannabis advice. As each state is currently responsible for drafting and monitoring its own cannabis legislation, it is imperative for states to mandate some form of educational certification for any individual providing cannabis advice to patients, not just physicians. Furthermore, given the quickly evolving literature in this field, it seems necessary for individuals to receive regular updates via continuing medical education. Given the increasing availability and preferences for myriad methods of cannabis consumption (e.g., edibles, extracts, dabs)^2,24 and corresponding risks,^25,26 patient and provider education programs should strive to include trainings in safe and effective use of cannabis as a function of preparation.

The present study data, although novel, are not without limitations. First, given the cross-sectional nature of the investigation, we were unable to determine changes in staff behavior over time or as a function of the implementation of particular training programs. Second, while the utilization of structured surveys allowed for the systematic and quantitative analysis of staff characteristics and practices, such surveys are limited in that they do not allow for nuanced information regarding staff behavior. Future prospective qualitative work that incorporates open-ended questions would aid in fleshing out the present findings. Third, although both medicinal and nonmedical dispensary staff were recruited, higher response rates in specific states may limit generalizability of findings to dispensaries across the United States or in other countries. Web-based recruitment methods also limit our ability to determine overall sample representativeness. Indeed, the survey response rate may have been restricted by perceived stigma associated with both medical and nonmedical cannabis use and/or skepticism of researchers by dispensary staff. Finally, the current study aimed to describe overall behavior among dispensary staff, and in doing so the survey did not collect information about physician practices or detailed information about the provision of services for certain, particularly vulnerable, populations (e.g., individuals with PTSD). Limitations notwithstanding, the present study serves as a “call to action” for consistent and evidence-based training of providers in the cannabis industry.