A small study of 20 primary care physicians found that nearly half felt incompetent to counsel patients about medical cannabis, and only 10% had ever received training specific to older adults. Despite this, every physician reported that patients across all age groups regularly ask about cannabis, highlighting a widening gap between patient demand and physician preparedness that has immediate implications for safe clinical guidance.

Cannabis use among older adults has risen sharply in recent years, driven by expanding legal access and growing patient interest in symptom management for chronic pain, insomnia, and anxiety. Yet primary care physicians, the clinicians most likely to field these questions, are navigating this terrain without formal training or evidence-based guidelines. When physicians feel unprepared, patients often turn to dispensaries or online sources that may not account for polypharmacy, fall risk, or age-related pharmacokinetic changes. Understanding the depth and dimensions of this counseling gap is a prerequisite for designing the educational interventions that patients and their doctors urgently need.

As cannabis legalization expands and adult use increases across the age spectrum, patients increasingly expect their primary care physicians to offer informed guidance. Older adults face distinct vulnerabilities, including heightened sensitivity to psychoactive effects, greater fall risk, polypharmacy complications, and age-related changes in drug metabolism, yet structured training addressing these concerns remains exceedingly rare. This research letter describes a cross-sectional, mixed-methods study conducted at five primary care clinics within a single academic health system in San Diego, California, designed to explore how physicians approach cannabis counseling and whether their comfort and strategies differ for younger versus older patients.

Twenty internal medicine and family medicine physicians completed surveys and qualitative teleconference interviews between June and October 2023. All 20 reported that patients in both the 21 to 64 and 65-plus age groups ask about medical cannabis, yet 45 to 50 percent disagreed that they were competent to advise patients of either age group. Only 25 percent agreed they felt competent. Physicians were substantially more comfortable with CBD-only products (80 to 85 percent agreed these might benefit patients) than with THC-containing products (only 20 percent agreed). Qualitative interviews revealed that physicians recognized older-adult-specific risks such as falls, cognitive impairment, and drug interactions, but only 10 percent had received any cannabis education focused on older adults. Many described relying on informal harm-minimization strategies, such as recommending low doses and discouraging smoking, rather than evidence-based protocols. The authors acknowledge that the study is exploratory and that the very small, geographically and institutionally homogeneous sample precludes generalization to broader clinical populations.

This study puts numbers, however preliminary, to something I have witnessed for years: most primary care physicians are flying blind when patients ask about cannabis. The finding that only 10 percent had any training on cannabis and older adults is sobering but not surprising. Medical education has simply not caught up with the reality that cannabis is one of the most commonly discussed therapeutic topics in a primary care visit. What the study gets right is the framing: this is not primarily a knowledge deficit among physicians, it is a systemic failure of medical education infrastructure.

In my practice, I see older adults daily who are already using cannabis, often without any physician guidance. I treat them the way I would approach any medication adjustment in a complex patient: I review the full medication list, assess fall risk, discuss realistic expectations, and start with very low doses of well-characterized products. The reality is that waiting for formal curricula to appear is not a viable strategy when patients are making decisions right now. Physicians need to develop interim competence, and studies like this one, small as it is, help make the case for why.

This study occupies an early, hypothesis-generating position in a growing body of literature on physician preparedness around cannabis. It does not measure clinical outcomes, actual counseling behaviors, or patient safety events. Its value lies in confirming, within a defined clinical population, what several larger surveys have suggested at the national level: that a substantial proportion of primary care physicians feel they lack the competence to have informed cannabis conversations, and that this gap is especially pronounced for older adults. For clinicians, the qualitative findings are arguably more informative than the survey data, as they reveal the specific heuristics physicians use when formal guidance is absent, such as favoring CBD over THC, recommending edibles or topicals over inhalation, and advising start-low-go-slow dosing.

From a pharmacological perspective, the differential comfort with CBD versus THC products reflects a rational but incomplete risk assessment. CBD carries its own interaction risks, notably as a potent inhibitor of CYP3A4 and CYP2C19, which can elevate plasma concentrations of common medications including warfarin, clopidogrel, and certain statins. Clinicians should not assume that recommending CBD alone eliminates pharmacokinetic complexity, particularly in older adults on multiple medications. One actionable step: incorporate a standardized cannabis use screening question into geriatric intake assessments, ensuring that cannabis, including CBD products, appears in medication reconciliation workflows alongside conventional prescriptions and supplements.