A total of 270 webpages were identified across searches, and after removing 199 duplicate webpages, 71 unique webpages remained. Twenty-eight webpages did not meet our exclusion criteria, for the following reasons: general news website (n = 8), peer-reviewed journal/article (n = 8), targeted towards healthcare professionals rather than consumers (n = 5), not publicly available (n = 2), online forums (n = 2), major e-commerce website (n = 1), discussed cannabis as an addiction not a treatment (n = 1), and invalid URL (n = 1). Of the remaining 43 webpages, 7 webpages belonged to websites already captured by the search and were collapsed into a single item. Therefore, 36 unique websites were deemed eligible for data extraction, and were assessed using the DISCERN instrument. This process is depicted in Fig. 1.
Web information search strategy and assessment flowchart
General characteristics of eligible websites
Eligible websites were identified as belonging to 1 of 6 categories, as follows: health portal (websites that provide information on many types of diseases/conditions, n = 8), professional (websites marketing cannabis as a medical therapy, n = 8), cannabis news (websites that report specifically on emerging cannabis and pain related information, n = 6), non-profit (organization websites operating in a research and/or educational capacity, n = 5), commercial (websites that market cannabis products/services, n = 4), and finally, other (websites that do not fit into any of the aforementioned categories, n = 5). Of the 36 eligible websites, 28 appeared in multiple searches, while 8 appeared only once (3 websites from USA, 3 websites from the Netherlands, and 2 websites from Canada). Of the 36 websites, the following non-cannabis topics were discussed: surgery (n = 28), pharmaceutical medications (n = 28), and complementary and alternative medicine (CAM, n = 23). Full details associated with the general characteristics of eligible websites are shown in Table 1.
DISCERN instrument ratings
The mean summed DISCERN score was 48.85 (SD = 8.13, range from 33.50 to 65.00). The mean overall score (question 16) was 3.10 (SD = 0.62, range from 2.00 to 4.50). The three highest scoring websites were Medical News Today (65.00), WebMD (64.50), and Very Well Health (62.50). The lowest scoring websites were SepaPain (37.50), People’s Cali (37.50), and Denver Dispensaries (33.50). DISCERN scores for each eligible website are provided in Table 2.
Trends identified across resources assessed
Questions 1-8: reliability of the publication
Question 1 asks if the aims of the publication are clear. Specifically, this question ascertains what the publication is about, what it is meant to cover, and who might find it useful. In general, health portals scored highest in this section, with commercial websites scoring the lowest. The mean score for this question was 3.89 (SD = 0.89), and the scores ranged from 1 to 5.
Question 2 seeks to understand if the publication has achieved its aims (the aims that were evaluated by question 1). This question is closely linked to question 1. In general, websites that scored low on question 1 also scored poorly on question 2. Health portals scored highest on this section, and commercial sites scored lowest, however, question 2 also saw lower scores for professional sites, compared to question 1. The mean score for this question was 3.96 (SD = 0.94), and the scores ranged from 1.5 to 5.
Question 3 asks if the information in the publication is relevant. This question ascertains whether the publication addresses the questions that readers might ask. It also asks whether recommendations and suggestions within the publication concerning treatment choices are realistic or appropriate. Professional and commercial websites generally scored most poorly on this section. The mean score for this question was 3.38 (SD = 0.78), and the scores ranged from 2 to 4.5
Question 4 asks whether the sources used to compile the information available in the publication are clear and accessible. Cannabis news, commercial, and professional websites generally scored very poorly on this section (the lowest scoring website was SepaPain, with a score of 1). The mean score for this question was 3.19 (SD = 0.98), and the scores ranged from 1 to 5. Question 5 evaluates whether the dates of any source information. All publication revisions are readily available on the site. Generally health portals scored well on this question while commercial websites scored poorly. The mean score for this question was 2.97 (SD = 1.24), and the scores ranged from 1 to 5.
Question 6 asks if the source of consumer health information is balanced and unbiased. Both professional and commercial websites (and cannabis news websites to a lesser degree) scored lower in this category when compared to health portals and non-profit websites. Eleven out of 12 professional. Commercial websites scored below a 3 on this item. These websites presented more persuasive and positive language when discussing cannabis, had fewer reputable or easily traceable sources, and discussed the possibility of alternatives to cannabis much less frequently as opposed to health portal or non-profit websites. The mean score for this question was 2.68 (SD = 1.21), and the scores ranged from 1 to 5.
Most websites scored comparatively higher on question 7 of the DISCERN instrument. In fact, only 4 out of 36 websites scored below a 3.5 for this question. This section asks if information presented on the website was supported by additional sources, and whether links to pages/websites with similar topic information were available within webpages. Most websites provided references and hyperlinks to other websites (such as government agencies or other pages within the website with similar topics). The mean score for this question was 3.96 (SD = 0.77), and the scores ranged from 2 to 5.
Question 8 asks if the publication refers to areas of uncertainty. For example, this question ascertains if there is discussion of the gaps in knowledge or differences in expert opinion concerning treatment choices. Commercial and professional websites generally scored very poorly on this section (i.e., Denver Dispensaries and Med Card Now). However, the lowest scoring website for this particular question was Medical Cannabis, a non-profit website. The mean score for this question was 2.96 (SD = 1.08), and the scores ranged from 1 to 4.5.
Questions 9-15: specific details of the information about treatment choices
Question 9 assesses whether the publication describes how the proposed treatment works. Commercial and professional websites, in general, scored most poorly on this section, as they provided little to no explanation of treatment mechanisms. Such websites typically only provided a list of treatment benefits, while providing, at most, a cursory explanation of the treatment’s physiological mechanisms. The lowest two scoring websites were Lab Blog UofM. Cannabis Clinics (both professional websites). The mean score for this question was 3.38 (SD = 0.72), and the scores ranged from 2 to 4.5.
Question 10 asks if the publication describes the benefits of each treatment. Most websites scored well on this question, with detailed descriptions of the many possible benefits associated with cannabis use included. Of the 36 included websites, 23 scored at or above a 4.5 on question 10, and only one website, Lab Blog UofM, scored below a 3.5. The mean score for this question was 4.31 (SD = 0.51), and the scores ranged from 3 to 5. Question 11 investigates if the publication accurately. Fully describes the risks of each proposed treatment. Most websites, with the exception of health portals and non-profits, scored poorly on this question. Most commercial, cannabis news, and professional websites either only discussed treatment risks briefly, or omitted mention of risks completely. The two lowest scoring websites were People’s Cali (commercial) and SepaPain (professional) with a score of 1.5 each, indicating an almost complete lack of risk warnings. The mean score for this section was 3.18 (SD = 0.83), and the scores ranged from 1.5 to 4.5.
Question 12 of the DISCERN instrument assesses whether a publication explains what would happen to a patient who did not undergo treatment. Twenty-eight websites scored a 2 or lower, with only one website scoring above a 3.5. While a variety of treatment options were often discussed with respect to pain conditions, the impact of receiving no treatment for these conditions was rarely discussed. Although some websites stated that the pain condition could be resolved without treatment, they did not directly discuss how chronic conditions could progress without treatment, or provide more details about this information. Some websites, even if briefly, supported the idea that cannabis is a preferential pain management option to opioids, claiming that it causes less damage and cannot result in addiction. The mean score for this question was 1.72 (SD = 0.74), and the scores ranged from 1 to 4.
Question 13 asks if the website takes into account the various impacts a specific treatment choice could have on an individual’s quality of life (i.e., financial strain, ability to continue work, and any potential impact on interpersonal relationships). Only two websites in this category scored higher than a 3.5, indicating an overall lack of this information. Twenty-two websites discussed this generally in terms of short-term effects of cannabis (i.e., decreased driving ability), but did not discuss long-term impacts on patients' quality of life, while the remaining 14 websites did not discuss this at all. The mean score for this question was 2.60 (SD = 0.69), and the scores ranged from 1 to 4.
Question 14 assesses whether it is made clear in the publication that there may be more than one possible treatment choice. In general, professional and commercial websites did not mention any possible alternatives to cannabis therapy for pain, and solely focused on describing cannabis benefits. In contrast, health portals scored higher for this question. The mean score for this question was 3.11 (SD = 1.60), and the scores ranged from 1 to 5.
Finally, question 15 asks if the publication provides support for shared decision-making. In other words, this question asks if the publication encourages patients to discuss treatment options with a healthcare provider, such as a physician, prior to using medical cannabis. Generally, cannabis news and commercial websites scored poorly on this section. The mean score for this question was 3.68 (SD = 0.93), and the scores ranged from 1.5 to 5.
Recommended websites for patients and consumers
The five highest-rated websites had a mean summed score of 61.20 (out of 75), and a mean overall score (question 16) of 4.20 out of 5. All 5 websites were either characterized as a health portal or a non-profit. All of these websites scored highly on question 15, as they placed a significance on shared decision-making (i.e., discussing treatment options with friends, family, and healthcare providers). In addition, question 6 of the DISCERN instrument asks whether the publication is balanced and unbiased, and all 5 websites scored 3.5 or higher on this question as they provided more objective language, while accounting for any potential competing interests. All 5 websites aimed to provide less biased information and encouraged the reader to discuss treatment options with their family and professionals. Additional characteristics of the 5 recommended websites are provided in Table 3.
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