Ever since the state of Minnesota legalized medical cannabis, petitions have been sent to the Department of Health with one request: Certify generalized anxiety disorder as a condition qualified for treatment.
Over the years, the petitions have been reviewed, and last year a collection was presented to Minnesota Commissioner of Health Jan Malcolm. Because of departmental concern about a lack of engagement with the medical community, the petitions were denied.
Chris Tholkes, director of the Office of Medical Cannabis, explained that Commissioner Malcolm has signaled that she is likely to announce a decision on the issue by December 1. “Last year, the commissioner said she would decline it,” Tholkes said of the petition, “but she said she doesn’t want to keep leaving people in the position that they have to keep petitioning us each year.”
Popular support for the certification of medical cannabis as a treatment for anxiety has run high since the Office of Medical Cannabis was founded in 2015, Tholkes said. “Last year we were in the position where we got hundreds of comments from layfolks that said, ‘Yes, please add anxiety,’ and one letter from a psychiatrist that said, ‘Don’t do that,’” Tholkes said. “It left us with no real answers about what the medical community feels.”
That has changed. This spring, in order to get a better idea of where the state’s medical professionals stand on the issue, Tholkes and her staff assembled a working group of seven mental health and addiction professionals to review the literature, speak with representatives from Minnesota’s medical cannabis industry and compile an official report for her office.
Alik Widge, assistant professor of psychiatry and researcher at the University of Minnesota, was a member of the working group. Widge’s experience in the group, which held three remote meetings in 2021, introduced him to a range of information, but only slightly shifted his opinion, he said.
While Widge said that he may now be a bit more open to the idea that medical cannabis could be safely used to treat anxiety in certain conditions, he also said that a lack of solid medical research on the topic continues to keep him on the more skeptical side of the issue. “If I could see enough strong research, I would be more comfortable,” he said. “I don’t think it would be a good idea in most situations, but I would say that in the right case you could get me to be cautiously okay with studying it.”
Many members of the state’s mental health community appear to feel the same way. Earlier this month, citing a range of concerns — including the risk of addiction and the potential to trigger psychosis in some patients and an increased risk of cardiovascular morbidity and mortality — the Minnesota Psychiatric Society released a position paper opposing authorization of medical cannabis as a treatment for every and all anxiety disorders.
Widge said that many of his colleagues — some of whom were members of the working group and many who were not — have seen the potentially negative impact that cannabis use can have on their patients’ mental health. “A representative sample of psychiatrists in the state of Minnesota would be against certification of cannabis for anxiety,” Widge said, “because all of us have horror stories of patients whose symptoms are being exacerbated but they are unwilling to give up using cannabis.”
He added that even though the Department of Health has been reviewing the issue for years, he is still concerned that Malcolm may be making the decision hastily. “The state should try to generate solid data on this issue, not just act on the basis of, ‘We get a lot of pressure from advocacy groups on this.’
“I don’t know what’s going through the commissioner’s head, but I want this decision to be made in a measured fashion,” he said. “What if this just becomes a free-for-all and people are deferring actual medical treatment and using cannabis instead?”
Members of the state’s addiction treatment industry are also weighing in, including Hazelden Betty Ford President and CEO Joseph Lee, who earlier this month sent Malcolm and members of the Minnesota Department of Health’s Cannabis Review Panel a letter of opposition.
Lee, who is a psychiatrist with a focus on addiction medicine, said that so far he has not been impressed with existing research on medical cannabis’ efficacy as a treatment for anxiety. “If people are falling on science as they make these decisions about a treatment for a mental health condition,” he said, “I would say the existing research isn’t strong or compelling at all.”
Lee added that he is also concerned that state approval of medical cannabis as a treatment for anxiety could encourage commercialization of the drug, which he fears could lead to over-prescribing. “In America, we have a long history of over-prescribing medication,” Lee said. “Before opioids it was sedatives that we don’t use anymore, like Valium or Quaaludes.”
While he believes that anxiety disorders “are very real,” Lee added that these disorders are treatable with therapy and limited use of some medications.
“There is a difference between being anxious and having an anxiety disorder,” Lee said. “Our history shows us that those lines get blurred. It’s not that we don’t want to help people, but you have to wonder: Virtually everyone who goes in with a request is approved for medical cannabis. If you have a symptom set that speaks to a diagnosis, that gets pretty squishy. I worry about what happens next.”
Another concern, said George Realmuto, University of Minnesota professor emeritus of psychiatry, is the way medical cannabis is prescribed and dosed, and how it could lead to confusion about the use of other medications. “Physicians don’t prescribe a dose of medical cannabis,” Realmuto explained. “A pharmacist does, which is maybe OK, but If I’m treating somebody for XYZ, and cannabis is being dosed out by somebody else and they don’t let me know what the dose is or the patient isn’t clear about those details, there may be confusion. There is no collaboration between the pharmacist and the physician. I think that is a mistake in patient care.”
That concern is one of the reasons that he and his colleagues have been wary of medical cannabis from the start.
When the Office of Medical Cannabis was being organized, Realmuto said, “Physicians didn’t want to have anything to with cannabis. I was at those meetings.” He added that he and many of his colleagues continue to be afraid that if the generalized anxiety petitions are granted approval for treatment with medical cannabis, other mental health conditions will soon follow. “Anxiety is today’s issue,” Realmuto said “What’s tomorrow’s? What is the process through which these decisions are made? I think this is the bigger issue.”
Tholkes explained that her office is taking a careful approach to collecting and summarizing the varied points of view. “We will compile and summarize all of the comments,” she said. “We read them all. We try to get a sense of, ‘Was there an organized campaign? Are there 70 comments that read the same that we can put in one bucket? Or should we look at them more closely because they are citing literature?’”
Over the years there has been a range of comments on anxiety disorders and cannabis, Tholkes added: “It is always very interesting. It is everything from a two-word sentence that just says, ‘Add it.’ Some people don’t say anything but they just give us a list of links to various articles. Sometimes we get a pro or con letter from a medical provider. They might say they are for or against this issue but they won’t say why.”
Tholkes said she understands physicians’ and other health care providers’ reluctance on this issue: “They are scientists. That is their training. They want scientific evidence. That is the lens that I expect when I visit my physician.”
As part of the process of compiling a report for the commissioner, Tholkes explained that her staff collects self-reported data from patients about their experience using. It is called a “patient-experience survey.” Patients fill it out every time they go to a medical cannabis dispensary. Some qualified conditions, including PTSD, feature anxiety as a symptom. “It is not a clinical trial, but it is really fantastic self-report data that a lot of other programs don’t have,” she said.
The next step in the process is to synthesize petitions, research briefs and work group findings into a final report that will be presented to Malcolm, Tholkes said.
If medical cannabis is approved for the treatment of anxiety this year, Widge would like to see a pilot program. “We should allow 100 patients in the state to be certified and we can watch them closely and see the outcome [of their treatment]. The federal government is not going to support a clinical trial for cannabis for anxiety. The only way we might get this information is if the state says, ‘Okay, but a limited yes, with monitoring.’”
But Tholkes isn’t confident that such an approach could work in real-world application. “If our criteria is that in order to have qualifying conditions and to have our program we need to have the threshold of research that most of us are used to with other pharmaceuticals, we wouldn’t have a program at all because there has been such limited research on cannabis. If the threshold is that we need an FDA-approved product, I’m not sure why we have a program.”
If anxiety becomes a qualifying condition for medical cannabis, Tholkes said that one major concern raised by mental health providers will be addressed: “Medical cannabis, if approved for anxiety disorder, would only be available to patients age 25 and older,” she said. “The work group discussed extensively the potentially negative impact of cannabis use on the developing brain and that the risk was significantly lower at age 25. We heard that loud and clear, and it would be reflected in a final decision.”