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.
[image_caption]Chris Tholkes[/image_caption]
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.
[image_caption]Dr. Alik Widge[/image_caption]
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?”
[image_caption]Joseph Lee[/image_caption]
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.”
[image_caption]George M. Realmuto[/image_caption]
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.”
Next steps
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.”
The reality is that millions of people are using cannabis to treat anxiety. Legalizing it just means that the cannabis will be regulated and standardized, and can be tailored to individual needs. You can’t analyze this in a vacuum.
“What if this just becomes a free-for-all and people are deferring actual medical treatment and using cannabis instead”
Here is where the analysis breaks down. Why isn’t cannabis actual medical treatment? The medical treatment he is talking about it just different kinds of pharmaceuticals. I had terrible insomnia years ago and tried a number of prescription drugs, without success. The drug that actually worked was cannabis.
And kudos to Minnpost for using the term “addiction treatment industry.” Because it is an industry, and there is a huge conflict of interest at work here for those people.
Is not one of the issues that it is difficult to study due to Fed regs,and the regs dont change due to lack of research?
Bingo.
“And kudos to Minnpost for using the term “addiction treatment industry.” Because it is an industry, and there is a huge conflict of interest at work here for those people.”
Absolutely, not only is it an industry but it’s a huge industry without a particularly great track record of success.
As far as anxiety treatment is concerned, let’s please not pretend that the sanctioned pharmaceutical drugs are all perfectly safe and effective with no side effects.
I understand the concerns here but the only reason we get to debate this as a medical issue is because we’re talking about medical cannabis instead of straight up legalization. I would prefer to see across the board legalization and let docs and patients deal with medical treatment where appropriate.
I agree. Let us simply say, that many people would like to be able to buy marijuana on the street without shame. Cooking up anxiety as a problem is not what we need. Let the medical world decide to prescribe cannabis as they would pharmaceuticals which also have risks and may not help the illness. This way, people who need therapy from professionals may get the treatment they need.
Yes, without shame AND without risking their risking their lives. A lot of people are getting killed in this drug war in gang shootings and by cops.
There’s a couple good documentaries our about the Green Triangle in California, and those growers report that legalizing medical marijuana actually ramped up the violence in the area because it just added another layer of black market dealing to cope with the increased demand. Partial legalization always keeps some point along the supply chain within criminal control, and that gets people killed. Full legalization mostly eliminates that, we’ve seen this with our alcohol prohibition experience. Sure, you still have some bootleggers out there, but by and large people stopped killing each other over alcohol decades ago.
In my opinion, and at our present state of knowledge on the subject, I feel that authorizing–and in effect recommending–cannabis as a one size fits all remedy for symptoms of general anxiety is no better than telling sufferers to go get drunk. And please note: no one says that cannabis treats the underlying cause or process of anyone’s anxiety. So I agree with the psychiatrists.
Psychiatry exists in a rather ephemeral zone of classifiable evidence itself, so I can see the impulse of psychiatrists to “defend their turf” as it were. It does come across as more than a little self serving of course. Please don’t read this as some anti-psychiatry screed, many folks find their treatments helpful, but to act as if they are the be-all, end all, in the field of mental health would be to ignore centuries long debate on the matter.
Lots of strawmen here.
I missed where anyone was saying that cannabis was a one-size-fits-all remedy. Again, part of the point of legalization is that you can tailor the Cannabis strain and dose to the individual user. And it may not work for some people. But they should have the option to try it.
The other pharmaceuticals these guys prescribe also do not treat the underlying cause. We are just asking to treat Cannabis like any other drug.
I respect the views and skepticism of the psychiatric community, but those views are based upon the narrow segment of the population they see in their practices. This is not a reason to disregard their medical experiences and opinions, but it is a reason to weigh their input with that in mind. Many people who don’t see psychiatrists already self-medicate with cannibals to treat a1nxiety.
There is an easy solution to this dilemma: legalize cannabis use in general.
The other folks who’ve commented above strongly suggest that some people, maybe quite a few, are already using cannabis because of anxiety; no doubt even more people use it simply because they like it. A whole lot of people drink for the same reasons. That doesn’t alter my opinion about either one as a prescription for anxiety. It seems pretty obvious that cannabis needs more study before making it an official anxiety drug.
A thorough psychiatric approach would seek to disarm the key underlying mechanisms of the anxiety.
Again, none of the prescription drugs these guys prescribe treat the underlying cause of anxiety. The chemical are different, but the mechanism at work isn’t any different than using cannabis.
And using Cannabis to treat anxiety is nothing like getting drunk. And to be clear, some people who are using alcohol for anxiety aren’t getting drunk either. Sometimes a glass of wine at the end of the day takes the edge off and lets people relax. When you go to the Cannabis store (in legal states) you can get Cannabis that is tailored to anxiety and doesn’t get you high. And people can certainly abuse prescription drugs as readily as illegal drugs. Opioids have killed far more people than Cannabis, which has never in itself killed anyone. People are using Cannabis as a safer alternative to opioids for pain management.
“Millions of people are using cannabis to treat anxiety.” I’ll say what the psychiatrists were too polite to say. Everything people say about the effectiveness of cannabis on anxiety could be said about booze. And we don’t need another legal intoxicant in this society.
Having used both extensively, I can say that the effects are completely different. And while there certainly are people who self-medicate with alcohol, even the psychiatrists will admit that they are completely different drugs.
I take care of psychiatric patients already using cannabis on their own. Does not appear to be of much help to them at all. It seems to just exacerbate their problems of not being able to cope.
Ok, let’s break down that response:
Your patients are using Cannabis even though it isn’t legal. Your opposition to legalization isn’t stopping anyone from using. Your opposition just denies them access to safe, regulated, measured Cannabis from a store. From getting Cannabis that is tailored to their individual needs. Your opposition is hurting their treatment.
Yeah about this idea that pot is supposed to be some one-size fits-all anxiety med. If you think psychiatrists currently choose among dozens of “different” meds to treat anxiety you should bow out of this conversation. I’ve haven’t worked in the field for a couple decades now so I don’t know what the current popular meds are, but basically at any given time there just a handful of possibilities and there’s always one or two drugs that dominate treatment. For anxiety most people were taking Ativan when I was working in the field in the late 80’s and mid 90’s. For schizophrenia, bi-polar, depression, etc. there are always one or three preferred drugs. You adjust dosage to personalize the treatment but it IS essentially one drug fits all scenario for the most part. If nothing else med choice can be dictated by insurance coverage, as you may well know if you’re taking meds for anything right now.
Now I’m in now way intending to be anti-psychiatry here, but we should avoid industry mythology wherever possible. Look, if Docs don’t want to prescribe one med for some reason, they can always write a scrip for something else. If docs don’t think pot is a good anti-anxiety med, they won’t prescribe it right? It doesn’t really matter if we change the law on this, it won’t create an medical obligation to prescribe pot. So what’s this really about? Almost no treatment is completely risk free, even aspirin has it’s downside.
Now it’s true that pot hasn’t undergone some of the rigorous testing that pharmaceuticals typically comply with. However, while those tests are critical for safety, let’s not pretend we have a water-tight regime here that flawlessly detects all dangers and adverse outcomes. While it may be true that pot hasn’t been “tested” as much, it’s also true that people have been using and smoking pot for what? Thousands of years? It may not be appropriate to compare pot to previously non-existent chemicals that pharma has cooked up in labs within the last few years; chemicals (unlike pot) we have absolutely no experience with.
You can say we don’t know ALL of the harmful effects of pot, but you also have to admit that human beings are very very familiar with most of it’s effects despite the lack of published research.
My biggest concern is the extent to which the war on pot is killing, incarcerating, and injuring so many more people than the drug itself would if it were legal. Sure, it can be abused but the damage most drug abuse causes typically falls on the abuser, whereas the damage the war on drugs is causing is killing all kinds of people who have nothing to do with abuse. I think the human toll and over-all corrosive effect that illegality is causing is many magnitudes more than the legally using pot would cause. I’d rathe see more people in treatment if it comes to that than see people in prison or graves.
I agree with every word of your comment, especially your last paragraph.
The problem is that these psychiatrists (and a lot of other people) don’t take the damage caused by prohibition into account. They are just looking at this in a vacuum. We aren’t really debating using Cannabis – that is going to happen no matter what. We are debating legal cannabis. We are debating whether you should be able to buy your cannabis at a store, where the product is regulated and labeled with the precise ingredients, and not in a baggie in a Burger King parking lot.
It is my hope — with or without the healthcare industry buy-in — that Minnesota enacts cannibus growing, selling, and buying as an act of commerce as opposed to morally-vacant excuses to keep it from Minnesota’s commerce complex. Colorado is just one example — lots of independent grass shops everywhere! The trade is cash-only. The reporting to the state is cash-only. This makes a great deal of sense to me. The revenue generated to the state coffers has shown to produce good deeds over and over. Public education in Colorado was almost in the tank before cannibus revenues were directed to reform it, and voila! Public education has risen x-fold over the years. We can learn a lot from Colorado. Let us begin the work.
The doctors raise valid concerns. Prescription drugs used to treat anxiety, like valium, often lead to dependency and misuse. Over-medication and misuse of prescription drugs are major problems in the U.S. An estimated 40 million adults in the U.S. suffer from anxiety (source: https://www.gatewayfoundation.org/what-we-treat/drug-abuse-treatment/valium-addiction/). It’s important to consider the risks involved in any treatment when so many people may be affected.