Medication Management

Treating anxiety disorder

Is medical cannabis an option?

BY NICK LEHNERTZ, MD, MPH, MHS, AND PETER RAEKER, MA

Since 2016, every year during an annual petition process, petitioners have requested addition of anxiety disorder or panic disorder as a qualifying medical condition. Each past petition was denied due to lack of clinical evidence and the desire to avoid any unintended consequences.

At the conclusion of the 2020 petition cycle, however, Minnesota Health Commissioner Jan Malcolm requested that the Office of Medical Cannabis (OMC) take a more in-depth look at the issue. That deeper dive included an additional review of the literature and research: interviewing states that have added or denied anxiety as a qualifying medical condition for their medical cannabis program, and convening a work group of health care professionals with experience in anxiety disorder. To read a report on the results, go to “Anxiety Disorder Review.” Minnesota Department of Health. <https://www.health.state.mn.us/people/cannabis/petitions/ anxiety report.html>.

This summer, Commissioner Malcolm requested that OMC submit a new petition for anxiety disorder as a qualifying medical condition for this petition cycle. Under current state rules, a new petition must be submitted in order for anxiety disorder to be considered again this year.

Benzodiazepines can be dangerous.

Outreach to Minnesota’s medical community

OMC uses a formal petition process to solicit public input every year on potentially adding qualifying medical conditions and delivery methods. Once petitions have been accepted for consideration, the public is invited to submit written comments in support of or opposition to them. A separate petition this year requested the addition of gastrointestinal uptake infused edibles (GI edibles) as a new delivery method.

During the comment period for the 2020 petition cycle, OMC received more than 100 comments from people, including some who identified as current medical cannabis patients, in support of adding anxiety disorder. OMC heard from four people who did not support the petition, including one member of the medical community–a practicing addiction psychiatrist–who raised significant concerns about adding the diagnosis.

In order to gain greater engagement with the medical community, OMC invited seven professionals with experience in anxiety disorder to participate in a work group. Their backgrounds included general practice, psychiatry, therapy, and substance abuse. The goal was to conduct a provider-based review of the potential benefits and potential harms of adding or not adding anxiety disorder as a qualifying condition.

What themes emerged from the work group?

Over the course of the work group sessions, six major themes emerged:

• Protect the developing brain Providers expressed concerns about protecting the brains of young adults, stating the human brain continues to develop until age 25. Exposure to high tetrahydrocannabinol (THC) products can induce psychosis and unmask underlying schizophrenia, which can be damaging for the developing brain.
• Safer alternative to benzodiazepines Benzodiazepines are often used as a long-term treatment for generalized anxiety disorders, though their use as a chronic medication in most anxiety disorders is not indicated. All participants of the work group agreed benzodiazepines can be dangerous, due to their high risk for addiction as well as death if overdosed, and opportunities to reduce use of benzodiazepines would be beneficial. Some providers posited that medical cannabis may be a safer therapeutic choice and would limit the need for chronic benzodiazepine therapy.
  

Therapy This, potentially with concomitant use of SSRIs/SNRIs as an adjunct, is the standard for anxiety disorder. However, patients may be unwilling to participate in therapy and/or experience limited access to therapists and psychiatrists. In addition, many people report side effects from SSRIs/SNRIs.

Health equity Known disparities exist in the level of care available for anxiety disorder among historically disadvantaged communities. Medical cannabis may offer some patients an option for an alternative to current medications. This view was not shared by all work group participants.

Limited research The ability to study cannabis through the normal channels is not readily possible due to its status as a Schedule 1 drug as determined by the FDA.

Harm reduction Approving medical cannabis for anxiety disorder may offer a safer option and potentially reduce harm among people seeking illicit drugs to manage their symptoms.

Experience of other states

As part of the deeper dive, OMC contacted states that have added or recently considered anxiety disorder as a qualifying condition for their medical cannabis programs. Nevada, New Jersey, North Dakota, and Pennsylvania have approved or included anxiety disorder as a qualifying medical condition. Unlike Minnesota, those states do not have formal patient data collection practices in place.

Medical cannabis for anxiety disorder may offer a safer option.

These four states saw a rapid rise in the number of people participating in their respective programs who have a diagnosed anxiety disorder, to the point where anxiety disorder became either the top or second most common qualifying condition.

Four other states (Alaska, California, Mississippi and Missouri) have a provision that allows physician discretion to recommend cannabis outside of the qualifying condition and two (Oklahoma and Virginia) have no predetermined qualifying conditions. Two states (Hawaii and Ohio) have received petitions to add anxiety disorder as a qualified condition, but both states denied the requests, citing a lack of clinical evidence as the reason.

Background on petitions submitted in 2021

Anxiety Disorder In the petition for anxiety disorder, OMC listed specific sub-conditions, as identified in the DSM-5. In addition, OMC recommended limiting certification for these conditions to registered patients age 25 and older. The specific sub-conditions are:

• Generalized anxiety disorder.
• Social anxiety/social phobia.
• Panic disorder.
• Specific phobias.
• Separation anxiety disorder.
• Agoraphobia.

GI Edibles In the petition for GI edibles, Sensible Change Minnesota pointed out that when eligible medical cannabis patients have access to raw cannabis (expected on or before March 1, 2022) they could make their own GI edibles at home, leading to inconsistent dosing, waste of medical cannabis, and possible criminal liability. Sensible Change Minnesota noted in the petition: “Minnesota’s medical cannabis manufacturers have a track record of producing safe, consistently dosed, cannabis products, and we believe, in the interest of patient safety, this addition will allow them to add one more product type that may suit the needs of patients who are not currently being served.”

To review the petitions, go to “Petitions Process for Adding Qualifying Medical Conditions, Delivery Methods.” Minnesota Department of Health. n.d. Web. <https://www.health.state.mn.us/people/cannabis/petitions/index.html>.

How the petition process works

When the 2014 Minnesota Legislature authorized the creation of the state’s medical cannabis program, the law included a set of nine medical conditions qualifying a person to receive medical cannabis treatment. Since then, eight more conditions have been added through the annual petition process.

People who submit petitions are asked to provide a range of information to make their case. For qualifying medical conditions, that includes the symptoms of the proposed medical condition and/or its treatment, availability of conventional medical therapies, anticipated benefits from medical cannabis and scientific evidence of support for medical cannabis treatment. For delivery methods, much of the requested information is similar, with the addition of a description of how current delivery methods are inadequate.

Next steps

OMC has opened a public comment period on the petitions and encourages the medical community to weigh in. Deadline to submit comments is Oct.1, 2021. 

Submit your comments 

By email to:

health.cannabis.addmedicalcondition@state.mn.us for anxiety disorder as a new qualifying medical condition.

health.cannabis.adddeliverymethod@state.mn.us for GI edibles as a new delivery method.

By U.S. mail to:

Office of Medical Cannabis

Box 64882

St. Paul, MN 55164-0882

This fall, the Medical Cannabis Review Panel will provide Commissioner Malcolm a written report identifying potential public health benefits and potential public health harms from adding or not adding anxiety disorder as a qualifying medical condition. The panel does not review petitions for delivery methods.

Commissioner Malcolm will approve or deny petitions (including the petition for GI edibles) by December 1, 2021. If the anxiety disorder petition is approved, patients with anxiety disorder could get certified by a participating health care practitioner, effective July 1, 2022, and receive their medical cannabis from one of the state’s Cannabis Patient Centers starting Aug. 1, 2022. If the GI edibles petition is approved and either of the state’s two medical cannabis manufacturers decides to offer them, that delivery method would be available starting Aug.1, 2022.

Nick Lehnertz, MD, MPH, MHS, is a medical specialist at Minnesota Department of Health (MDH) in the Division of Infectious Disease, Epidemiology, Prevention and Control.

Peter Raeker, MA, is the communications planner for the Office of Medical Cannabis at MDH.