The Minnesota Medical Cannabis program is considering anxiety and panic attacks as an indication for the use of medical cannabis in this state. Like several other states, there was a reluctance to legalize or just decriminalize cannabis and the legislature constructed a medical cannabis program that is very expensive for most people, does not allow for smoked cannabis products, and generally acts like a mini-FDA - approving the use of an non-FDA approved compound that has really not been adequately studied. The current reasons are anxiety and panic attacks and it has failed several times for these conditions. This time they have an extensive report at this link that I will be critiquing this weekend. My longstanding position on medical cannabis is that it is essentially a way to get cannabis approved to eventually legitimize legalization or to have these compounds available in lieu of legalization. In other words, it is the next best thing to legalization. The scope of the medical cannabis arguments are not compelling and if the regulators of the state of Minnesota believe that cannabis is that safe and efficacious - why don't they just legalize it without a medical indication? In talking with people in the medical cannabis program - cost and inability to titrate the dose (by smoking) are common problems. Surveys by the Program suggest even more problems.
What follows is my brief letter to the public comments section on this issue. If you look at all of the comments - it reminds me of the public comments section at the FDA for electroconvulsive therapy and whether additional trials would need to be done to relicense those devices. It was clear that those comments in favor of that process outnumbered the pro-ECT comments - but the FDA overruled the naysayers. It is not clear to me that cannabis advocates will be overruled by the Minnesota Cannabis program but I will write more about that in my critique.
Public commentaries can be submitted to this email address:
health.cannabis.addmedicalcondition@state.mn.us
Petition comments can be read at this address:
https://www.health.state.mn.us/people/cannabis/petitions/docs/2021/commentsmedcond.pdf
The Anxiety Disorder Review (by the MN Medical Cannabis Program) can be read at this address:
https://www.health.state.mn.us/people/cannabis/petitions/anxietyreport.html
Comments should be submitted by October 1, 2021
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I am a Minnesota psychiatrist who has practiced for 22
years as an acute care inpatient psychiatrist followed by 10 years as an
addiction psychiatrist. Before that I was a community psychiatrist in Superior,
Wisconsin for 3 years at a community mental health center. I am
no longer affiliated with any of those institutions and this email is
based on my cumulative clinical experience.
In those 35 years of practice, I have done
thousands of comprehensive psychiatric evaluations that typically include
an assessment of any associated substance use disorder. One of my standard
questions in those assessments is "Were you ever a daily marijuana
smoker?" In following up that question I ask about the duration and why
they may have stopped. The typical reason for stopping is that they started to
get high anxiety and panic attacks. Depending on the degree of euphoria
from cannabis - some people continue to use it and expect that their anxiety or
other symptoms can be treated so that they can continue to use it.
As an acute care psychiatrist, I saw many people
who were psychotic or manic as either the direct effect of cannabis or because
it exacerbated an underlying major psychiatric disorder. In the
outpatients that I have treated cannabis was associated with
chronic depression and cognitive symptoms that were often seen by the
patient as evidence that they needed treatment for
attention-deficit/hyperactivity disorder. In both scenarios, cannabis use
was more than a psychiatric diagnosis - it led to these patients having
significant impairment in their relationships, vocational achievement, and
general ability to function. Some tried to stop and developed cannabis
hyperemesis syndrome or other symptoms of withdrawal.
As part of my comprehensive evaluations, every patient
I saw was also assessed for suicide and aggressive potential. Populations of
people seeing psychiatrists will be biased in that direction because in many
settings suicidal and aggressive thinking is why they are scheduled to see
us. There is a clear link between cannabis use and increased suicidal
thinking. More recent research also suggests that Black/African
American, Hispanic/Latinx, and Native Americans were at elevated risk for
suicidal ideation if they have a cannabis use disorder
and Black/African American and Hispanic/Latinx groups using cannabis
were at higher risk for suicide attempts.
Many of the patients I see have complicated medical
problems that can be compounded by cannabis use. Cannabis has a
significant hypotensive effect that typically triggers a rapid heartbeat
and "heart pounding effect." That is a potential problem for
people with cardiovascular problems or who take antihypertensive medications.
In a recent large study of 18–44-year-olds, cannabis users (defined as use more
than four times a month) were more than twice as likely to experience a heart
attack.
There are better and safer treatments for anxiety
disorders. There are better and safer treatments for anxiety disorders that do
not respond to first line treatments. I recommend against an anxiety or panic
attack indication for medical cannabis because in the vast majority of people I
have seen it caused significant anxiety and panic. It also obscures psychiatric
diagnoses and considering that most people will not have access to a
psychiatrist - will probably result in more medications to treat the cannabis
induced symptoms. At a time when there is more focus on suicide
prevention, cannabis use is implicated in suicidal ideation and suicide
attempts. Finally when there has been concern about the lack of medical
research on cannabis for positive effects, the negative effects are becoming
more apparent.
George Dawson, MD, DFAPA
References:
1: Kelly LM, Drazdowski TK, Livingston NR, Zajac K. Demographic risk factors for co-occurring suicidality and cannabis use disorders: Findings from a nationally representative United States sample. Addict Behav. 2021 Nov;122:107047. doi: 10.1016/j.addbeh.2021.107047. Epub 2021 Jul 12. PMID: 34284313; PMCID: PMC8351371.
2: Ladha KS, Mistry N, Wijeysundera DN, Clarke H, Verma S, Hare GMT, Mazer CD. Recent cannabis use and myocardial infarction in young adults: a cross-sectional study. CMAJ. 2021 Sep 7;193(35):E1377-E1384. doi: 10.1503/cmaj.202392. PMID: 34493564.
3: Parekh T, Pemmasani S, Desai R. Marijuana Use Among Young Adults (18-44 Years of Age) and Risk of Stroke: A Behavioral Risk Factor Surveillance System Survey Analysis. Stroke. 2020 Jan;51(1):308-310. doi: 10.1161/STROKEAHA.119.027828. Epub 2019 Nov 11. PMID: 31707926.
4: Shah S, Patel S, Paulraj S, Chaudhuri D. Association of Marijuana Use and Cardiovascular Disease: A Behavioral Risk Factor Surveillance System Data Analysis of 133,706 US Adults. Am J Med. 2021 May;134(5):614-620.e1. doi: 10.1016/j.amjmed.2020.10.019. Epub 2020 Nov 9. PMID: 33181103.
5: Desai R, Fong HK, Shah K, Kaur VP, Savani S, Gangani K, Damarlapally N, Goyal H. Rising Trends in Hospitalizations for Cardiovascular Events among Young Cannabis Users (18-39 Years) without Other Substance Abuse. Medicina (Kaunas). 2019 Aug 5;55(8):438. doi: 10.3390/medicina55080438. PMID: 31387198; PMCID: PMC6723728.
Graphic Credit:
Medical Cannabis graphic is from Shutterstock per their standard agreement.
