I have written about this program in the past. In Minnesota, we have a medical cannabis
program that allows for the prescription of specific forms of cannabis for a
list of what are seen as indications. To
get on that list is basically a review of opinions and the Commissioner. Even
though this program runs like a mini-FDA, it does not have a standard for
approving conditions for medical cannabis use.
And let’s face it - that is because the supporting evidence for using
medical cannabis is very weak and in many if not most instances – non-existent.
And as I have pointed out in the past – the evidence collected by the program
is also weak. As far as I know the
program does not produce any detailed adverse drug effect information and a lot
of that advice depends on the pharmacists dispensing the medical cannabis.
This year the conditions up for placement on the list of
indications include opioid use disorder, obsessive compulsive disorder, and
irritable bowel syndrome. I restricted my comments to the first two conditions
and the rationale is very clear. In the case of opioid use disorder (OUD), it
is a widespread drug epidemic at this point fueled by widespread availability
of opioids and synthetic opioids. Even though physician prescriptions have
decreased overdose deaths continue to increase on a year-to-year basis. The
pattern of overdoses has also changed substantially since OUD has spread from
metropolitan to rural areas. Thirty years ago, OUD and overdose deaths were
practically unheard of in rural areas and now they are commonplace. There are
effective treatment for OUD as listed in the letter that follows. There is a problem with access to substance
use disorder treatment. Most states have
practically no detoxification facilities.
Access to physicians who are prescribing medication assisted treatment
(MAT) for OUD (MOUD) is also very limited.
Like most political movements in the country – there is no
critical analysis of the various cannabis initiatives. To me – it was obvious from the start that medical
cannabis was a way to start building political consensus for legalization
of cannabis. Adding more intoxicants to the environment is never a good idea –
but the practical issue is that the lesson of alcohol prohibition was that it
could not be done without increasing crime, corruption, and the health dangers
of unregulated alcohol. So a medical cannabis initiative is really not a
genuine attempt to treat medical conditions with cannabis.
On that basis – it is not surprising that there is
significant overreach in finding conditions where medical cannabis can be used.
OUD and OCD are just two more diagnoses on that list. I was informed that my
comments will be added but the vast majority of comments are not by physicians
and are basically testimonials to cannabis. The FDA receives a lot of criticism
and they also elicit public commentary but there is a core body of scientific
decision makers.
With the writing of this post President Biden just came out
with a statement that he is going to pardon people who are incarcerated for simple
possession of marijuana and encourage governors to do the same (1). That may be easier said than done since there
was also a news report that the majority of these people have additional
complicating charges. He also initiated
a review process by Secretary of Health and Human Services and the Attorney
General on the way marijuana is listed in the Control Substance Act
schedule. It is currently a Schedule I
drug making it the most dangerous and without medical applications according to
this ranking. That results in a large grey zone when it is legally prescribed
in some states and approved for recreation use in others. There are associated problems with banking
due to the federal scheduling but in an election year when any number of people
from both parties are tripping over each other to legalize it – it seems like a
foregone conclusion that it will be rescheduled at the minimum.
The Minnesota legislature approved low dose cannabis
edibles earlier this year. There is a question about whether that was done by
mistake. This is another step toward the eventual legalization of cannabis in
Minnesota and will probably lead to the extinction of the Medical Cannabis
program. This story also illustrates the
confusion among legislators about the basic differences between raw materials
and cannabinoid derivatives. My viewpoint is legalization of cannabis was the
goal all along and the users of medical cannabis have objected to higher fees
for the medical product and many prefer smoking cannabis rather than using
other forms.
George Dawson, MD, DFAPA
1: Statement from
President Biden on Marijuana Reform October 7, 2022 Link.
2: Miranda S. Minnesota lawmakers voted to legalize THC
edibles. Some did it accidentally. July
2, 2022 Link.
The letter not in support of indications for opioid use disorder or obsessive compulsive disorder:
October 3, 2022
Office of Medical Cannabis
PO Box 64882
St. Paul, MN 55164-0882
To Whom It May Concern:
I am a Minnesota psychiatrist
who recently retired from clinical practice. I continue to research and write
about psychiatry. I worked at one of the largest substance use disorder
treatment facilities in the United States. Every person I saw had a substance
use disorder (SUD) that was significant enough to need residential treatment.
Alcohol use disorder was the most common followed by opioid use disorder (OUD).
I was also an adjunct professor and lectured on the epidemiology,
assessment, and treatment of substance use disorders. Areas of focus included
the neurobiology of SUD, opioid use disorders, chronic pain, and Attention
Deficit~Hyperactivity Disorder. I did research on medication assisted treatment
of alcohol use disorder and depression.
As an SUD develops, there are
several associated biases that lead to chronicity. The first is the
euphorigenic effect or “high” that occurs with all substances. That becomes a
permanent memory that all subsequent episodes of use are compared against.
Tolerance to drug effects limits the ability to experience that same degree of
euphoria. That leads to attempts to use more or more powerful versions of
the same drug. In the case of OUD, that has led to the use of more powerful
opioids like fentanyl. A second bias is the idea that all emotions and
reactions to stress can be controlled by external substances. Cannabis,
alcohol, and benzodiazepines are used for that purpose. In that situation,
withdrawal symptoms are misinterpreted as anxiety or depression.
That leads to an additional substance being taken. Detoxification
is required to determine a person’s baseline state and whether there is a
treatable anxiety or depressive disorder. A third bias is that “I have a lot of
time to quit.” Young people with severe SUD will often tell themselves: “I am
only in my 20s, I can quit later and at that time go to work or school.” That
prolongs their risk exposure and the associated morbidity and mortality. A fourth
bias is people with SUD are not risk averse. In other words, if they knew a
substance contained fentanyl and were risk averse, they would avoid it. This is
not true. Many will seek out fentanyl products or products they know contain fentanyl
in pursuit of getting high. That pursuit can get to the point that greater
amounts of substances or more novel substances are used and they do not care
what the outcome is. They are willing to risk a fatal outcome in pursuit of
getting high. Finally, withdrawal symptoms from substances create a
negative reinforcement bias – substances need to be taken to avoid withdrawal
symptoms.
Easy access to opioids is a
major factor in the continuing opioid crisis and the “three waves” of this
epidemic that are described by the CDC (1). There were several papers (3)
published that suggested that medical cannabis use was associated with less
opioid use. Those findings have not been validated over time. There
has been a study done showing that opioid use was more likely to increase
rather than decrease (4) with cannabis use. That study is consistent with what
I have seen in the clinic.
To summarize:
1. We are still in the midst of a 2 decades long
opioid use epidemic that has produced significant overdose mortality and
morbidity.
2. There are current FDA approved treatments (10
drugs in 3 categories) that have demonstrated ability to prevent opioid
overdoses and treat opioid use disorder (2).
3. Suggesting that Minnesota residents with an
opioid use disorder use cannabis with no proven treatment efficacy over the FDA
approved medications that have efficacy presents a clear ethical problem
considering the level of mortality associated with this disorder.
For these reasons medical cannabis
should not be approved for opioid use disorder.
I am also recommending that
medical cannabis not be approved for the treatment of obsessive-compulsive
disorder. The bulk of my argument rests on the information that I submitted
last year recommending no medical cannabis approval for generalized anxiety
disorder. In that submission, I pointed out that for many people cannabis use
leads to anxiety and panic attacks rather than alleviating them.
Obsessive-compulsive disorder (OCD) has effective psychotherapies and medical
therapies. In fact, psychotherapy is the primary treatment modality. We
currently have a healthcare system that rations access to both psychotherapy
and medical treatment. When the lack of clinical trials of cannabis in OCD is
considered, the same ethical dilemma presents as in the case of opioid use
disorder. Is cannabis approved for OCD because health care systems and
government regulators refuse to provide access to proven methods of treatment?
In both the case of opioid use
disorder and obsessive-compulsive disorder, neither should be an indication for
medical cannabis for the above stated reasons.
Sincerely,
George
Dawson, MD, DFAPA
Lino Lakes,
MN
References:
1: CDC.
Understanding the Epidemic:
https://www.cdc.gov/opioids/basics/epidemic.html
2: FDA Information about Medication-Assisted
Treatment (MAT): https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat
3. Bachhuber MA, Saloner B,
Cunningham CO, et al. Medical cannabis laws and opioid analgesic overdose
mortality in the United States, 1999–2010. JAMA Intern Med. 2014;174:1668–1673.
4: Olfson M, Wall MM, Liu SM, Blanco C. Cannabis
Use and Risk of Prescription Opioid Use Disorder in the United States. Am J
Psychiatry. 2018 Jan 1;175(1):47-53. doi: 10.1176/appi.ajp.2017.17040413. Epub
2017 Sep 26.
