Minnesota health officials are set to decide within the next several weeks whether to add four conditions, including opioid use disorder, to the list of qualifying conditions for the state’s medical cannabis program.
While three of those conditions — gastroparesis, irritable bowel syndrome and obsessive compulsive disorder — appear to have support in the medical community, allowing cannabis for opioid use disorder is more controversial. Last month, the Minnesota Psychiatric Society officially registered its opposition by sending a letter to Minnesota Department of Health Commissioner Jan Malcolm, and multiple Minnesota psychiatrists also registered their concerns through the Office of Medical Cannabis’ medical condition petition public comment process.
The health department is set to decide on or before Dec. 1 whether to add opioid use disorder and the three other conditions to the medical cannabis program.
Last year, a similar process occurred when a number of the state’s psychiatrists publicly opposed the proposed inclusion of anxiety disorder to the list of qualifying conditions, and the Minnesota Psychiatric Society also sent a letter of opposition to Malcolm’s office. In the end, anxiety disorder did not make the list of qualifying medical conditions in the state’s medical cannabis program — though the condition was approved in neighboring North Dakota.
Minnesota Psychiatric Society president Matt Kruse explained that there are many reasons for his organization’s opposition to including opioid use disorder, such as concerns about the lack of research into the substance’s medical benefit for people struggling with opioid addiction.
“There is no evidence to support the use of cannabis for [opioid use disorder],” Kruse said. “We have decades of research that support the benefits and effectiveness of currently available established treatments for acute opioid withdrawal and longtime treatment of opioid use disorder.”
Chinmoy Gulrajani, associate professor of psychiatry at the University of Minnesota and past president of the Minnesota Psychiatric Society, said he believes that best practice requires that the commissioner and her staff review each medical cannabis petition carefully, studying existing medical research before making a final decision to include a condition in the program.
“Even if a decision has been made to legalize medical use of cannabis in the state, there still needs to be close scrutiny behind each indication for every condition,” Gulrajani said. “We find as a medical community that the evidence for the use of cannabis in treating OUD is not compelling and should not lead to approval.”
Supporters focus on treatment options
The proposal has support from a number of individuals who filed comments on the Office of Medical Cannabis website. On the site, a range of people, identified by initials, registered their support, including:
“This email is in regards to our family’s extreme support in favor of adding medical cannabis for opiate use disorder. Medical cannabis would be a life-saving method of diversion of the serious life or death use/abuse of opiates— BK & TK”
“After having gone [through] 9 years of pain killer use under medical prescription for pain I know that the use of cannabis would help ease the [withdrawal] side of it. I only use cannabis now. — TB”
Kathy Nevins, a family nurse practitioner at a clinic in Walker, left a comment of support for the use of medical cannabis in the treatment of opioid use disorder. She said that many of the patients in her practice, which is located near two large tribal nations, struggle with opioid addiction. One of the reasons she supports its inclusion in the state’s medical cannabis program is because she has seen it be helpful for her Native patients, many of whom grew up with cannabis being used in religious ceremonies.
“It has a traditional cultural aspect for them,” Nevins said, adding that her opinions on this issue are her own, and not those of her employer. “Medical cannabis was not considered a drug of abuse. Because it is not legal in the state of Minnesota other than for one of these certifying diagnoses, they can’t continue to use it legally, but I have seen that is very helpful for people with [opioid use disorder].”
Nevins said that she often prescribes FDA-approved treatments for opioid use disorder (“Suboxone in all forms is my go-to treatment,” she said. “That’s what helps the vast majority of my patients.”), but her clinic’s remote location in northeastern Minnesota makes other substance use disorder treatments like methadone nearly impossible.
“We don’t have a methadone program in our clinic,” Nevins explained. “The closest one for anyone up here is in Brainerd. That is 85 miles away. To have people go to Brainerd on the bus every day to receive methadone, that controls their life. They can’t work. They can’t take care of their kids. It is not a viable option in this part of the state.” This geographical hurdle, she said, makes the idea of medical cannabis as a supplemental treatment option for patients with substance use disorder feel appealing, though she doesn’t think it should be used as a replacement for FDA approved medications for opioid use disorder.
One concern expressed in the Minnesota Psychiatric Society letter and in individual psychiatrists’ comments is cannabis’ potential for addiction. Nevins said that while some people may develop an addiction to cannabis if they take more than their prescribed dose, many FDA-approved medications including suboxone create some level of dependency in users.
“A person could have withdrawal symptoms with many treatment substances if they abruptly got off of it,” Nevins said. With many medications, “A person needs to taper down when they want to stop. That would be the same with medical cannabis.”
Gulrajani disagrees. He said that cannabis is addictive because, as time goes on, a person needs to take larger doses to feel the drug’s impact. “People don’t get addicted to Prozac in the same way,” he said, “because they don’t have to take larger doses to get it have the desired effect.”
Kruse said that cannabis’ status as a Schedule I drug has made in-depth research into its medical benefits difficult at best. If more substantiated scientific studies on medical cannabis’ impact on OUD are made available, he would be willing to rethink his position.
“We absolutely would welcome data in one direction or the other to help guide our work,” Kruse said. “We think any pharmacologic treatment needs to be held to the same scientific standards and rigor regardless of whether it is a recreational drug, a pharmaceutical or an herbal remedy.”
Nevins agrees that all medical substances should be carefully regulated for safety. She’s seen many people harmed by illicit substances purchased off the street or online and fully supports the Office of Medical Cannabis’ careful approach to regulation.
“I am very supportive of medical cannabis for the medical conditions that have been certified in Minnesota,” Nevins said, “not the flashy CBDs, the paraphernalia that is marketed to teens that you can buy at every gas station and convenience store. There is no regulation on that. That is not medical cannabis, and that is not safe.”
A representative from Malcom’s office said the commissioner has a policy of not commenting directly on decisions while they are under process, and, as in previous decisions, she is likely to take the allotted time to make up her mind.
Chris Tholkes, director of the Office of Medical Cannabis, said that her staff is responsible for collecting background information on each medical condition and public response that the commissioner uses to weigh her decision.
In the past, Tholkes said, response from the state’s medical community to her office’s official review process has been muted, but in recent years, thanks to efforts to publicize the review process combined with increased media attention, response from medical professionals has picked up.
Tholkes said she’s pleased with this shift. She and her colleagues welcome feedback in their process.
“This year I felt rewarded for those efforts because we did get a lot of feedback from the medical community,” she said. She isn’t bothered that all physician commenters were in opposition to opioid use disorder’s inclusion in the medical cannabis program: “That’s fine. We just want them to weigh in. Please tell us the science and your opinions. We are thrilled to have folks weigh in. The discussion and debate is an important part of our process.”