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MEDICAL IN MINNESOTA MEDICAL CANNABIS Six years in, Minnesota’s program is growing and changing BY LINDA PICONE

innesota’s medical cannabis pro- Upcoming changes in Minnesota’s product is stable and consistent in dosage, gram started just a little more than medical cannabis program as are the non-smokable products. Msix years ago and has grown, as ex- Although the Minnesota Legislature did Recreational cannabis would be “a pected, in the number of qualifying medi- not legalize recreational in the whole different ballgame,” Tholkes says. cal conditions covered, the number of pa- 2021 session (the House passed a bill, but “Most other states have seen a decline in tients registered, the number of healthcare it was not taken up by the Senate), it did the medical side when they go to recre- providers participating and the number of make several significant changes to the ational, but lots of folks, I think, would medical cannabis units sold and product medical cannabis program. continue in the medical program. People sales made by the state’s two authorized The biggest change allows medical can- really value that conversation with phar- manufacturers. nabis patients who are 21 or older to access macists and there is some comfort in It also has grown in terms of the knowl- medical cannabis flower—which means knowing how it is processed.” edge base about medical cannabis. smokable cannabis. Currently, Minnesota Other 2021 legislative changes to the “We continue to be one of the only is one of only a few states with medi- medical cannabis program: states in the nation collecting patient ex- cal cannabis access that prohibits use of • Allow curbside pickup of medical can- perience data,” says Chris Tholkes, MA, flower products. Medical cannabis flower nabis products. director of the Office of Medical Cannabis. products will be allowed once policy is • Allow a single designated caregiver to “What we’re learning from the data is that developed by the Minnesota Department pick up medical cannabis products for patients are seeing tremendous benefit of Health’s Office of Medical Cannabis, no up to six registered patients (it has been from participating in the program. We later than March 1, 2022. restricted to one). hear story after story about not just a re- With smokable products, Tholkes says, • Make it possible for the Commissioner duction in symptoms but being able to get there likely will be a reduction in cost to of MDH to remove a health condition off other medications.” the patient—and cost of the current prod- from the list of those qualified for medi- The Office of Medical Cannabis has ucts is a complaint of many in the program cal cannabis, after receiving a petition commissioned and performed several and likely keeps others who could benefit from the public or a task force. Until studies on use of medical cannabis for out of the program. now, the Commissioner has only been specific conditions—and will do more “Other states have seen a reduction in able to add or modify conditions. in the future. “There have been so many costs with smokable cannabis,” Tholkes • Allow pharmacist-patient consultations restrictions on cannabis research (because says. “The biggest cost now is that the by phone or other remote means, in ad- marijuana/cannabis is still a Schedule I il- manufacturers have to extract the oil, so dition to videoconference. legal under federal law). I really have smokable should in theory be less expen- • Remove the requirement for a pharma- a great love for what we can contribute to sive.” cist-patient consultation when there is research,” says Tholkes. The regulations for smokable cannabis no change in dosage or product. will be designed to make sure that the • Remove the requirement that a health- care practitioner determine whether a

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patient is disabled and needs caregiver • 1,130 patient caregivers who have re- 113,832 in the fourth quarter of 2019, with assistance with medical cannabis be- ceived background checks and are ap- net sales of $1.6 million in the last quarter cause of that disability. proved. of 2016 to $7.2 million in the last quarter The curbside visit and telephone con- of 2019—an increase of $5.6 million or sultation came about through executive The price of medical cannabis 350 percent. order during the pandemic shut-down, Prices of most medical cannabis products By the end of 2019, Minnesota’s autho- says Tholkes dropped by 20–24 percent from 2016 to rized medical cannabis compa- 2019. For example: 120 ml Heather oral nies, LeafLine and Green Goods, had sold: Medical cannabis numbers suspension, cherry vanilla flavor, sold by • 503,980 vape oil units at a total of $37.8 The Office of Medical Cannabis posts up- LeafLine, cost $207 in October 2016 and million. dated registration data on its site https:// $158.28 in December 2019 (and today). • 174,981 oral suspension units at a total www.health.state.mn.us/people/cannabis/ The average 30-day “spend” for a pa- of $16.8 million. about/medicalcannabisstats.html on Fri- tient with one qualifying condition was • 177,978 units at a total of $8.2 days. $355 in 2016 and $311 in 2019. In 2019, million. The cumulative statistics from the be- the average ranged from $189 for a person • 26,376 topical units at a total of $1.2 ginning of the program on June 1, 2015 with terminal illness to $364 for someone million. through August 5, 2021 are: with seizures. Report on Medical Cannabis Price Study May 2020 • 1,946 healthcare practitioners registered In 2019, 10,755 patients with intractable by BerryDunn of Portland, Maine, for Minnesota and authorized to certify patients for pain spent an average of $314 every 30 days Department of Health, Office of Medical Cannabis medical cannabis. on medical cannabis products. The next • 50,482 patients who were approved for largest group was 3,008 with PTSD, who Medical cannabis and PTSD medical cannabis (since the program spent an average of $320. Some 1,223 pa- Post-traumatic stress disorder (PTSD) was started). tients with cancer spent an average of $236. added to the list of qualifying conditions • 23,772 patients currently active in the The number of units sold by both medi- medical cannabis registry. cal cannabis manufacturers went from 17,691 in the fourth quarter of 2016 to (continued on next page)

SEPTEMBER/OCTOBER 2021 | MINNESOTA MEDICINE | 19 MEDICAL CANNABIS IN MINNESOTA

practitioners said medical cannabis was of MEDICAL CANNABIS little or no benefit (score of 1, 2 or 3). Six years in, Minnesota’s program is growing and changing The most-mentioned benefits included reduction in pain severity (64 percent) and (continued from previous page) improved sleep (27 percent). Patient com- for medical cannabis effective August 1, • “Better sleep, better appetite, I’m not so ments included: 2017. angry all the time. My memories don’t • “This program has opened up a world for In the first year after PTSD was added, seem to bother me like they used to. This me I thought I lost. I started on this just a 15,538 products were purchased by those has been a life changer for me!” few short months ago and am totally off who were certified because they had a • “Since starting medical cannabis it’s like my narco’s and nicatin. I also have had PTSD diagnosis as a qualifying condition. I’ve been given a fair chance to treat my less spasms and cramping throughout my Patients who responded to a survey PTSD symptoms I’ve struggled with over body. I even chanced getting on a motor- about their use of medical cannabis ranked a decade now. My family sees a night cycle and going for a short ride with a the benefit they felt they had received from and day difference and it’s easier to com- friend before it snowed. Thought never 1 (no benefit) to 7 (great deal of benefit); municate with them. I’ve since found a do that again. It has also helped me gain 76 percent of responding patients rated part-time job with flexible hours to work weight. And silence some demons in my benefit 6 or 7, 4 percent rated benefit 1, 2 around starting college in January, 2018. head from my PTSD. So, thank you. Now or 3. The only hope I have is that it becomes all I ask is make it affordable to stay on.” The most important benefits, patients more affordable as I’m barely able to af- • “At first, when I began using the medical said, were anxiety reduction (23 percent), ford it now.” cannabis for pain, I Definitely noticed a improved sleep (16 percent), improved About 25 percent of the patients who Drastic Relief in my pain levels - that was mood and/or emotional regulation (13 responded reported physical or mental So Wonderful - I was So Hopeful. Then, percent) and pain reduction (12 percent). side effects related to medical cannabis unfortunately, after the first week of using Comments from patients who re- use. The most common adverse side ef- the cannabis regularly, the efficacy for the sponded included: fects were dry mouth, increased appetite, pain relief I had been receiving began to • “Fewer periods of dissociation due to anxiety, drowsiness and fatigue. No serious steadily wane..., to the point of no notice- increased mindfulness, being able to toler- adverse events were reported during the able pain relief at all within a 6 to 8 week ate processing trauma in therapy without observation period. period - even though I carefully “upped” dissociating, improved sleep, improved the dosage and the frequency of dosing, Post-Traumatic Stress Disorder Patients in the transition from sleeping to wakefulness, Minnesota Medical Cannabis Program: Experiences etc... I’m so disheartened..., but I know decreased body pain, eating more, not of Enrollees During the First Five Months July 2019, others with the same type of pain that I report of the Minnesota Department of Health, isolating from friends and family as Office of Medical Cannabis have that are experiencing and sustaining much, being able to tend to my house far better pain relief.” more.” Medical cannabis and • “Medical cannabis has not made a differ- • “Sleeping has been AMAZING, pain is way From August 1, 2016 through December ence for me. I have never used it before down, not helping my anxiety as much as I 31, 2016, 2,290 patients were enrolled and was a little hesitant to try. When I would like, but nothing is perfect.” under the qualifying condition of intracta- did I found that I had no relief of pain • “Controlled doses. I used cannabis before ble pain (45 of them were already enrolled and I didn’t like the way I felt so I discon- this program in such an uncontrolled dos- for another condition). tinued use.” age that it affected my other medications. According to the Patient Self-Evaluation • “Reduction in occurrence and The control of the cartridge has been ex- (PSE) completed by patients prior to each severity, improved sleep, less overall mus- tremely helpful.” medical cannabis purchase, from patient cle aching and cramping, pain relief from • “Being able to go to work with less anxi- and healthcare practitioner surveys and arthritic joints, reduction in GI reflux ety and feeling like I can function. No from pain scale information at certifica- which also aids sleep.” more night terrors and screaming in my tion, about half of those certified for in- • “I have fibromyalgia. I lived my life in sleep.” tractable pain saw a high degree of benefit constant pain my daily pain on an aver- • “Feeling less anxious and having to deal from medical cannabis (61 percent of age was an 8. I started taking medical with less has overall im- patients who responded and 43 percent of cannabis in August. I now have a daily proved my quality of life a great deal. I healthcare practitioners) or a score of 6 or pain average between 2 and 3. After 2 have more moments of happiness and it’s 7 on a seven-point scale. About 10 percent weeks of cannabis I cooked my first meal opened up many doors to me that I have of patients and 24 percent of healthcare in 15 years. My husband was doing all had shut for a long time.” of the cooking and housework I am now able to help with it.” 20 | MINNESOTA MEDICINE | SEPTEMBER/OCTOBER 2021 MEDICAL CANNABIS IN MINNESOTA

Nearly 60 percent said they were able to mental clouding/”foggy brain.” About serious adverse events were reported dur- reduce their use of other pain medications 35-40 percent reported experiencing at ing the observation period. MM while on medical cannabis. least one mental or physical , Intractable Pain Patients in the Minnesota Medical The most common adverse side effects with about 90 percent saying the adverse Cannabis Program: Experience of Enrollees During were dry mouth, drowsiness, fatigue and effect was mild to moderate in severity. No the First Five Months, report of the Minnesota Department of Health, Office of Medical Cannabis

The work group was her office’s at- tempt at getting a better sense of where Medical cannabis for stood on the issue, Tholkes says: “Support was there from patients or regular people in our program or people who want to be patients in our program.” ANXIETY DISORDER? After much review and consideration, she adds, “Where we landed was, ‘It feels like working group takes a closer look we have to go back out and try to do a deeper engagement with the medical com- BY ANDY STEINER munity.’” Recruiting a diverse group of physicians early every year since medical can- also aware of valid concern that’s been ex- to take a deeper look at the issues felt like nabis was legalized in Minnesota, the pressed by members of the state’s medical an important step. Because a warning flag NMinnesota Department of Health’s community. had been raised about the safety of can- Office of Medical Cannabis has received “There’s obviously tremendous interest nabis in treating anxiety, Tholkes and her petitions requesting that anxiety disorder in adding this condition,” Tholkes says. “It colleagues believed it was important to be included in the list of conditions eli- didn’t feel fair to ask people to just keep measure physicians’ collective pulse: Min- gible to be certified for medical cannabis submitting petitions every year. We felt nesota’s medical cannabis program can’t treatment. Every year the petitions have like we weren’t elevating the discussion work without physician support. been rejected. with the passive approach we were taking. “We think it is important to engage the This year, in what may be a small step We weren’t hearing from the medical com- medical community on these issues,” she toward certification, a working group of munity.” says. “We want the guard rails up. We want physicians and other mental health and The relative silence from physicians medical input on these decisions.” professionals were recruited needed to be addressed, Tholkes says: The by the office to discuss medical cannabis petitions of support felt troublingly un- A diversity of opinion and its efficacy in the treatment of anxiety even, with laypeople clearly on the side of To assemble members of the working disorders. (MDH is accepting public writ- certification and physicians uncharacteris- group, Tholkes and her staff set out to find ten comments on medical cannabis and tically reluctant to weigh in on the issue. a group of physicians who represented a anxiety disorders through October 1. Send “We got hundreds of letters from indi- range of backgrounds, opinions and expe- comments to health.cannabis.addmedical- viduals,” Tholkes says. “We got one letter rience treating patients with anxiety—as [email protected].) from a psychiatrist who raised some very well as physicians who’ve worked with pa- Chris Tholkes, MA, director of the Of- valid concerns about the use of cannabis tients who self-medicate for anxiety with fice of Medical Cannabis, explained that in treating anxiety.” Minnesota’s medi- cannabis. the group of seven, which included five cal cannabis system requires a physician, To assemble a list of possible working physicians in a range of specialties, met physician assistant or advanced practice group members, Tholkes and her staff this spring in three two-hour-long virtual registered nurse to certify a patient for started with a blank slate. “We did a ton sessions. treatment, she explains, and because of of outreach,” she says. “We brainstormed. While her department is well aware this fact, staff wanted to fully address this We did internet research on who is work- of the level of public interest in adding concern and further test the waters with ing in this space. We reached out to the anxiety to the list of qualifying conditions, members of the medical community be- Tholkes says she and her colleagues are fore diving in. (continued on next page)

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