January 2021, Volume XXXIV, Number 10

Pharmacy

Minnesota’s Medical Cannabis Program

A look back and a look ahead

By Nick Lehnertz, MD, MPH, MHS, and Peter Raeker, MA

ince it first launched in 2015, Minnesota’s Medical Cannabis Program has provided health care practitioners a treatment option for patients who sometimes are facing debilitating medical conditions, helping to improve their quality of life.

Change and growth have been constant for the program. When the Minnesota Legislature authorized the creation of the state’s Medical Cannabis Program in 2014, the law included nine medical conditions that qualified a patient to receive medical cannabis. Since then, the list of qualifying conditions has grown to 15, with two new conditions becoming eligible in August 2021.

The program has seen steady growth in other ways. As of Sept. 30, 2020, the program had 1,778 health care practitioners – which include Minnesota-licensed medical doctors, physician assistants, and advanced practice registered nurses – who can certify patients to receive medical cannabis. That is an increase of 10% or 166 additional practitioners from the previous year.

As of Sept. 30, 2020, there were 25,356 patients actively enrolled in the Medical Cannabis Registry, up 41% or 7,395 patients from the same time in 2019. The current active patient number is slightly inflated because patient enrollments are not expiring during the COVID-19 pandemic (see ‘How COVID-19 impacted program operations’).

New Cannabis Patient Centers open

Growth in the program in 2020 also means that patients across Minnesota have more options to getting their medicine closer to home. State law now allows Minnesota’s two medical cannabis manufacturers (Leafline Labs and Vireo Health of Minnesota) to each operate up to eight dispensaries, double the amount the legislature originally authorized when medical cannabis was first legalized.

Change and growth have been constant for the program.

Leafline Labs opened a new Cannabis Patient Center in Willmar in April 2020, with new centers planned for Mankato, Golden Valley, and Rogers. They already operate dispensaries in Eagan, Hibbing, St. Cloud, and St. Paul.

Vireo Health opened new dispensaries in Hermantown, Blaine, Burnsville, and Woodbury in 2020. The company already has locations in Bloomington, Minneapolis, Moorhead, and Rochester. Their Cannabis Patient Centers operate under the name of Green Goods.

How COVID-19 impacted program operations

Minnesota’s health care system experienced significant disruptions as a result of the COVID-19 pandemic. The state took action early to allow for telemedicine options for patients and health care practitioners who are participating in the Minnesota’s Medical Cannabis Program.

On March 31, 2020, Minnesota Governor Tim Walz signed an Executive Order that ensured the continuing operations of the Medical Cannabis Program during the COVID-19 Peacetime Emergency (read the full text of the Executive Order at mn.gov/governor/assets/Signed%20EO%2020-26%20Filed_tcm1055-425757.pdf).

COVID-19 is particularly dangerous for people with serious underlying health conditions. Many patients participating in Minnesota’s Medical Cannabis Program are seriously ill and often immunocompromised. The Executive Order is making it easier for patients to stay at home and limit their interactions with people outside of their home, reducing the risks associated with COVID-19.

Among the key provisions of the Executive Order, participating health care practitioners can certify a patient’s qualifying medical condition after a visit through videoconference, telephone, or other remote means; the Executive Order temporarily waives the requirement that the certification be made only after an in-person visit. The certifying health care practitioner must still meet the applicable professional standards of care when certifying a patient’s qualifying medical condition.

Normally, patients are also required to re-enroll on an annual basis; the Executive Order extends enrollments that are expiring during the pandemic to 60 days after the peacetime emergency ends.

While the Executive Order is temporary and will remain in place for the duration of the state of emergency, it provides flexibility for health care practitioners in the program as well as staff who work at Cannabis Patient Centers. As part of the temporary changes, the state’s medical cannabis manufacturers are providing telephone pharmacist consults and curbside pickup at Cannabis Patient Centers to dispense medical cannabis to patients or their registered caregiver.

Qualifying medical conditions to expand in 2021

The Minnesota Department of Health accepts petitions from the public from June 1 through July 31 every year for new qualifying medical conditions and delivery methods. In 2020, Commissioner of Health Jan Malcolm approved petitions for sickle cell disease and chronic vocal or motor tic disorder as qualifying medical conditions.

When the Minnesota Legislature authorized the creation of the state’s Medical Cannabis Program, the law included nine conditions that qualified a patient to receive medical cannabis. Since then, the list of qualifying conditions has grown to 15. Those qualifying conditions include:

  • Cancer*
  • Glaucoma
  • HIV/AIDS
  • Tourette syndrome
  • Amyotrophic lateral sclerosis (ALS)
  • Inflammatory bowel disease, including Crohn’s disease
  • Seizures, including those characteristic of epilepsy
  • Severe and persistent muscle spasm, including those characteristic of multiple sclerosis
  • Terminal illness with a probable life expectancy of less than one year*
  • Intractable pain
  • Post-traumatic stress disorder (PTSD)
  • Autism
  • Obstructive sleep apnea
  • Alzheimer’s disease
  • Chronic pain

*If the illness or its treatment produces one or more of the following: severe or chronic pain; nausea or severe vomiting; or cachexia or severe wasting.

Some patients were even able to eliminate opioid use.

Anxiety disorder petition to undergo more study

In 2020, MDH considered a petition for anxiety disorder in addition to sickle cell disease and chronic vocal or motor tic disorder for new qualifying medical conditions. The petition for anxiety disorder was not approved, but Commissioner Malcolm said that the agency would commit to a deeper look at the condition in early 2021 and move forward carefully.

This is the third time anxiety has been petitioned, with earlier petitions received in 2017 and 2019.

As part of the additional study, MDH will convene a work group that will include health care practitioners who are treating patients with anxiety disorder. More information about the work group is available at the Office of Medical Cannabis website at www.health.state.mn.us/medicalcannabis.

During the 2020 petition process, MDH received written comment from only one practitioner – an addiction psychiatrist – who had concerns about making anxiety a qualifying medical condition for medical cannabis. On the other hand, MDH received nine pages of public comment in support of adding anxiety as a qualifying medical condition.

Among the concerns raised, anxiety is a broad term for a group of specific disorders. In addition, there is evidence that using cannabis can contribute to and make anxiety worse for some people. Adding to the complexity of the issue, the available evidence on the effectiveness of medical cannabis on anxiety disorders is limited due to the federal restrictions on medical cannabis research.

In addition to convening the work group, MDH staff will reach out to other states with medical cannabis programs that have anxiety as a qualifying medical condition and gather additional information about their patients’ experiences.

Looking ahead

While still prohibited under federal law, medical cannabis is legal in 36 states and four territories, and cannabis can be legally purchased by anyone over 21 years old in 15 states and three territories (South Dakota voters in 2020 approved an amendment to legalize medical cannabis and adult-use cannabis in the state). Also of note for Minnesota, in 2020 the Red Lake and White Earth nations approved medical cannabis programs through referendum and are in the process of standing up those programs.

Policy discussions about legalizing adult use of cannabis have picked up in Minnesota, with supporters citing racial disparities and criminal justice reform as some of the reasons for changing the law.

Discussions are also taking place on the potential for expanding the state’s Medical Cannabis Program, which is considered one of the most restrictive programs in the country. State law limits the program to two manufacturers and 16 Cannabis Patient Centers, and does not allow for use of medicine in plant form. Advocates are expected to introduce a bill during the 2021 Minnesota Legislative session to allow plant form in the Medical Cannabis Program.

What impact is the program having on its patients? MDH asks health care practitioners participating in the program to take note of how medical cannabis treatment can change their patients’ lives. Among the results for patients certified for intractable pain, for instance, practitioners reported on how medical cannabis treatment resulted in reducing dosage or eliminating medications that patients used for pain. Between 2015 and 2017, of the 1,166 MDH survey responses for intractable pain patients, nearly 60 percent of the practitioners reported a reduction of pain medications for their patients, with 382 surveys (33%) indicating a decrease in opioid medication for their patients. Some patients were even able to eliminate opioid use.

Whatever the future holds on possible expansion of the program, health care practitioners interested in participating are encouraged to visit the Office of Medical Cannabis website at www.health.state.mn.us/medicalcannabis or email health.cannabis@state.mn.us. The website provides information about how practitioners can enroll, which is done online and takes only a few minutes.

Nick Lehnertz, MD, MPH, MHS, is a medical specialist at 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.

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