High Anxiety

When Lehigh Valley doctor Charles Harris started approving patients for medical marijuana a few years ago, most of them were dealing with chronic pain. Using cannabis helped them tremendously, he said. Patients told him their pain wasn’t keeping them awake at night anymore — they could finally get a good night’s sleep or at least a few hours of rest in a row.

Then, in the summer of 2019, the Pennsylvania Department of Health changed its rules to allow patients to use medical marijuana for another condition: anxiety disorders.

The move, Harris later joked with friends, caused his business phone to melt.

“It was a veritable tsunami of patients,” Harris told Spotlight PA.

That wave spread to doctors across Pennsylvania, one of only a few states to specifically endorse cannabis as a treatment for anxiety. Anxiety disorders are now the leading reason Pennsylvanians get a medical marijuana card, a first-of-its-kind analysis of more than 1.1 million certification records obtained by Spotlight PA reveals.

The records — which the Department of Health attempted to keep secret by suing Spotlight PA in state court — offer the first comprehensive look at how a decision by former Democratic Gov. Tom Wolf’s administration transformed Pennsylvania’s medical marijuana program, and, in the eyes of some, made it possible for basically anyone to get a medical marijuana card.

In 2021, the most recent full year of data, doctors created more than 385,000 medical marijuana certifications — and anxiety disorders were a factor in 60% of them.

Anxiety often is the only reason a patient qualifies for medical marijuana. Health department data show that most of the time doctors list one condition for a certification. In 2021, nearly 40% of certifications — or more than 151,000 — listed anxiety disorders as the sole qualifying condition, ranking well ahead of others such as chronic pain and cancer.

But medical evidence that cannabis or its compounds help treat anxiety is limited and mixed. In fact, a major national study in 2017 noted that regular “cannabis use is likely to increase the risk for developing social anxiety disorder.” Medical marijuana program leaders in at least three other states have rejected it as a qualifying condition, citing the lack of scientific evidence, the potential for some doses and types of cannabis to worsen anxiety symptoms, or other unintended consequences.

Supporters of Pennsylvania’s decision say it has given patients another treatment option at a time when more people are suffering from anxiety, and that it has worked for many. And they note that federal restrictions have limited cannabis research, making it harder to prove the benefits.

Still, a wide range of medical professionals — including supporters of cannabis as a treatment option for anxiety — told Spotlight PA they are concerned about the medical marijuana certification process in Pennsylvania, the Department of Health’s oversight of doctors, and the information patients receive from physicians who approve them.

Harris, a retired emergency room physician, supports cannabis as a treatment option for anxiety disorders and said his patients have had impressive results. But he questions how thorough most doctors are during their medical marijuana consultations. His impression, he said, is “they spend very little time with their patients.”

Some patients schedule appointments with doctors through third-party certification companies — businesses that the state Department of Health says it cannot regulate. Previous Spotlight PA reporting revealed that some of these businesses make misleading or incorrect medical claims, benefit from unequal advertising rules, and allegedly tie a doctor’s payment to patient approvals. Their profits are often dependent on patient approvals, with some offering money-back guarantees if customers are not approved for a card.

Steven Evans, a medical marijuana physician in Berks County, said some of the stories his patients have told him about their experiences with large certification companies gave him concerns. He worries that some medical card companies and doctors aren’t doing enough “to try to screen out people who really don’t have anything wrong with them — they just want to use marijuana as a recreational drug.”

“I don’t think that most of these telephonic services are demanding any kind of documentation that the person actually has that problem,” Evans told Spotlight PA. “I think that’s a huge issue.”

A recent Facebook post from Keystone Cannabis Coalition, a group that advocates for adult-use legalization in Pennsylvania, underscores the worries some medical providers have about the current system.

The post argued medical cannabis should be well-regulated for those with “legit medical needs.” But if lawmakers will not legalize marijuana, the group wrote, the medical program “should act as the Underground Railroad so that people have some legal protection against the brutality of the state.”

The ongoing adult-use cannabis legalization debate looms over the medical program. In recent years, two Republican state senators have come out in support of ending the prohibition — a historic step in Pennsylvania. Last fall, Democratic legislative victories in the state House gave new hope to legalization advocates.

And this year, Maryland residents will join two other neighbor states — New York and New Jersey — where adult-use is already legal. It’s not clear whether new Democratic Gov. Josh Shapiro — who supports adult-use legalization — will bring any significant changes to the medical marijuana program. When questioned by Spotlight PA this past fall and in December, Shapiro’s campaign and transition teams did not identify any specific changes he supports for the medical program.

For now, Pennsylvania doctors are the gatekeepers to who can legally use marijuana.

The Department of Health’s rules and enforcement give those physicians great leeway in deciding whether to issue certifications. The department adopted regulations that require medical marijuana doctors to review available health care records, but those rules do not spell out how providers should determine if records exist. The department has also stated that patients might not have records for certain conditions and certifying doctors may be the ones “making the initial diagnosis.”

Some medical marijuana card companies actively court clients who lack a prior diagnosis or medical records showing they have an anxiety disorder.

Elevate Holistics, which offers to serve Pennsylvania patients, features online guidance titled “How to Get a Medical Card Without a Condition.” The same company’s website also refers to “good excuses for getting a medical card” and describes anxiety disorders as one of the “loopholes” on Pennsylvania’s list of qualifying conditions.

The Wolf administration defended its enforcement of the program’s rules and its actions to expand the program. But the department did not provide any formal criteria it uses when it considers whether to add a qualifying condition, and also did not clarify how it expects providers to make an anxiety disorder diagnosis.

The press office would not say what scientific research informed former health secretary Rachel Levine’s decision to add anxiety disorders as a qualifying condition, and information obtained under the state’s Right-to-Know Law offered limited insight into the department’s decision making.

“Medical marijuana is just one of many available options for Pennsylvanians working to manage anxiety under medical guidance,” spokesperson Maggi Barton said in a statement in December.

Why anxiety disorders dominate

To better understand how Pennsylvania’s medical marijuana program serves hundreds of thousands of patients, Spotlight PA analyzed six years’ worth of data.

The records were obtained after a court battle with the Pennsylvania Department of Health, which argued that releasing them would violate patient privacy protections. An attorney with the Reporters Committee for Freedom of the Press represented the news organization for free, and in August, Commonwealth Court ruled in favor of Spotlight PA.

Spotlight PA’s analysis of the anonymized data found that in the program’s early years, chronic pain was the primary driver of certifications. Certifications for chronic pain continued to rise, but not as steeply as ones for anxiety.

In 2020, the first full year anxiety could be a qualifying condition, it was listed in 51% of all certifications. By the following year, anxiety dominated — a trend that continued into 2022, according to data from the first eight months of the year.

Spotlight PA shared its findings with the department and more than 20 medical providers, patients, researchers, industry officials, and other experts.

A few believed — or openly wondered whether — a significant number of patients were seeking an anxiety disorder diagnosis as a pretext for recreational use.

“Anxiety disorder is … just the easiest thing you can say,” Keith Humphreys, a psychiatry professor and addiction researcher at Stanford University, told Spotlight PA.

“As long as you say those magic words,” he added, “then you meet the qualification. And so that’s what I assume is happening in most cases.”

But other experts who reviewed Spotlight PA’s findings — including ones who are skeptical or critical of the idea of anxiety as a qualifying condition — did not raise that issue or actively downplayed it. For them, the explanation was relatively simple: Anxiety disorders are a common condition.

“I don’t think there’s a story here about abuse of a government program for people to get high,” said Alik Widge, a psychiatrist and assistant professor at the University of Minnesota Medical School. “I think there’s a story here about people with anxiety who are hurting and want help.”

An estimated 31% of adults in the United States experience an anxiety disorder at some time in their lives, according to national survey data. The National Institute of Mental Health notes that occasional anxiety is normal, but when people have an anxiety disorder, “the anxiety does not go away and can get worse over time.”

Guidelines from the American Psychiatric Association say generalized anxiety disorder is marked by having some symptoms for six months.

In its response to questions from Spotlight PA, Pennsylvania’s health department pointed to a report from the U.S. Centers for Disease Control and Prevention showing that the percentage of adults with recent symptoms of an anxiety or depressive disorder increased from 36% to 42% from August 2020 to February 2021. However, those data were based on self-reported information from the past seven days, not a clinical diagnosis.

Spotlight PA spoke to several patients for this story, including some who did not want to be named because they feared limiting their job options.

One patient described undergoing a thorough appointment with her primary care physician for an initial certification. But when it came time to renew, which patients must do at least annually, she found a company online, paid $99, and received approval after a brief call. The doctor only asked if she was happy with the drug and if she had experienced any hallucinations, she said.

Edward Long, a 49-year-old from Blair County, said he qualified for the program because of multiple health conditions, including post-traumatic stress disorder and anxiety. He told Spotlight PA he seeks out “reputable doctors” who require him to provide proof of a prior diagnosis and are available for questions.

He said cannabis has allowed him to stop taking prescription medications, better manage his panic attacks, and rest at night.

“I don’t have the nightmares,” Long told Spotlight PA. “It’s not as hard to fall asleep because my mind’s not racing.”

John Gavazzi, a psychologist in Cumberland County, told Spotlight PA that most of his patients who have used medical marijuana have benefited, particularly ones suffering from insomnia. The patients he works with are also continuing in therapy.

“It has really helped a lot of people,” Gavazzi said.

Why anxiety was added

It took years of advocacy and compromises to make Pennsylvania’s medical marijuana program a reality.

The state in 2016 legalized medical marijuana for patients with one of 17 qualifying conditions, including cancer, epilepsy, post-traumatic stress disorder, and severe chronic pain. The Wolf administration later used its executive power to add six more, including opioid use disorder.

In February 2019, the state’s Medical Marijuana Advisory Board considered applications for several new conditions. With little discussion or debate, they approved an application for anxiety with a 5-3 vote.

The board’s recommendation went to Pennsylvania’s health secretary. Levine told the board she thoroughly reviewed existing research. A department resource guide obtained by Spotlight PA listed two dozen reference articles. When she approved adding anxiety disorders as a qualifying condition, she said in a July 2019 news release that marijuana should not be a “first line treatment.”

“Medical marijuana would be medicine to assist in their treatment, but counseling and therapy is absolutely critical, and medical marijuana should not replace that,” Levine said at an advisory board meeting in August 2019.

But those statements have not resulted in any health department regulations requiring marijuana be used along with counseling or therapy.

Until recently, James Rochester interviewed medical marijuana patients for his work as an occupational medicine physician in Lancaster County. Many of those patients were in the medical marijuana program because of an anxiety diagnosis, he told Spotlight PA.

“The vast, vast majority of them have never had a formal psychological evaluation,” Rochester said.

Many patients had not tried alternative options either, Rochester said, and they often could not afford counseling. He does not oppose medical marijuana for anxiety disorders, but he thinks doctors frequently certify patients without exploring other options.

“You have to develop a rapport and relationship with the patient,” Rochester said. “That’s really, really important. It’s never going to happen in a video visit in five minutes.”

The Pennsylvania Psychiatric Society, which has objected to anxiety disorders as a qualifying condition, has also raised concerns about the certification process for patients.

“They’re not really being told about all the pros and cons of using cannabis,” Marina Goldman, a psychiatrist speaking on behalf of the Pennsylvania Psychiatric Society, told Spotlight PA.

“If we’re using the word medical, it should be done with appropriate safeguards,” she added later.

Widge, the psychiatrist at the University of Minnesota, said there’s great uncertainty over whether cannabis will do more harm than good for anxiety patients.

“In many ways what … is happening all around the country is this giant, uncontrolled experiment on people’s brains,” he said.

Practices may vary

It is impossible to know how all certification companies and the state’s more than 1,800 approved medical marijuana doctors assess patients to participate in the program.

Harris, the retired emergency room doctor from the Lehigh Valley, told Spotlight PA he spends about 40 minutes talking to patients before approving them for an initial certification. He also requires documentation from another provider to confirm an anxiety disorder diagnosis.

“It can be a bit of a pain,” Harris said. “And it does turn some of our patients away from us.”

But he said that’s what it takes for him to feel comfortable with the approval. Evans, the Berks County medical marijuana doctor, told Spotlight PA he also won’t certify new patients for anxiety unless they have documentation from another provider.

“Whether it’s a psychologist or a psychiatrist, I need someone who has expertise in making this diagnosis to evaluate you and tell me that that’s what you’ve got,” Evans said.

Some medical marijuana card companies try to attract customers who haven’t previously been diagnosed.

“Do you suffer from ANXIETY or PTSD but have NO records?” the website for medical marijuana card company Releaf Specialists reads. “Self-medicating and you want your card?”

Bob Scherer, owner and founder of Releaf Specialists, told Spotlight PA the company uses in-house forms to determine a patient’s eligibility and that the doctors he contracts with can require supporting documentation. But he defended approving patients based on their statements. He said patients often have trouble accessing health records or might struggle to afford seeing another doctor.

“Our physicians feel that they’re … competent enough to make that determination based off of the questions that they’re asking and the responses that they’re getting from the patients,” Scherer said.

Another medical card company, Elevate Holistics, says on a company webpage that patients should not “be afraid to say that you have not always had access to health care,” and offers advice on getting approved if they lack records of a diagnosis. Another page on the site, which refers to “good excuses for a medical card,” describes qualifying conditions in several states.

“Pennsylvania has a lengthy but very specific list with seemingly little chance for loopholes — but they are there, e.g., anxiety disorders and medical marijuana for chronic pain,” the website reads.

When asked about the language Elevate Holistics uses on its website, company CEO Stephen Stearman acknowledged that the word “loophole” was “a tough word” and said the company would review it.

But he defended the company’s language overall, saying it is meant to help patients advocate for themselves. The company’s posts, he said, are designed to attract people who are asking these questions online.

Stearman said the company does not compensate doctors based on approvals — a complaint that has been levied against other medical marijuana card companies — but he would not elaborate on how doctors are paid. He said doctors follow state requirements and that patients fill out comprehensive health forms.

“The doctors have all the information they need,” Stearman said. “And if the patient’s lying, then that’s on the patient.”

Increasing scrutiny

There have been some calls to change the system. Some Medical Marijuana Advisory Board members in November called for greater scrutiny of advertising by third-party businesses and certifications done over the phone or on a computer. One doctor on the board specifically singled out anxiety. In a January response, the health department said it investigates all complaints and it expects doctors to “practice ethically and responsibly.”

The Pennsylvania Psychiatric Society in 2021 urged the state to mandate that medical marijuana patients receive detailed information about the risks to patients associated with marijuana use and the lack of scientific evidence for certain conditions.

A health department spokesperson did not provide a direct response when asked about the society’s recommendation. But she said protections are in place for patients: they must be under a doctor’s continuing care, dispensaries have medical professionals available, and safety inserts are included with medical marijuana products.

Pennsylvania’s list of qualifying conditions has remained the same since 2019. The advisory board voted in November 2021 to add chronic hepatitis to the list, but the recommendation had not received final approval as of mid-January. The board also approved a process last year to allow academic programs to apply to have conditions added exclusively for research purposes, but had not received any applications as of early January.

That research approach was not an option when William Trescher, a pediatric neurologist at Penn State Health Children’s Hospital, served on the advisory board. He is one of the members who voted against adding anxiety as a qualifying condition.

His views on marijuana are nuanced.

Trescher said that speaking personally, and not as a doctor, he supports legalizing adult-use cannabis. And he supports marijuana as a treatment for some conditions. But as a member of the advisory board, he was reluctant to have the state endorse cannabis as a medical treatment option for anxiety.

“People can go out and make their decisions about using alcohol,” he said. “But I probably wouldn’t want to be in a position of saying … ‘OK, I’m going to write a prescription. You should have a glass of wine every night because I think that’s good for you.’”