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 people. 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 often depend 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.”

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.

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 December statement.

Spotlight PA is an independent, nonpartisan newsroom powered by The Philadelphia Inquirer in partnership with PennLive/The Patriot-News, TribLIVE/Pittsburgh Tribune-Review, and WITF Public Media.

To read the complete story, visit spotlightpa.org/anxiety.