Medical Marijuana · •Cases pending in other states •Other states prohibit health insurers from paying; handful of states preclude employers or workers’ comp payers from paying

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Navigating Medical Marijuana in Workers’ Compensation

Medical Marijuana


Agenda

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• Federal and State Laws

• Public Health

• Adverse Effects & Concerns

• Clinical Use

• Implications for Employers

• Implications for Workers’ Compensation

• Conclusion


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Federal Law: Marijuana

Marijuana is a Schedule I drug under Federal Controlled Substances Act

• Makes possession, usage, purchase, sale, and/or cultivation of marijuana illegal at the federal level

• Physicians recommend but don’t issue prescriptions or dispense.

• Other Schedule I drugs include:• Lysergic acid diethylamide (LSD), Diacetylmorphone (Heroin), Gamma Hydroxybutyric

Acid (GHB), MDMA (aka: “Ecstasy”)

• Makes research difficult


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State Regulatory Status vs. Federal Law: Schedule I

• Shifting Sands as of Jan 2018:

• Current administration: Memo on enforcement

• Each state is different with state laws on dispensaries, growing, possession:• Blue = legalized medical

• Green = recreational & legal

• 29 States and DC have marijuana in some form

• 9 States and DC allow recreational use as well as medical use

• 17 states allow for low THC use but not broad medical use

• Other gray states may have specific medical uses


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Marijuana Basics:

• What’s marijuana? • Dried leaves, flowers, stems and seeds from Cannabis satvia or Cannabis

indica plants

• May be found in a variety of dosage forms

• Contains TCH (tetrahydrocannabinol) and other compounds like CBD (cannabinoids)

• THC is the compound that causes euphoria

• Cannabinoids and other compounds do not cause the same “high,” and have other qualities

Goldfrank’s Toxicologic Emergencies - Chapter 83: Cannabinoids; Hemp: http://norml.org/marijuana/industrial/item/introduction-5;

DEA Scheduling: http://www.justice.gov/dea/pr/multimedia-library/publications/drug_of_abuse.pdf#page=68

http://norml.org/marijuana/industrial/item/introduction-5

http://www.justice.gov/dea/pr/multimedia-library/publications/drug_of_abuse.pdf#page=68


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Strains of Marijuana

• 2 Main Strains for Medical Marijuana• Cannabis Sativa

• Cannabis Indica

• Less Common Strain• Cannabis Ruderalis


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Recreational vs. Medical Marijuana

• User Intent (High vs. Relief of medical condition)

• % THC typically higher in Recreational (causes euphoria)• THC content has risen over the years

• Other chemicals typically higher in medical (including CBD and others)


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Increasing Potency of THC


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Marijuana Use: SAMHSA

• Most commonly used illicit drug in the US

• 2.6 million people aged 12 or older in 2016 tried marijuana for the first time in the past year. • Only about a third of people aged 12 or older perceived great risk of harm from weekly

marijuana use.

• When asked, 44.7 percent of youth aged 12 to 17 reported that it would be fairly easy for them to obtain marijuana.

Substance Abuse and Mental Health Services Administration Report 9/28/17


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Marijuana & Public Health: FDA & CDC Perspective

https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm

https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm


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Health Effects: CDC

According to the CDC:• About 1 in 10 marijuana users will become addicted.

• For people who begin using younger than 18, that number rises to 1 in 6

• Poisoning risk rises with THC content

• Marijuana directly affects the brain- specifically memory, learning, attention, decision-making and coordination

• Long term health risks may include heart attack, stroke, addiction, lung health (bronchitis and other chronic conditions), cancer risk is uncertain

• Regular teen marijuana use has been linked with psychosis and increased risk for several mental problems, including depression, anxiety, suicidal thoughts, and personalitydisturbances


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• Contradictory studies, caution advised

Cannabis and Driving


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• Marijuana use remains unacceptable for workers subject to DOT regulations• Safety-sensitive work

• Those subject to drug testing under DOT

• Pilots, bus drivers, truck drivers, armed security personnel, locomotive engineers, etc.

• Drug testing must follow specific guidelines

DOT and marijuana use


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• Medical Marijuana is not a prescription drug-• Not FDA approved

• No NDC • unless a state grants a state-specific one for PDMP like like CT- anomaly

• State Laws determine how a physician certifies a patient or grants a card

• State Laws determine the set up of dispensaries

• There are some FDA approved pharmaceuticals but those are not the same

Access to marijuana


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Marijuana – Medicinal Use

• Marijuana contains more than 500 compounds

• Approximately 107 are called the cannabinoids• Delta-9-tetrahydrocannabinol (THC) is the main psychoactive

cannabinoid in marijuana

• Cannabinoids are extremely lipid soluble

• Besides THC, there are varying proportions of other cannabinoids, cannabidiol (CBD), cannabinol (CBN), etc.

• Lethal doses in humans are not known


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Marijuana – Medical Use

• Marijuana has medicinal properties• Anti-emetic properties that relieve side effects of anticancer chemotherapy • Muscle-relaxing & anticonvulsant effects • The capacity to reduce the elevated intraocular pressure of glaucoma• These medical benefits come at the cost of the psychoactive effects that often impair normal

activities• Growing research for pain, including neuropathic pain

• Medical marijuana is not included in any Workers’ Compensation treatment guidelines, such as the Official Disability Guidelines (ODG) and the American College of Occupational & Environmental Medicine (ACOEM) Practice Guidelines • There are no clear indications for which medical marijuana has greater efficacy for the above

conditions• Patient’s who have tried and failed other therapies may benefit


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Endocannabinoid system


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States vary in terms of conditions covered under medical marijuana regulations

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Top 20 Common Conditions


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Dispensaries

• Each state has different laws for dispensaries

• Staffing & Training

• Location

• Testing


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Pharmacists as Dispensers of Marijuana

• Some states require pharmacy involvement in different ways:• Three states require dispensing to be done by a pharmacist in the

dispensary (CT, NY, MN).• Dose (dosage form, %THC/CBD) is determined by condition• Training for pharmacists varies by state• May have patient counseling requirements & restrictions on days

supply • PA requires a pharmacist or physician on-site for dispensary when

facility open to patients• AR requires a pharmacist consultant for each dispensary

• States may have specific training requirements for physicians to certify patients for specific conditions (i.e., NY)• Review state regs for NP, naturopaths, PAs, MDs

• Different testing requirements by state


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Pharmacists’ Attitude

Some in Support • Seek a more active role in clinical

applications for cannabis-based medicines

• Believe pharmacist should be involved as the drug experts and need to seize the opportunity

• Pharmacists are already experienced at dispensing controlled substances to the public

Some Opposed• Unresolved legal and regulatory issues

• Marijuana scheduling and threat of federal prosecution

• Potential to lose DEA license for dispensing marijuana

• Request more trials showing clinical safety and efficacy

• Desire federally approved dosage forms and reclassification to enable legal sales

• No standard guidelines for dosing currently existNEED FOR TRAINING ON DOSING AND DRUG

INTERACTIONS


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• Texas is now one of 17 states to pass a law allowing for the use of "low THC, high CBD" products for medical reasons in limited situations

• 3 dispensaries in the state

• 20 physicians registered to prescribe CBD oils• Texas Compassionate Use act for specific uses

• Childhood seizures not responsive to other treatments

TX Dispensaries


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Variety of Dosage Forms

• Vaporized

• Smoked

• Edibles

• Topical

• Oils (CBD)

State Laws determine allowed forms for medical marijuana…


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Pharmaceutical Dosage forms

• Synthetic THC products:• Cesamet® (nabilone) -

• chemotherapy-induced nausea/vomiting

• Marinol® (dronabinol)• Chemotherapy-associated nausea and vomiting refractory to

other antiemetics• AIDS-related anorexia

• Syndros® (dronabinol)• Liquid• Loss of appetite (anorexia) in people with who have lost weight.• Nausea and vomiting caused by anti-cancer medicine

(chemotherapy) in people whose nausea and vomiting have not improved with usual anti-nausea medicines.


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• Sativex (nabiximols): • General Information

• Oromucosal spray; close to 1:1 ratio of THC/CBD• Indicated for muscle spasms in muscular sclerosis patients

who do not respond to other treatments• Available in 25 countries; mostly in Europe• Undergoing Phase III trials in the US (GW Pharmaceuticals)

• Epidolex (cannabidiol)• Orphan drug for pediatric epilepsy

• Dravet & Lennox-Gastaut Syndromes

• Still an investigational drug; NDA filed with FDA 2017• 98% CBD and no THC• Liquid form like Charlotte’s Web

Not yet approved in US


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Workers’ Comp and Medical Marijuana

• Important to review case law and legal advice

• Review Drug Testing and Drug Free workplace policies

• Case law in some states has upheld that payers must reimburse medical• Recent NCCI study cited 5 states and cases:https://www.ncci.com/Articles/Pages/II_Marijuana-Conversation-Insurer.aspx• Connecticut, Maine, Minnesota, New Jersey, and New Mexico • Cases pending in other states

• Other states prohibit health insurers from paying; handful of states preclude employers or workers’ comp payers from paying• Examples, Florida and North Dakota

• Other states have upheld discrimination if employee with medical marijuana prescription fired solely on basis of use (RI, ME)

https://www.ncci.com/Articles/Pages/II_Marijuana-Conversation-Insurer.aspx


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• Financial institution limitations due to federal status• Can’t pay dispensary directly• Contracts with wholesalers, third-party payers and other business entities

may prohibit because of the federally illegal status

• Consultation with attorney familiar with specific state workers’ compensation law is recommended to review policies

• Testing• Not standardized limit like alcohol• Need attorney review pre-employment, random and post-accident

Other Challenges for payers


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Diagnostic Testing Cannabis

• Cannabinoids can be detected in plasma or urine

• Not an agreed upon standard for intoxication

• Variables affecting the duration of detection of urinary metabolites include:

• Dose• Duration of use (chronic users vs new or intermittent users)• Acute versus chronic use• Route of exposure • Sensitivity of the method • Urine volume, concentration, and pH

• Using GC/MS, metabolites may be detected in the urine up to 7 days following single marijuana cigarette

Goldfrank’s Toxicologic Emergencies - Chapter 83: Cannabinoids


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Areas of Potential Abuse in Medical Marijuana Laws

• Doctors who prescribe the drug for conditions not covered by the law

• Prescribing without evaluation of patient

• Drug seekers: people who lie about their symptoms to acquire a prescription• Fake chronic pain & migraines

• Legitimate patients selling their medical marijuana to non-patients for a profit


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• Evaluate for specific patient; Medical marijuana is not a “silver bullet”

• Dosage is difficult to determine and requires physician engagement

• Should be evaluated carefully and patient risk for substance abuse should be considered

• Conflicting evidence on impact on opioid use• Can find evidence drawn from population studies in states with legalization• Recent evidence shows that use may increase use of prescription opioids

• Am J Psychiatry. 2018 Jan 1;175(1):47-53. doi: 10.1176/appi.ajp.2017.17040413. Epub 2017 Sep 26.

Things to consider

https://www.ncbi.nlm.nih.gov/pubmed/28946762


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Questions?

Documents

Medical Marijuana · •Cases pending in other states •Other states prohibit health insurers from paying; handful of states preclude employers or workers’ comp payers from paying