Medical Marijuana. Navigating Medical Marijuana in Workers Compensation

Transcription

1 Medical Marijuana Navigating Medical Marijuana in Workers Compensation

2 Agenda Federal and State Laws Public Health Adverse Effects & Concerns Clinical Use Implications for Employers Implications for Workers Compensation Conclusion 2

3 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 3

4 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 4

5 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: DEA Scheduling: 5

6 Strains of Marijuana 2 Main Strains for Medical Marijuana Cannabis Sativa Cannabis Indica Less Common Strain Cannabis Ruderalis 6

7 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) 7

8 Increasing Potency of THC 8

9 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 9

10 Marijuana & Public Health: FDA & CDC Perspective 10

11 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, decisionmaking 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 personality disturbances 11

12 Cannabis and Driving Contradictory studies, caution advised 12

13 DOT and marijuana use 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 13

14 Access to marijuana 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 14

15 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 15

16 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 16

17 Endocannabinoid system 17

18 NUMBER OF STATES States vary in terms of conditions covered under medical marijuana regulations 30 Top 20 Common Conditions CONDITIONS 18

19 Dispensaries Each state has different laws for dispensaries Staffing & Training Location Testing 19

20 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 20

21 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 NEED FOR TRAINING ON DOSING AND DRUG INTERACTIONS 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 exist 21

22 TX Dispensaries 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 22

23 Variety of Dosage Forms Vaporized Smoked Edibles Topical Oils (CBD) State Laws determine allowed forms for medical marijuana 23

24 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. 24

25 Not yet approved in US 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 % CBD and no THC Liquid form like Charlotte s Web 25

26 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: 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) 26

27 Other Challenges for payers 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 27

28 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 28

29 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 29

30 Things to consider 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 Jan 1;175(1): doi: /appi.ajp Epub 2017 Sep

31 Questions? 31