Medical Marijuana in Workers Compensation Thursday, Sept 17, 2:15 pm 3:30 pm

Transcription

1 Medical Marijuana in Workers Compensation Thursday, Sept 17, 2:15 pm 3:30 pm Kevin Glennon, RN, BSN, CDMS, CWCP, QRP VP of Clinical Education & Quality Assurance One Call Care Management

2 Learning Objectives At the end of this session, you will: Know the U.S. states that have legalized marijuana for medical and recreational use and those considering it. Identify the legal, clinical and financial risks associated with legalized marijuana (for both recreational and medical use). Understand the good and bad, as well as intended and unintended consequences of legalized marijuana in the workplace. Discuss current legislation on a Federal Level. Discuss what constitutes levels of intoxication.

3 What is Marijuana? Number of slang terms Weed, pot, grass, etc. Cannabis sativa From green mixture of dried, shredded leaves and flowers Hemp plant Over 100 different cannabinoids THC, most common & most psychoactive (Marinol) Cannabidiol and Cannabinol also prevalent forms

4 Biology & Pharmacology Biology of Cannabis Marijuana may have different percentages of different cannabinoids, depending on the strain and how it was grown Active ingredient, THC its effects are modulated by other cannabinoids Clinical Pharmacology Receptors mainly in hippocampus, cerebellum, and peripheral nerves Brainstem receptors inhibit nausea Different biological mechanism than opiates, may have synergistic effects

5 Marijuana Legislation by State

6 Medical Marijuana Current literature documents various medical uses (below) Delivery: Inhalation or oral ingestion AIDS (HIV) and AIDS Wasting Alzheimer s disease Arthritis Asthma/breathing disorders Crohn s/gastrointestinal disorders Epilepsy/seizures Glaucoma Hepatitis C Migraines Multiple sclerosis/muscle spasms Nausea/chemotherapy Pain/analgesia Psychological/psychiatric conditions/disorders Tourette s syndrome Spasticity Cancer Cachexia Other terminally ill conditions * According to US Government Accountability Office (GAO), Harvard Medical School, and the National Institute for Mental Health (NIMH)

7 Medical Marijuana Clinical Trials Works on neuropathic pain (Abrams, et al) Mixed results for spasticity (Wade, Zajicek, et al) Appetite improvement by THC Generally well tolerated, minimal drug drug interactions, minimal adverse effects with short term use Multiple long term affects Trials hampered by government regulations

8 Smoked Marijuana DEA and federal government opposed to smoked marijuana and they are not alone Many view it as having no documented medical value Medical community has not fully accepted smoked marijuana as medicine American Society of Addiction Medicine s (ASAM) reject smoked marijuana as a means of medicinal drug delivery American Cancer Society (ACS) not an advocate of inhaled marijuana American Glaucoma Society (AGS) can lower intraocular pressure, but due to side effects, short duration, and lack of evidence that it can alter course of glaucoma, precludes recommending smoked marijuana Even the scientists and researchers who believe marijuana has medicinal value Discount smoked marijuana as medicine

9 FDA Approved Forms Medical marijuana not approved as safe and effective medication Marinol, only drug currently approved by FDA Man made, synthetic form of THC, active natural substance in marijuana Available through prescription and comes in pill form Used to treat nausea and vomiting caused by chemotherapy for cancer Used to treat weight loss and loss of appetite in HIV/AIDS patients Controversy whether creates high or intoxication reports say it doesn t Sativex, an oral mucosal spray Used to treat spasticity due to Multiple Sclerosis Approved in Canada, New Zealand, Spain, and United Kingdom Contains 2 cannabinoids found in marijuana THC and Cannabidiol (CBD) but unlike smoked marijuana, removes contaminants, reduces intoxicating effects Grown in a structured and scientific environment Administers a set dosage and meets criteria for pharmaceutical products

10 States with CBD only Legalization Cannabidiol (CBD) compounds in marijuana that have medical effects but do not make people feel stoned, 11 States 1. Alabama 2. Florida 3. Kentucky 4. Mississippi 5. Missouri 6. North Carolina 7. South Carolina 8. Utah 9. Wisconsin 10. Iowa 11. Tennessee

11 States with CBD only Legalization

12 Federal Law Controlled Substances Act (CSA) of 1970 Categorizes marijuana as Schedule I substance Cultivation and distribution (which includes gift as well as sale) are felonies Possession for personal use is a misdemeanor Use is not itself a crime, but there is no way to use marijuana without possessing it first, and possession of paraphernalia is also illegal Cultivating marijuana, 100 plants or more, carries a mandatory minimum sentence of five years under federal law

13 Federal vs. State Laws Oct. 19, 2009, Attorney General Eric Holder announced formal guidelines for federal prosecutors in states that enacted laws authorizing the use of marijuana for medical purposes Not to focus on individuals who are in compliance with state laws Continue to prosecute those whose claims of compliance with state and local law conceal operations inconsistent with the terms, conditions, or purposes of the law Reiterated Department of Justice is committed to enforcement of Controlled Substances Act (CSA) in all states Guidance does not legalize marijuana or provide legal defense to violations of federal law Some interpret guidelines to mean federal government has relaxed its policy on medical marijuana, this in fact is not the case

14 Drug Enforcement Administration DEA s Position Properly Categorized as Schedule I Substance U.S.C. 801, et seq. The clear weight of the currently available evidence supports this classification, including evidence that smoked marijuana has a high potential for abuse, has no accepted medicinal value in treatment in the United States, and evidence that there is a general lack of accepted safety for its use even under medical supervision.

15 Medical Marijuana in WC In WC, predominantly requested to manage chronic pain Studies on efficacy for pain management produce conflicting results Some studies had positive results, but they were small in scale Others showed synergistic effects when using marijuana with opioids, which could lower opioid dosage and abuse However, no large scale randomized controlled human trials have been conducted on medical marijuana Lack of definitive medical evidence continues to be a barrier to adoption, and as a Schedule 1 drug, obstacles remain with regard to testing and prescribing Side effects, may be less risky than opioid pain relievers

16 Claims Best Practices: Medical Marijuana in WC Schedule I drug per Controlled Substance Act (CSA) Illegal to distribute, prescribe or purchase in U.S. Prohibits assigning NDC or procedure code for billing purposes Not FDA approved to treat any medical conditions or diseases Not FDA approved to treat any common WC injuries Payers deny medical marijuana claims for WC Several states, including Colorado, Michigan, Montana, Oregon, and Vermont, contain provisions. WC not required to cover cost of medical marijuana. Not approved in the ODG or ACOEM practice guidelines or any of the state medical treatment guidelines and denied by UR if recommended by a treating physician

17 Reasonable & Necessary Treatment Defining reasonable and necessary treatment is an enduring challenge Determinations of necessary care rely on medical evidence, as encapsulated in clinical guidelines Determinations rarely straightforward, given the complexity of individual cases Evidence based medicine consider that there are currently no WC treatment guidelines that support marijuana recommendations In many states, medical marijuana can be recommended but not prescribed by a doctor. Treatment guidelines will claimants find support in states?

18 Case in Point: Medical Marijuana in WC 2014, a judge in New Mexico ruled that the employer and its workers compensation carrier had to reimburse employee For costs associated with purchase of medical marijuana (Vialpando v. Ben's Auto. Servs. And Redwood Fire & Casualty, 2014 NMCA 32, 920, N.M. Court of Appeals, May 19, 2014) Back injury case, illustrates that once medical marijuana is available in a state, expanding the conditions it is used for as a treatment is quite common Since marijuana is still classified as an illegal substance under federal law, insurance carriers are prohibited from paying for it directly In this case, the carrier was required to reimburse the injured worker, not to pay for the marijuana directly This decision is being challenged in the New Mexico Supreme Court No ruling has been handed down

19 Affect on Work Performance Marijuana affects each user differently, depending on: Person's mood, personality, size, and weight Amount taken and whether it is mixed with anything else Environment in which drug is used If used in workplace, it can affect health and safety of workers Marijuana has following effects (Wadsworth EJ et al, 2006): Short term memory problems Impaired thinking Loss of balance and coordination Decreased concentration Changes in sensory perception Impaired ability to perform complex tasks Decreased alertness Decreased reaction time Marijuana has following effects (Wadsworth EJ et al, 2006): Hazardous, if operating heavy machinery or driving a vehicle Greater risk of accident, due to poor performance of simple manual tasks Regular users will exhibit loss of energy and interest in tasks Difficulty in learning new work skills

20 Driving on the Job Legal limit for DUI of marijuana 5 nanograms of active THC in blood No recognition in the legislation that the effects of marijuana and alcohol together may be more than the sum of their parts

21 Cannibuster

22 A roadside marijuana test Cannibuster May be the Holy grail for states were marijuana is legalized Similar to the breathalyzer, uses saliva test On the spot results No way to determine level of intoxication when marijuana, alcohol and prescription drugs are used in combination

23 Drug Free Workplace & Random Drug Testing Workplace drug testing can identify a marijuana user Stored in fatty tissues, slowly released into bloodstream and excreted from body Traces of marijuana can be found: In urine for 1 5 days after occasional use Up to six weeks (or more) in regular users (3x a week over a number of years) Identified for a much longer time period compared to most other drugs

24 Future Outlook: Is Reclassification Possible? Cultural outlook and public opinion polls support marijuana use Significant momentum at state legislative level Some experts feel it s only a matter of time before the federal government reclassifies marijuana, allowing legal use Reclassification would create significant upheaval in employers drug free workplace policies Transition from zero tolerance to impairment policies, similar to alcohol Would need standards for measuring THC impairment and determining if someone is under the influence of marijuana No research on marijuana impairment levels affects people differently Blood tests are unreliable No breathalyzer

25 Sens. Paul, Booker, & Gillibrand Announce CARERS Act New Bipartisan Medical Marijuana Bill to Allow Patients Including Veterans to Access Necessary Care without Fear of Federal Prosecution Recognize States Responsibility to Set Medical Marijuana Policy & Eliminate Potential Federal Prosecution Reschedule Marijuana from Schedule I to Schedule II, Recognizing Accepted Medical Use Allow States to Import Cannbidiol (CBD), Recognized Treatment for Epilepsy and Seizure Disorders Provide Veterans Access Permit Financial Services and Banking for Marijuana Dispensaries Expand Opportunities for Research

26 Congress Rethinks Policy on Medical Marijuana Regulate Marijuana Like Alcohol Act, Rep. Jared Polis (D Colo.) Remove marijuana from the Controlled Substances Act's schedules Transfer oversight from Drug Enforcement Administration to Bureau of Alcohol, Tobacco, Firearms and Explosives Regulate marijuana in way similar to alcohol in U.S. Marijuana Tax Revenue Act, Rep. Earl Blumenauer (D Ore.) Set up a federal excise tax for regulated marijuana Polls show 78% of Americans believe medical marijuana with a physician recommendation should be legal

27 Takeaways At the federal level, marijuana is classified as an illegal drug May carry a fine or criminal conviction Zero tolerance, there is no protection for employees who use medical marijuana, even if prescribed by a physician and even if used after hours Use of marijuana is currently not acceptable in the workplace Affects work performance, employee safety must be considered WC policies must be based on federal law Currently, WC payers without exception deny claims for medical marijuana Work with service providers, such as TPAs and pharmacy benefit managers, to establish and enforce policies; re review as new case verdicts emerge Monitor state and federal legislation More states may legalize medical marijuana, creating additional pressure to reclassify marijuana at the federal level Stay abreast of new cases, judgments and verdicts that may forecast a change in public sentiment, which could then impact policies

28 Q&A Kevin Glennon, RN, BSN, CDMS, CWCP, QRP VP of Clinical Education & Quality Assurance One Call Care Management