Has it ever been more important to be mindful, stay present and set a clear path for health and wellness than it is right now? For this year’s RIMS 2020 conference, Sedgwick had planned to invite attendees to join us in the annual Wellness ZENter, a real-time resource for escaping the whirlwind and finding a moment or two of focus and fresh perspective. Since we couldn’t come together in Denver this year, we went virtual instead! From May 4-6, Sedgwick’s thought leaders and partners shared expertise — and a little pet therapy — online rather than in person, and if you weren’t able to join us, or would like to go back and catch the sessions again, we’ve archived the virtual Wellness ZENter experience at www.sedgwick.com/rims/wellness-zenter.
We all invest considerable time and energy in finding solutions that will improve the well-being of our organizations and the people who support them now and into the future. In our virtual Wellness ZENter, we discussed ideas to guide your organization’s next steps toward well-being and productivity in the workplace — whatever our workplaces look like for the immediate future. Let’s take a deeper look at one of the topics shared as part of this year’s sessions.
MEDICAL MARIJUANA, HAZY HEALTH AND CLOUDY COMPLIANCE
As the use of medical and legalized recreational marijuana continues to grow, so do the questions. Before we dive into the debate over health benefits and risks, let’s first make sure we’re all speaking the same language.
A whole new lexicon
Cannabis is a natural substance that’s been consumed for thousands of years via inhalation, oral ingestion or topically. Cannabis is popular for medical uses like pain, nausea, muscle spasms, arthritis, epilepsy, migraines and other terminal medical conditions. It’s available in a variety of forms, from edibles to tinctures to topical creams.
While hemp and marijuana are often referred to as species or strains of cannabis, they actually do not qualify as either one. Both are simply broad classifications of cannabis that were adopted into our culture.
Cannabis contains more than 100 different types of cannabinoids; the two most common are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the major psychoactive component of the plant that gives users a “high,” while CBD is the major non-psychoactive component. THC and CBD levels vary among different strains and between hemp and marijuana. Hemp, which is federally legal, cannot have more than 0.3% THC concentration, whereas marijuana can range from 15-40% of THC.
Potential issues of cannabis
To date, there have been no reported overdoses or deaths related to cannabis use alone, but associated side effects include worsening psychosis, increased depression, increased anxiety, risk of myocardial infarction, stroke, testicular cancer, hyperemesis and cannabis use disorder.
- Dispensaries have a menu of items on their shelves, but what the label indicates is not always what it contains.
- Formulations vary from state to state, and there is no standardized laboratory testing that can verify the strength or strain of a cannabis product.
- There’s been so much cross-breeding in recent years that even cannabis cultivators may have a hard time identifying the type of strains they’re producing.
- Physicians and pharmacists are not given the tools to recommend or dispense the right cannabis strain for a patient.
- Some states require clinicians to fulfill continuing education credits for cannabis, but resources are limited.
- Dosing and frequency is patient-dependent and, due to lack of standardized formulation, getting the same batch of cannabis from the same dispensary can be a problem.
- Drug testing is still in an exploratory phase; since the drug can stay in the fatty tissue and is slowly released into the blood stream, it can be detected in the urine up to five days after a single ingestion, and up to six weeks for regular users.
- State laws and regulations regarding medical cannabis use are constantly evolving, and this poses a challenge for workers and insurance payers.
- While there are no conclusive studies linking marijuana’s legalization to increases in workplace accidents or injuries, THC can lead to intoxication (feelings of euphoria and relaxation), impairing coordination, cognitive flexibility and reaction time, all of which pose dangers in workplace safety.
And potential benefits
THC is known to cause relaxation, delayed muscle response, and can alter the senses related to smell, sight and hunger. The Food and Drug Administration (FDA) has approved two prescription medications on the market (dronabinol and nabilone) used to prevent chemotherapy-induced nausea and vomiting, and to stimulate appetite in cancer patients. It should be noted, though, that a significant number of users report experiencing more benefit from using cannabis than from pure THC.
CBD is believed to have beneficial effects in treating neuropathic pain, but the evidence is limited and it only shows minimal efficacy with no functional improvement. CBD can help with seizures, and there is an FDA-approved drug, Epidiolex, indicated for the treatment of Lennox-Gastaut syndrome and Dravet syndrome in patients over the age of two. Sativex is an investigational new product composed primarily of CBD and THC. GW Pharmaceuticals plans to seek FDA approval for the drug in the U.S. to treat spasticity and other neurological conditions; it’s already being used in Europe and Canada to treat multiple sclerosis and cancer-related chronic pain.
Despite its growing popularity and mainstream acceptance, many widely used treatment protocols still discourage the use of cannabis. The Official Disability Guidelines (ODG) do not recommend using cannabinoids to combat pain. The American Society of Addiction Medicine states physicians should not recommend their patients use marijuana for medical purposes. Smaller-scale studies compared cannabis (THC + CBD) against placebo, CBD and low-dose THC and concluded that medical marijuana might be beneficial for pain, but only at higher doses. The risk of side effects like depression and anxiety increase with increase in THC dose and there is no functional improvement or quality of life.
Although cannabis has a long history of use and is a natural substance, it’s important to remember that it’s still classified by the U.S. Drug Enforcement Administration as a Schedule I substance. It should be carefully evaluated, taking into consideration patient-individual characteristics, before being recommended to patients or pain management or as an alternative to an opioid therapy.
Compliance and compensability
A total of 34 states and the District of Columbia currently allow medical marijuana use, and beginning with Colorado and Washington in 2012, ten states and the District of Columbia have now legalized recreational use. But marijuana is no longer just a medical or health-related issue; with a trend toward decriminalization across the country comes more widespread use and cultural acceptance. From an economic standpoint, the market for legal retail sales of marijuana and cannabis-related products is currently around $19 billion in the U.S. and the global market is projected to grow: different sources project it reaching anywhere between $60-140 billion by 2025. Not only does that mean legalized marijuana won’t be going away anytime soon, but it also will continue to be something we address in the workplace. The need for coverage in the industry — for businesses from growers to transport to retail — is creating a new insurance vertical, as well.
How do all of these trends impact the way we manage workers’ compensation claims, treatment, usage and review when marijuana is involved? We must keep our fingers on the pulse. We’re seeing more physicians prescribing because either a patient has requested marijuana as an option in their case or because they’ve tried and exhausted other options.
A marijuana review process, triggered by a request in a claim, is one tool for making well-reasoned decisions. This can include running a full history of the claim, the individual’s comorbidities, and health risks, compared to what we know from clinical studies and evidence-based medicine. Whether marijuana is ultimately allowed in a claim or not, a review process can inform our choices and help show that determinations were based on more than just legality or doctor’s recommendations.
Will carriers or payors be required to cover marijuana as part of the claims process? This is another ambiguous question. Some states have required compensability, some states have explicitly denied coverage, but more have taken a stance that leaves room for interpretation — saying “medical marijuana reimbursement is not required” but may be allowed in a claim. Beyond legislation, court decisions continue to shape the compensability and compliance landscape. State-specific guidelines must be watched carefully as statutes and standards change.
In two other areas of concern for employers — drug-free workplace programs and employment decisions — states and federal guidelines are inconsistent. On a federal level, drug-free workplace programs are promoted and suggest that violators can or should be disciplined for being under the influence. But how is “under the influence” determined in the case of marijuana? Everyone wants a safe work environment, but until testing with better validity becomes available, judging what is considered a level of impairment for those testing positive will remain difficult. The technology is being refined; there have been recent breakthroughs for breathalyzer-type or saliva swab tests for point-in-time assessment of impairment. With improvement in testing, more consistent standards may emerge.
Still more factors complicate the situation for employers. On the federal level, the Americans with Disabilities Act (ADA) does not protect employees who choose to use marijuana as a treatment option for a medical condition. However, it’s well established in states where marijuana is legalized that taking employment actions against an employee who tests positive is considered discrimination. The Occupational Safety and Health Administration (OSHA) has flip-flopped; initially after saying employers should not drug test after an accident, reasoning that the practice discouraged individuals from submitting workers’ comp claims, they have since changed stance and now say that employers may drug test after a workplace accident to encourage safety.
Position yourself wisely
The most reasonable way to ensure you will be in a defensible position in the case of any possible legal action or complaint is to follow five best practices:
- Have a sound drug testing policy
- Educate all employees regarding the policy on a continual basis
- Enforce the policy consistently and document your actions
- Focus on deterring employee drug use while at work
- Emphasize workplace safety and performing work in a safe manner