Medical Marijuana's Changing Environment Increases Concerns for WC Industry

Sarasota, FL (WorkersCompensation.com) – It’s no longer called ‘weed,’ or ‘pot;’ the new preferred term is ‘cannabis.’ ‘Buds’ are now ‘flowers;’ ‘hash’ is ‘extract.’ And please don’t refer to them as ‘stoners;’ they are ‘high per capita consumption consumers.’

The latest politically correct terminology for all things marijuana reflects the effort by well-funded companies seeking to legitimize themselves as businesses and ward off the reputation as high end drug dealers. The new lingo is but one of the many changes taking place around the use of the drug.

“It’s such an evolving landscape that it’s difficult to keep up,” said Lisa Ann Bickford, director of Government Relations for Coventry. “So, if you’ve listened to me speak to this before you may be hearing me say different things than you heard the last time because that was soooo 90 seconds ago and things are changing constantly.”

From the rapid changes in state and local statutes, to the recent widespread proliferation of ‘CBD,’ movement is afoot in the marijuana biz. “It’s a tricky world to navigate,” said Nikki Wilson, Coventry’s director of Pharmacy Product Development. Bickford and Wilson outlined the latest marijuana-related laws and  offered some practical advice during a recent webinar on Medical Marijuana Highs and Lows: Work Comp Regulatory & Clinical Update.

CBD Products

Marijuana is illegal under federal law. However, a majority of states have approved it for medicinal use, while 11 states and jurisdictions also allow it for recreational use. But it seems lately ‘CBD’ and products infused with it are being sold in many areas  – even in states where marijuana is not allowed for recreational use.

“CBD is literally everywhere,” Wilson said. “You can walk into a pharmacy, you can buy it online, it’s in convenience stores, it’s in coffee shops, it’s in pet stores – it’s everywhere.”

Despite its widespread availability, many people have no idea what it even is. CBD, or cannabidiol, is a chemical found in the Cannabis sativa plant. It can be derived from marijuana or its cousin, hemp. Unlike the molecule tetrahydrocannabinol or THC, CBD from hemp produces little to none of the ‘high’ users experience.

The enactment of the 2018  Agriculture Improvement Act, or ‘Farm Bill,’ made it legal to sell hemp and hemp products in the U.S. While it cannot be legally included in foods or dietary supplements or in products marketed with therapeutic claims, CBD can be included in cosmetic products – if it contains less than 0.3 percent THC.

It is most commonly used for seizure disorder, but is also promoted to treat anxiety, pain, the muscle disorder ‘dystonia,’ Parkinson’s, Chron’s disease, and other conditions.

Whether CBD can help injured workers is highly speculative at this point. However, some physicians suggest it pre- and post-surgery. The potential to reduce anxiety leads some to believe it has positive benefits before patients go under the knife. Some also say it can help with post-surgical pain and, possibly, avoid the use of opioids.

But Wilson and Bickford have some words of caution for those who see the potential value in CBD for injured workers. One is the labeling accuracy of products.

A 2017 study showed that 7 out of 10 CBD products available online did not contain the amount of the chemical that was indicated on the label; either more of it or less.

"Even more concerning to me were the findings that 1 in 5 ‘CBD only’ products also contain THC  which is the [part of] marijuana that  can lead to  euphoric effects that would potentially show up on a urine drug test, particularly concerning when we’re talking about return to work for injured workers,” Wilson said.

Concerns for Clinicians

The lack of clear-cut standards for CBD and marijuana in general make it difficult for stakeholders working with providers and/or injured workers who seek the drug – and reimbursement. Organizations are increasingly taking the issue on a case-by-case basis in those jurisdictions where the drug is legal. Still, there are many issues to consider. 

• Drug-drug interactions. Like many other substances, marijuana can affect or be affected by other drugs. There are indications, for example, that it may have adverse consequences when used in conjunction with central nervous system or tricyclic antidepressants, Warfarin, corticosteroids (hydrocortisone) and antibiotics. There are contraindications when the drug is used by people with a history of psychosis, cardiovascular disease, respiratory disease, current or past substance use disorder and pregnancy. Caution is advised before suggesting  marijuana use for people younger than 25, those with active mood disorders, have risk factors for cardiovascular disease or liver impairment, or are on high doses of benzodiazepines or alcohol. 
• Quality and purity. The variations in the percentages of a product’s composition mean each can be very different from one another. While they may have the same ingredients, they may be at different levels; or inactive ingredients could change the effect on the user. “If you go down the street and [the product] has the same percentage it might be a completely different effect just because they are completely different chemical classifications,” Wilson said. 
• Lack of guidance. Unlike legal medications, providers cannot ‘prescribe’ marijuana, but can only recommend its use. That means it’s generally up to the injured worker to determine the type, amount, dose and duration. Marijuana dispensaries typically have ‘bud tenders,’ people who can suggest products based on their own experience and the buyer’s ailments. “It’s trial and error, Wilson said. “As far as dosing goes, the best solution is to start low and go slow.”

As with any ‘legal’ medication, providers should be encouraged to discuss with injured workers their histories, potential side effects, and other medications the worker is taking that could affect or be impacted by the drug.

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