Caught in the Middle; Choosing Sides

Living and having my employer’s corporate headquarters based in the great State of Colorado provides a lot of benefits. Being presumed a pot expert, everywhere I go, isnot one of them.

The Drug Enforcement Agency’s denial of two petitions to reclassify marijuana last week maintained the topic’s position at the top of mind for Workers’ Compensation patients and professionals. Various articles, white papers, position papers, etc., have surfaced to add context to the discussion.

One piece struck a chord:  The article expressed, “While states generally involve physicians in the process by which patients obtain marijuana, national drug policies have traditionally had a chilling effect on these conversations.” Referencing the Journal of the American Medical Association (JAMA), the article also notes federal laws’ contradiction to state regulations as being the reason “many doctors say they feelcaught in the middle.” (1)

Many of the issues in Workers’ Compensation can be solved within the clinic-experience between the doctor and their patient. If we can get this part in care continuum correct, many (if not most) other facets will maintain a track for improved health outcomes.

The American Pain Society (APS), the Federation of State Medical Boards (FSMB), theAmerican College of Occupational and Environmental Medicine (ACOEM), have all publicly stated that irrespective of law inconsistencies, federal to state, providers must be adequately equipped to address medical marijuana’s place and use among the working population.

To paraphrase Mark Pew’s personal take – Medical marijuana is appropriate for somepeople for some conditions for some of the time.

While mixed feelings exist about the quality of available scientific evidence supporting the efficacy of medical marijuana, there is no disagreement about its continued and increased presence among the working population. Thus, the need to equip physicians with reliable information to educate employees of potential health risks and safety implications.

ACOEM’s “Marijuana in the Workplace: Guidance for Occupational Health Professionals and Employers” position paper, published in April 2015, has served as a great resource for Occupational Health Professionals and Employers whose workplaces are impacted by marijuana use for medical purposes. Since then, a number of other tools have emerged as valuable resources for front-line professionals who deal with the matter on an ongoing basis.

FSMB’s “Model Guidelines for the Recommendation of Marijuana in Patient Care” is an effective resource for “state medical boards in regulating physicians and physician assistants with full and unrestricted license participating in marijuana programs”. The guidelines are also “valuable in educating licensees as to the board’s expectations when recommending marijuana to a patient for a particular medical condition”. The precautions and steps provided for physicians considering recommending medical marijuana to a patient are similar to guidance provide for opioid prescription: patient evaluation, consulting the state Prescription Drug Monitoring Program (PDMP),documentation of a treatment plan, establishing goals of the treatment plan,ongoing assessment of patient’s response to the use of marijuana and overall health and level of function. (2)

Healthesystems’ Chief Medical Officer, Robert Goldberg, MD, FACOEM, published a white paper this month (August 2016), “Medically Speaking”, identifying “moderate level” evidence speaking to the benefits of marijuana to treat specific types of pain. As we learn more about the substance, the scientific evidence seems to be indicating some positive results from applications with appropriate, ongoing monitoring of functional improvement. Dr. Goldberg’s piece is optimistic about medical marijuana’s potential to reduce or eliminate opioid use for pain management. (3)

Contrasting the multiple medical societies (APS/FSMB/ACOEM), the Work Loss Data Institute’s (WLDI) data-driven Official Disability Guidelines (ODG), do not recommend the use of cannabinoids citing “no quality studies supporting cannabinoid use” and “serious risks”. Ken Eichler, from WLDI, went on record with WorkComp Central stating that the reimbursement for medical marijuana would “open the door” forheroin and ecstasy due to the drugs’ similar classification as Schedule 1 substances [meaning they have a high potential for dependency or addiction, with no accepted medical use according the Controlled Substance Act]. (4) However, when consideringmedical necessity, marijuana is significantly removed from the other two illicit drugs.

The need for alternative treatment options for pain is extremely evident. With the nation’s aggressive crackdown on the use of opioids, there is legitimate concern with the treatment pendulum swinging to another extreme (from over-prescription to non-prescription without trustworthy scientific basis). The answer lies somewhere in the middle, always supported by reliable, trustworthy, scientific evidence. In the absence of high quality studies, EBM standards call for the reliance of best practices and expert consensus for safe, medically-responsible treatment recommendations.

It would be of value for Workers’ Compensation as a whole to lean on the understanding of the medical societies mentioned above. The physician/patient relationship is a potent conduit for improved health and return to work outcomes. Equipping and empowering providers who feel they are caught in the middle of a legal struggle, between federal and state perspectives, will ensure patients have medically sound guidance should they inquire about medical marijuana as an alternative to treating their pain.

  1. Luthra, Shefali. “As States OK Medical Marijuana Laws, Doctors Struggle With Knowledge Gap.” KHN, Kaiser Health News, August 2016. Web. 15 August 2016 http://khn.org/news/as-states-ok-medical-marijuana-laws-doctors-struggle-with-knowledge-gap/
  1. “Model Guidelines for the Recommendation of Marijuana in Patient Care.” FSMB. April 2016. Web. 15 August 2016 http://www.fsmb.org/Media/Default/PDF/BRD_RPT_16-2_Marijuana_Model_Guidelines.pdf
  1. Goldberg, Robert. “Medically Speaking, Marijuana and Pain Management.”Healthesystems, August 2016. Web. 15 August. 2016. http://www.healthesystems.com/File%20Library/insights/06-1839_Whitepaper_Medical-Marijuana_VF.pdf
  1. Goodman, Elaine. “Guidance Begins to Emerge on Medical Marijuana Use.” WorkcompCentral, August 2016. Web. 15 August. 2016. https://www.workcompcentral.com/news/story/id/c620665e386963098f3c3d017a8f7d3caf88c7f2

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