The Decision to Provide Medical Marijuana Coverage

mmj-667836_1280As a plan sponsor, should your benefits provider cover medical marijuana for your employees?

The decision to cover medical marijuana as part of an employee’s benefits package is relatively new and uncharted. The associated stigma has few plan sponsors taking the initiative to inquire about coverage and employees may be apprehensive about discussing their needs with HR.

A briefing on medical marijuana (cannabis)

What’s the difference between medical cannabis and street marijuana?
Medical cannabis includes not only parts of the plant but also synthesized versions of the active chemical compounds present in cannabis, known as cannabinoids. There is chemically no real difference between medical cannabis and marijuana. Cannabis is the scientific name; marijuana comes from Mexican Spanish.
The terms will be used interchangeably in this article.

When was medical marijuana first used?
The earliest records date back to about 2700 B.C., when Chinese physicians were recommending a tea made from cannabis leaves to treat conditions like gout and malaria (cannabis was already in use as early as 4000 B.C. in China as a source of cloth, rope, fiber and cooking oil). Chinese surgeon Hua Tuo is credited with being the first recorded person to use cannabis as an anesthetic, and the Chinese term for “anesthesia” literally means “cannabis intoxication”.
From Ancient Egypt, India and Greece, to the Medieval Islamic world, medical cannabis has been recorded throughout history as treating ailments like glaucoma, insomnia, headaches, gastrointestinal disorders, ear obstructions, and pain. Arabic physicians made use of the diuretic, antiemetic, antiepileptic, anti-inflammatory, analgesic and antipyretic properties of Cannabis sativa, and used it extensively as medication from the 8th to 18th centuries. Even Queen Victoria was given medical marijuana by her physician to alleviate menstrual pain.
By the late 18th century, early editions of American medical journals recommend hemp seeds and roots for the treatment of inflamed skin, incontinence and venereal disease. At the first American conference on the clinical use of marijuana, held by the Ohio State Medical Society in 1860, physicians reported success in using marijuana to treat chronic cough, gonorrhea, pain, and a variety of other conditions.

What’s with the stigma?
Drug prohibition has been described as “an experiment of the 20th century” and was largely in response to panic and racism. Until 1908, Canadians could buy opium, cocaine and morphine from a pharmacy; Prairie farmers even planted hemp as a windbreaker for crops. But in the early 1900s, growing hostility towards Asian immigrants incited the government to target opium, and it didn’t take long for marijuana to be engulfed.
On the West Coast, newspapers printed volumes that chronicled the drug-induced downfall of previously upstanding white Canadians and provided sinister depictions of Chinese drug dealers.
Cannabis was added to the Confidential Restricted List in 1923 under the Narcotics Drug Act Amendment Bill, and scholars have long puzzled over this. Cannabis was not commonly used, and the average citizen might never have heard of it. The only recorded statement in the House of Commons was: “There is a new drug on the schedule.”
Cannabis did not begin to attract official attention in Canada until the latter 1930s, and even then it was minimal. The first seizure of cannabis by Canadian police was not until 1937, and between 1946 and 1961, cannabis accounted for only 2% of all drug arrests in Canada. It was not prohibited federally in the U.S. until 1937. Even in 1975, a deputy minister in the Health and Welfare department called the reasons for banning marijuana “somewhat obscure.”
Whatever the motivation, marijuana was banned without debate.

Where do the political parties stand on marijuana?
Our currently ruling Conservatives want to enact harsher laws penalizing marijuana use, possession, and trafficking, with mandatory minimum jail sentences.
The Liberals want to fully legalize and regulate the use and sale of marijuana, similar to alcohol and tobacco.
NDP leader Tom Mulcair has said that the use of marijuana should be a “personal choice,” but that there are still medical issues that need to be examined before the legalization of the drug goes ahead in Canada. He has, however, pledged to decriminalize marijuana ‘the minute [they] form government’.
The Green Party’s position, very similar to the Liberals, is that the criminalization of marijuana “has utterly failed and has not led to reduced drug use in Canada” and would choose to legalize and tax marijuana, believing that drug addictions should be treated as a health problem, not as crime.

So what do you, as a plan sponsor, do?

Here are four things to think about when determining whether or not to provide your employees with medical marijuana coverage:

The Law

The Government of Canada still considers marijuana a Controlled Substance and therefore is reluctant to acknowledge that marijuana-based therapies exist at all. Prime Minister Stephen Harper has had some particularly harsh (and not necessarily factual) words to say on the matter. Given its criminal standing, medical cannabis cannot be covered under regular supplementary health benefit plans (this could potentially change after the October 19 federal election). Medical cannabis or seeds purchased from a licensed producer, however, can be claimed as a medical expense on an individual’s personal tax return, or through an applicable Health Care Spending Account (HCSA).

Canada-government-sign-620x250Medical marijuana does not have a Drug Identification Number (DIN), which is the industry standard usually required before a pharmaceutical is authorized for sale and reimbursement by insurance providers.

Health Canada requires a pharmaceutical to undergo its assessment process and intensive research trials prior to being issued a DIN, which has not yet been done for medical marijuana.
In rare circumstances, it may be covered by providers on an exception basis, such as with Sun Life and Manulife.

Under Health Canada’s Marihuana for Medical Purpose Regulations (MMPR) which came into effect on March 31, 2014, the decision to use marijuana for medical purposes is between the patient and physician alone.

The Science

Cannabis and cannabinoid drugs are widely used to treat disease or alleviate symptoms, but their efficacy for specific indications is not clear.

2000px-Tetrahydrocannabinol.svgPenny F. Whiting, PhD and her colleagues report in JAMA that there is only moderate-quality evidence supporting the benefits of medical marijuana, and only for certain conditions. The scientists analyzed 79 randomized trials, in which volunteers are randomly assigned to take a cannabis product or a placebo. The studies evaluated marijuana’s ability to relieve a range of symptoms including nausea from chemotherapy, loss of appetite among HIV positive patients, multiple sclerosis spasms, depression, anxiety, sleep disorders, psychosis and Tourette syndrome. Most of the studies showed improvements among the participants taking the cannabinoid products over those using placebo, but in many, the scientists admitted that the association was not statistically significant.

The strongest trials supported cannabinoids’ ability to relieve chronic pain, while the least reliable evidence involved things like nausea and vomiting from chemotherapy, sleep disturbances and Tourette syndrome. Cannabinoids were, however, connected to more adverse events such as nausea, vomiting, dizziness, disorientation and hallucinations than placebo.

The regulation on access to cannabis for medical purposes, established by Health Canada in July 2001, defines two categories of patients eligible for access to medical cannabis:
Category 1 covers any symptoms treated within the context of providing compassionate end-of-life care or at least one of the symptoms associated with medical conditions listed below:

  • Severe pain and/or persistent muscle spasms from multiple sclerosis, from a spinal cord injury, from spinal cord disease
  • Severe pain, cachexia, anorexia, weight loss, and/or severe nausea from cancer or HIV/AIDS infection
  • Severe pain from severe forms of arthritis
  • Seizures from epilepsy

Category 2 is for applicants who have debilitating symptom(s) of medical condition(s), other than those described in Category 1. The application of eligible patients must be supported by a medical practitioner, as per the MMPR.

No physician is recommending medical marijuana as a first line of treatment. Only when standard regimens have been exhausted are alternative forms of therapy explored. Nor are prescriptions handed out to anyone who asks for one – doctors are weary to prescribe, saying they have little scientific data to guide their authorizations. The College of Family Physicians of Canada says there’s no research evidence supporting use of medical marijuana for low-back pain or fibromyalgia, but it can be considered for nerve-damage pain caused by such conditions as metastatic cancer, shingles and injury, when those conditions don’t respond to standard treatments, states their 2014 guideline on prescribing cannabis.

The Insurers

Insurance companies aren’t necessarily concerned with the stigma or controversial health benefits of medical marijuana. “If it was issued a DIN by Health Canada, it’s quite likely that the insurance companies would cover it,” says Wendy Hope, a spokeswoman for the Canadian Life and Health Insurance Association Inc.

Close-up of assorted Canadian paper currencyMany smaller, niche insurance providers already cover medical marijuana, but the insurance industry is fiercely competitive, and once the first big player makes a move, the rest will follow swiftly. In fact, insurance companies and plan sponsors would have a clear profit motive to cover medical marijuana. In many cases, medical marijuana is cheaper than other prescriptions, particularly opioids such as OxyContin. There are also factors of efficacy and liability, says Bruce Linton, chairman and co-founder of Tweed Marijuana in Smiths Falls, Ontario. “The compelling reason for an insurer is… something that has less liability, equal or better efficacy and a lower cost base probably is a winner,” he said. “If you have a choice of taking something that requires you to have frequent liver function tests or results in you having the inability to reliably turn up at work… or having something that doesn’t have those negative side effects, the patient (will) demand that.”
Therefore, the cost/risk benefits for insurers and plan sponsors in the case of medical marijuana vs. opioids are abundantly clear. So how do you, as a plan sponsor, get medical marijuana coverage? “It’s up to the employer to ask if they want to have it covered,” says Hope. It can never hurt to ask, and the more inquiries insurers get, the more they’ll recognize the demand.

The Implications

The implications of widespread medical marijuana coverage are arguably quite powerful to the health and welfare of our nation as a whole.

medicine-thermometer-tablets-pillsWe currently have a serious opioid problem. Canada is the world’s second largest per capita consumer of prescription opioids after the United States. The International Narcotics Control Board reports that Canadians’ use of prescription opioids increased by 203% between 2000 and 2010, an increase steeper than in the U.S.  Some First Nations in Canada have declared a community crisis owing to the prevalence of the harms associated with prescription drugs.

According to the Ontario coroner’s office, prescription opioid-related mortality in Ontario doubled between 1991 and 2004, and more than tripled between 2004 and 2012, the year that deaths totaled 536. The demand for treatment for addiction also increased. The number of prescription-opioid-related admissions to publicly funded centres for substance use treatment in the province doubled between 2005/6 and 2011/12. The Costs of Substance Abuse in Canada 2002  estimated the total societal cost of substance abuse to be $39.8 billion.
A key problem is the high rate of prescribing for chronic pain. Chronic pain is one of the most-prescribed uses of medical marijuana, and even the JAMA study found solid evidence that marijuana is effective at treating chronic pain.

Why should a workplace look at opioid abuse issues?

Many aspects of the workplace today require alertness, efficiency, and quick reflexes. An impairment to these qualities can cause serious accidents. Other ways that opioid abuse can cause problems at work include:

  • after-effects of substance use (withdrawal) affecting job performance
  • absenteeism, illness, and/or reduced productivity
  • preoccupation with obtaining and using substances while at work, interfering with attention and concentration
  • illegal activities at work including selling illicit drugs to other employees,
  • psychological or stress-related effects due to opioid abuse by a family member, friend or co-worker
  • lower morale of co-workers

Costs to the employer include:

  • medical / rehabilitation / Employee Assistance Programs (EAPs)
  • injuries / accident rates (ie. WSIB)
  • absenteeism / extra sick leave / loss of production

The National Bureau of Economic Researchers in the US found that access to state-sanctioned medical marijuana dispensaries was linked to a significant decrease in both prescription painkiller abuse, and in overdose deaths from prescription painkillers. Objectively, broader access to medical marijuana may have the potential to reduce use and abuse of opioids, which would in turn have a positive impact on the workplace.

Finally, there’s the compassionate side. Given the choice, many Canadians would prefer a less toxic approach to their potentially end-of-life treatment, with numerous testimonials comparing the efficacy and side effects of medical cannabis versus traditional HIV/AIDS and cancer treatments. Many families have also found success controlling rare disorders with medical marijuana.

What does all of this mean for employers dealing with employees who have medical marijuana prescriptions?
my_obligation_small
Employers have to understand their Human Rights obligations when facing an employee with a medical cannabis prescription, according to employment lawyer David Whitten, including the accommodation of the employee’s need to use the drug in the workplace. If an employee presents their employer with a prescription that says they need to be able to use medicinal marijuana at work, “there is now an onus to accommodate the medical use of marijuana in the workplace to the point of undue hardship,” Whitten says. While an employer cannot fire an employee or bar the use of the drug completely, he or she can request that it be ingested rather than smoked if a smoking area cannot be created at work.

Employees have obligations too, and an employee with a marijuana prescription should inform their employer, as failing to disclose it could mean the right to reasonable accommodation is forfeited. For an employee’s health, if edibles and sprays are not feasible, they could also discuss with their employer the use of a vaporizer, and potential benefits plan coverage for such a device.

What about medical cannabis pills?
Medical marijuana in pill form is not yet in existence, but appears to be on the horizon. Perhaps once it is, medical marijuana will face less of a stigma and its legitimacy will be strengthened, while also making accommodation in the workplace a little easier.
***

Hopefully you now have a broader understanding of medical marijuana and can make an informed decision about whether or not to request coverage for your employees. If you have questions, I encourage you to complete more research, including the reading the links I’ve provided throughout this article, and perhaps have a discussion with your employees to see how they feel.

If you are a smaller company without a dedicated Human Resources professional on staff, consider a consulting service to help you navigate these waters.
Comments on this article are welcomed and encouraged – thanks for reading.
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