CBD oil and how it may affect CA workers comp claim

CBD (Cannabinol) AND WORKERS’ COMPENSATION: PUBLISHED IMR DECISIONS CONCERNING CBD AND WORKERS’ COMPENSATION: WHAT YOU NEED TO KNOW

Many Injured Workers who are seeking treatment as a result of their industrial injury often seek to treat with alternative medicine. Rather than taking prescription pills or medications, they seek treatment via other means such as natural forms of treatment. There are many herbs and supplements that have been used in medicine to treat various conditions. One form of natural treatment that has been touted, is CBD or Cannabinol. CBD has been recommended for treatment for a variety of medical conditions.

In California Workers’ Compensation, medical treatment is subject to insurance company approval via a Utilization Review(UR) Program. Further, a UR denial of treatment is subject to an appeal via an Independent Medical Review(IMR) program. The IMR Program issues determinations on the appeals. Some of these IMR determinations have been published by LexisNexis. LexisNexis is a service which provides legal resources and research to the legal community. Frequently, reporting from LexisNexis is used as authority to support legal positions.

This article will discuss these recently published IMR decisions in which CBD was at issue. These published decisions provide some insight as to whether future requests for CBD will be authorized for industrial medical treatment. These published decisions provide us the current problems with the requests being made. The IMR decisions also provide some insight as to what medical providers need to put into their “requests for authorization” that should assist in getting CBD approved.

What is CBD?

Cannabidiol (CBD) oils are low tetrahydrocannabinol products derived from Cannabis sativa that have become very popular over the past few years. Patients report relief for a variety of conditions, particularly pain, without the intoxicating adverse effects of medical marijuana.” Clinicians’ Guide to Cannabidiol and Hemp Oils https://doi.org/10.1016/j.mayocp.2019.01.003 “One promising area has been use of the plant Cannabis sativa, both in medical marijuana as well as hemp and cannabidiol (CBD) oils, with some evidence that access to medical marijuana is correlated with a decrease in opioid use, although there has been controversy about the risks and benefits of encouraging poorly regulated medical use of a known substance of abuse.5, 6 Cannabidiol and hemp oils have become especially popular because of their low tetrahydrocannabinol (THC) levels, resulting in attributed medical benefits without the “high” of marijuana.7 However, clinicians have concerns about whether these treatment options are legal, safe, and effective and are largely unfamiliar with these products.8, 9 Supra.

There are a variety of uses for CBD, “[a]ccording to a recent systematic review on the medical uses of cannabinoids, there was moderate-quality evidence to support the use of cannabinoids for chronic pain and spasticity, and low-quality evidence to support use for nausea and vomiting due to chemotherapy, weight gain in HIV infection, sleep disorders, and Tourette syndrome.30 However, it is important to realize that most of the randomized controlled trials examined in this systematic review for each condition were of the 3 prescriptible THC drugs dronabinol, nabilone, and nabiximols; only 4 trials were found for CBD, and none for any of the other phytocannabinoids or terpenoids present in C sativa oils,30 again demonstrating the lack of solid scientific research conducted on them.”

It is noted that “[a]lthough the use of CBD has been theorized for a variety of other conditions from migraines and inflammatory conditions to depression and anxiety, only preclinical and pilot studies have been performed for any of these uses, and therefore there is little guidance for physicians if their patient is interested in trying CBD or hemp oils for these conditions.” Supra.

As for CBD and hemp oils’ potential for use in the treatment of chronic pain, in the most recent review on the topic in 2018, Donvito et al42 wrote that “an overwhelming body of convincing preclinical evidence indicates that cannabinoids produce antinociceptive effects in inflammatory and neuropathic rodent pain models.” Additionally, it has been reported that CBD may be able to treat addiction through reduced activation of the amygdala during negative emotional processing and has been found to reduce heroin-seeking behavior, likely through its modulation of dopamine and serotonin.43, 44, 85, 86 Cannabidiol therefore represents an attractive option in chronic pain treatment, particularly in the context of opioid abuse, not only because of its potential efficacy but also because of its limited misuse and diversion potential as well as safety profile.86 More research will be needed because these were pilot human studies with small sample sizes, but they represent potential future areas of cannabinoid use in the clinical treatment of pain relief and opioid abuse. Additionally, more reflection on the right political and industrial means to go about expanding access to CBD is needed in the context of controversial evidence supporting expanding access to medical marijuana as a pain control option.”

This Clinician’s Guide article clearly shows that there is currently a lack of significant positive research supporting CBD use. As research continues, we will begin to know more about CBD. It is important to note that medical treatment review looks toward “Evidence Based Studies.” Therefore, it is important that these be cited in requests. Also, functional improvement is also an important concept. This means that someone is actually getting better by the provision of the treatment.

What Is the Utilization Review Process?

Per the California Department of Industrial Relations, “[u]tilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers’ compensation claims administrators are required by law to have a[n] UR program. This program is used to decide whether or not to approve medical treatment recommended by a physician which must be based on the medical treatment guidelines.”

What is the Independent Review Process?

Per the California Department of Industrial Relations, “California’s workers’ compensation system uses a process called independent medical review (IMR) to resolve disputes about the medical treatment of injured employees. As of July 1, 2013, medical treatment disputes for all dates of injury will be resolved by physicians through an efficient process known as IMR, rather than through the often cumbersome and costly court system.

A request for medical treatment in the workers’ compensations system must go through a “utilization review” process to confirm that it is medically necessary before it is approved. If utilization review denies, delays or modifies a treating physician’s request for medical treatment because the treatment is not medically necessary, the injured employee can ask for a review of that decision through IMR.”

What Are Published IMR Decisions?

Since 2017, select IMR decisions have been published by LexisNexis. The “criteria for selection include discussion of relevant medical topics, including but not limited to prescription medicine, home health care, orthopedic issues, physical therapy, opioid prescriptions, etc.” These published decisions, however, are “not meant to be reflective of the proportion of all IMR decisions that overturn utilization review (UR) denials.”

In sum, these reported decisions are merely some select decisions and may not be representative of the totality of decisions. There may be some other CBD decisions of interest. These decisions discussed, however, will provide some insight as to how IMR views “requests for authorization” for CBD are addressed.

IMR Denial of a Prescription of Marinol

In IMR 83 Cal. Comp. Cases 1151, IMR Decision CM17-0187381, a request for authorization for the provision of Marinol was denied. It was noted that “ 2. Marinol 2.5mg #60 is not medically necessary and appropriate.” The UR Evidence cited was “Non-MTUS Official Disability Guidelines (ODG)” The IMR Evidence cited: was the ”MTUS Chronic Pain Medical Treatment 2016 Guidelines, Section(s): Cannabinoids.” The IMR Rationale was that “[t]he Chronic pain section of the MTUS states that cannabinoids are not recommended for pain. Cannabis use is associated with modest declines in cognitive performance, especially learning and recall, particularly when higher doses are used. Their use as analgesics can have undesirable CNS impact, and often dose optimization may not be achieved before the onset of excessive side effects. Nabilone, a synthetic cannabinoid, has been approved to treat severe nausea and emesis secondary to cancer chemotherapy, and may be useful for pain management and further trials for evaluation should be done. A preliminary study suggests that dronabinol, a synthetic THC, resulted in additional analgesia in patients taking opioids for chronic non cancer pain. Recent research shows that adolescents who use cannabis show an irreparable decline in their IQ. The American Society of Addiction Medicine has taken a position against medical marijuana because it is a dangerous and addictive drug. Also, cannabis is unstable and the drug should be subject to the same standards applying to other medications. The Chronic pain review states that for every disease and disorder for which it is recommended, there is a better FDA approved medication. The 2 main chemical ingredients of marijuana, delta9-tetrrahydrocannabinol [THC] and cannabidiol [CBD], appear to have different effects on behavior and the brain. Even a modest dose of THC, the ingredient responsible for the high of marijuana can cause psychotic symptoms, whereas CBD can be useful to treat psychosis. Regular use of marijuana in vulnerable persons is associated with increased risk of psychotic disorders such as schizophrenia. However, CBD had the opposite effect.

The provider desires to utilize Marinol, a cannabinoid medication, to treat anorexia. The MTUS states that cannabinoid medication are associated with decrease in cognition. It is noted to be both dangerous and addictive. The MTUS states that for every disease and disorder in which these drugs are recommended, there is a better FDA approved medication. It is felt that the request for Marinol 2.5 mg #60 is not medically necessary and appropriate.” Emphasis added.

IMR Denial of a Prescription for CBD

In IMR 83 Cal. Comp. Cases 1769, IMR Decision CM18-0062882, it was noted that “2. Cannabidiol (CBD) 5mg BID for 30 days (in the form of tablet / TSF in case of oil) is not medically necessary and appropriate.” The UR Evidence that was cited was “The guidelines used by the Claims Administrator are not clearly stated in the UR determination.” The IMR Evidence cited was “Non-MTUS Official Disability Guidelines, Pain Section/Cannabidiol Topic.” The IMR Rationale was “[t]he MTUS Guidelines do not address the use of Cannabidiol. Per the ODG, Cannabidiol is not recommended for pain. As of August 2014, 23 states and DC have enacted laws to legalize medical marijuana, but there are no quality studies supporting cannabinoid use, and there are serious risks. Restricted legal access to Schedule I drugs, such as marijuana, tends to hamper research in this area. It is also very hard to do controlled studies with a drug that is psychoactive because it is hard to blind these effects. At this time, it is difficult to justify advising patients to smoke street-grade marijuana, presuming that they will experience benefit, when they may also be harmed. One of the first dose-response studies of cannabis in humans has found that mid-range doses provided some pain relief, but high doses appeared to exacerbate pain. As Cannabidiol is not recommended by the guidelines, medical necessity has not been established. The request for Cannabidiol (CBD) 5mg BID for 30 days (in the form of tablet / TSF in case of oil) is not medically necessary.”[emphasis added]

Interesting Note: There is a Guideline for treating chronic pain with cannabinoids. A vague request of “street-grade marijuana” is not to be considered as sufficient.

IMR Denying Marijuana With CBD

In IMR Decision 83 Cal. Comp. Cases 1161, IMR Decision CM17-0220138, it was found that “1.  Marijuana with cannabidiol (CBD) dosage/quantity/frequency not specified is not medically necessary and appropriate.” The UR Evidence cited was “MTUS Chronic Pain Medical Treatment 2016 Guidelines, Section(s): Cannabinoids.” The IMR Evidence cited was “MTUS Chronic Pain Medical Treatment 2016 Guidelines, Section(s): Cannabinoids.” The IMR Rationale was “The claimant is a 32 year old female who sustained an industrial injury on September 29, 2012. She has a diagnosis of Lyme Disease. She is also noted to have chronic back pain and headaches and memory difficulty. This request is for “Marijuana with cannabidiol (CBD) dosage/quantity/frequency not specified.” MTUS guidelines state, “Not recommended for pain. A growing number of states (23 at the time of publication of this guideline) (NCSL, 2013) have approved the use of medical marijuana for the treatment of chronic pain, but there are no quality studies supporting cannabinoid use, and there are serious risks. Restricted legal access to Schedule I drugs, such as marijuana, tends to hamper research in this area. It is also very hard to do controlled studies with a drug that is psychoactive because it is hard to blind these effects. At this time it is difficult to justify advising patients to smoke street-grade marijuana, presuming that they will experience benefit, when they may also be harmed.” Regarding this claimant’s case, this claimant is well documented to have chronic pain. Cannabinoids are not currently recommended for the treatment of chronic pain due to a lack of supporting evidence based studies. Additionally, this request was submitted without specification of dosage/quantity/frequency. Likewise, the medical necessity of this request is not established.” [emphasis added]

Interesting Note: when this decision was made, there was a lack of quality studies concerning the employing Marijuana with CBD. This may change if there is further studies to support such a claim. These studies would have to be “evidence-based studies.”

IMR Decision Denying Request for CBD

In IMR Decision 83 Cal. Comp. Cases 1145, IMR Decision CM17-0187339, the IMR DECISION found “CBD 25mg #90 is not medically necessary and appropriate.” The UR Evidence cited was “MTUS Chronic Pain Medical Treatment 2016 Guidelines, Section(s): Cannabinoids, Medical foods.” The IMR Evidence cited was “MTUS Chronic Pain Medical Treatment 2016 Guidelines, Section(s): Cannabinoids. Non-MTUS Official Disability Guidelines, Pain, Cannabinoids.” The IMR Rationale was that “[t]his is a request for CBD [A cannabinoid] 25 mg #90.

This claimant was injured in November 2003. There was a complex regional pain syndrome, dysthymic disorder and lumbar radiculopathy status post fusion. As of July, there was an urgent visit due to severe pain. There was right knee and low back pain with radiation down the left leg. In August of this year the patient underwent a right total knee arthroplasty. The patient was doing well postoperatively. The patient stopped using a continuous passive motion machine because it caused his knee to swell. The patient had been on CBD since at least April of this year. Objective, functional improvement out of the cannabinoid use is not noted.

The MTUS Chronic Pain guidelines notes:

Not recommended for pain.

As of August 2014, 23 states and DC have enacted laws to legalize medical marijuana (Markoff, 2014), but there are no quality studies supporting cannabinoid use, and there are serious risks. Restricted legal access to Schedule I drugs, such as marijuana, tends to hamper research in this area. It is also very hard to do controlled studies with a drug that is psychoactive because it is hard to blind these effects. At this time, it is difficult to justify advising patients to smoke street-grade marijuana, presuming that they will experience benefit, when they may also be harmed. (Mackie, 2007) (Moskowitz, 2007) One of the first dose-response studies of cannabis in humans has found that mid-range doses provided some pain relief, but high doses appeared to exacerbate pain. (Wallace, 2007)

Cannabis use is associated with modest declines in cognitive performance, particularly learning and recall, especially at higher doses. The finding necessitates caution in the prescribing of medical marijuana for pain, especially in instances in which learning and memory are integral to a patient’s work and lifestyle. (Wilsey, 2008) Cannabinoids as analgesic agents can have an undesirable CNS impact, and, in many cases, dose optimization may not be realizable before onset of excessive side effects. (McCarberg, 2007) This study concluded that nabilone,  [**6] a synthetic cannabinoid approved for treatment of severe nausea and vomiting associated with cancer chemotherapy, may be a useful addition to pain management and should be further evaluated in randomized controlled trials. (Berlach, 2006) See also Nabilone (Cesamet®). The results of this preliminary study suggest that dronabinol, a synthetic THC, resulted in additional analgesia among patients taking opioids for chronic noncancer pain. (Narang, 2008) Adding a cannabinoid to opioid therapy may lead to greater pain relief at lower opioid doses, according to a new study, but more study is needed. (Abrams, 2011)

Given the incomplete verification of the effectiveness of CBD for pain management, the request is not medically necessary.” [emphasis added]

Interesting Note: In this matter, there was no evidence that the CBD was working. The Injured Worker had in fact been taking it and did not report any functional improvement. Functional Improvement is an important factor to justify continued use.

What are the Medical Treatment Utilization Schedule(MTUS) Chronic Pain Medical Treatment Guidelines for Cannabinoids?

As of 2016, the Guides provide that cannabinoids are “[n]ot recommended for pain. A growing number of states (23 at the time of publication of this guideline) (NCSL, 2013) have approved the use of medical marijuana for the treatment of chronic pain, but there are no quality studies supporting cannabinoid use, and there are serious risks. Restricted legal access to Schedule I drugs, such as marijuana, tends to hamper research in this area. It is also very hard to do controlled studies with a drug that is psychoactive because it is hard to blind these effects. At this time it is difficult to justify advising patients to smoke street-grade marijuana, presuming that they will experience benefit, when they may also be harmed. (Mackie, 2007) (Moskowitz, 2007) One of the first dose response studies of cannabis in humans has found that mid-range doses provided some pain relief, but high doses appeared to exacerbate pain. (Wallace, 2007) Cannabis use is associated with modest declines in cognitive performance, particularly learning and recall, especially at higher doses. The finding necessitates caution in the prescribing of medical marijuana for pain, especially in instances in which learning and memory are integral to a patient’s work and lifestyle. (Wilsey, 2008) Cannabinoids Chronic Pain Medical Treatment Guidelines MTUS – 8 C.C.R. § 9792.24.2 (July 28, 2016) 42 as analgesic agents can have an undesirable CNS impact, and, in many cases, dose optimization may not be realizable before onset of excessive side effects. (McCarberg, 2007) This study concluded that nabilone, a synthetic cannabinoid approved for treatment of severe nausea and vomiting associated with cancer chemotherapy, may be a useful addition to pain management and should be further evaluated in randomized controlled trials. (Berlach, 2006) See also Nabilone (Cesamet®). The results of this preliminary study suggest that dronabinol, a synthetic THC, resulted in additional analgesia among patients taking opioids for chronic noncancer pain. (Narang, 2008) Adding a cannabinoid to opioid therapy may lead to greater pain relief at lower opioid doses, according to a new study, but more study is needed. (Abrams, 2011) Recent research: Cannabis users who start using the drug as adolescents show an irreparable decline in IQ, with more persistent use linked to a greater decline, according to a New Zealand prospective study with over 1,000 patients. Adolescents are particularly vulnerable to developing cognitive impairment from cannabis and the drug, far from being harmless, as many teens and even adults believe, can have severe neurotoxic effects on the brain. Between the ages of 8 and 38 years, individuals who began using cannabis in adolescence and continued to use it for years thereafter lost an average of 8 IQ points, versus rising slightly in nonusers. Cessation of cannabis did not restore IQ among teen-onset cannabis users. Cannabis in New Zealand has a THC content of approximately 9%. (Meier, 2013) The American Society of Addiction Medicine (ASAM) has taken a position against medical marijuana, saying physicians should not recommend that patients use marijuana for medical purposes, because it is a dangerous, addictive drug and is not approved by the FDA. Cannabis is unstable and unpredictable and the drug should be subject to the same standards that apply to other medications. For every disease and disorder for which marijuana has been recommended, there is a better, FDA approved medication. (Gitlow, 2013) An RCT of smoked marijuana and oral dronabinol (tetrahydrocannabinol; THC) showed that both produce an analgesic effect, but this effect lasts longer with dronabinol, and it is less subject to abuse. Reported advantages to smoked marijuana are its faster onset and the relative ease with which doses can be managed, but it is not always safe or feasible to smoke marijuana. In addition to the cardiopulmonary risks this carries, smoking anything is not acceptable, such as on an airplane or at work. On the other hand, dronabinol is not approved for pain, only for chemotherapy-induced nausea and AIDS related weight loss. And, the recommended doses (2.5 mg to 5 mg) are much lower than those used in this study (10 mg to 20 mg) that seemed to have an effect on pain. (Cooper, 2013) The 2 main chemical ingredients in marijuana, Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD), can have very different effects on behavior and in the brain, this research shows. Even a single modest dose of THC, the main ingredient in marijuana that is responsible for the high, can induce psychotic symptoms, whereas CBD can be useful as a treatment for psychosis. Regular marijuana use in vulnerable individuals is associated with increased risk of developing psychotic disorders such as schizophrenia, in which patients lose contact with reality. CBD, on the other hand, had the opposite effect, increasing the response of the left caudate, an area of the brain weakened by THC. (Bhattacharyya, 2012) Long-term marijuana use has been linked to structural brain changes similar to those observed in schizophrenia patients, and they correlate with poorer working memory. Teens who smoked marijuana daily for about 3 years performed poorly on tests of working memory and had abnormal changes in brain structures akin to those seen in patients with schizophrenia, linking long-term use of marijuana to brain abnormalities that appear to last for at least a few years after people stop using it. (Smith, 2013) Epilepsy: Cannabinoids have therapeutic potential in epilepsy, but their efficacy and safety remain to be proven. There are no controlled trials demonstrating that marijuana is safe or effective for the treatment of epilepsy. On the other hand, there is evidence that marijuana may be harmful, particularly in the developing brain after regular use. Synthetic cannabinoids appear even more toxic. For patients who have exhausted conventional therapies, medical marijuana, with anecdotal evidence of seizure control, could be considered as an alternative therapy. Such use should be carefully monitored by a physician. (Robson, 2014)”

Note: You can see that this Guideline is cited within the IMR denials as well as the UR denials. A doctor needs to carefully review and explain their decision to employ CBD in light of these Guidelines. Further, if there are new Evidence Based Studies Post-2016, they may assist in getting the item approved.

What if I Need Advice?

If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. We have been helping people in Central and Southern California deal with their workers’ compensation cases for 27 years. Contact ustoday for more information.

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