More States Should Require Insurers to Pay for Medical Cannabis

By Paul Armentano, Guest Columnist

Should health insurance programs reimburse patients for their use of medical cannabis products? In a growing number of states, the courts are saying “yes.”

In the most recent example, a Pennsylvania Appellate Court ruled that workers’ compensation plans must cover cannabis-related expenditures when an employee uses it to recover from a workplace-related injury. The court ruled that employees in Pennsylvania possess “a statutory right” to be reimbursed for medical marijuana expenses that are reasonable and necessary to treat a work injury.  

“The MMA (Pennsylvania Medical Marijuana Act) specifically mandates that no medical marijuana patients be denied any rights for (the) lawful use of medical marijuana,” the Court said.

The Pennsylvania Court is not the first to issue an affirmative verdict in this matter. Courts in several states, including Connecticut, New Hampshire, New Jersey, New Mexico and New York, have provided similar opinions – determining that the denial of compensation claims would be antithetical to the legislatures’ express findings that cannabis is a state-legal therapy.

By contrast, courts in some other states, including Minnesota, have issued contradictory opinions – finding that it would be inappropriate for insurers to reimburse claimants for their use of a federally illegal substance. Federal law still classifies marijuana as a Schedule I controlled substance, placing it in the same legal category as heroin.

In most states, however, the law is largely silent on the issue. But don’t expect that to be the case for much longer. As scientific consensus and public attitudes surrounding the safety and efficacy of medical cannabis continue to evolve, the way insurers approach patients’ use of marijuana is likely to change too.

For example, lawmakers in Massachusetts recently introduced legislation explicitly providing that injured employees be reimbursed for their medical marijuana-related costs. In New York, lawmakers just advanced legislation, A. 4713, requiring public insurance plans to treat medical cannabis like any other medication. 

Thirty-eight states and the District of Columbia currently regulate the production and dispensing of cannabis for medical purposes. No state government has ever repealed or even rolled back these laws. That’s because these policies are widely accepted among both the public and among health professionals.

In fact, according to nationwide survey data recently compiled by the Centers for Disease Control and Prevention, over two-thirds of practicing physicians acknowledge the efficacy of medical cannabis and over one-quarter say that they have recommended it to their patients. 

Tens of millions of Americans are now using cannabis therapeutically. The number has doubled over the past decade, as peer-reviewed data that support the use of medical cannabis for the treatment of pain, multiple sclerosis, and other ailments has continued to grow. In many instances, patients are replacing their use of opioids, benzodiazepines and other prescription medications with cannabis because they find it more effective and with fewer adverse side effects. 

In short, most patients, most physicians, and most state laws view cannabis as a legitimate therapeutic option. Therefore, the millions of Americans who rely upon medical cannabis products ought to be afforded the same entitlements as those who use other conventional medications and therapies. Those privileges should include insurance-provided reimbursement for medical cannabis treatment.  

State legislators ought to see to it that this is a right provided for and protected in jurisdictions where medical marijuana is legally available under the law. 

Paul Armentano is the Deputy Director for NORML, the National Organization for the Reform of Marijuana Laws.

Overdoses Soar in 2 States Despite Fewer Rx Opioids

By Pat Anson, PNN Editor

New studies from two of the states hardest hit by the opioid crisis – Massachusetts and Pennsylvania -- are throwing a damper on recent speculation that drug overdoses may have peaked.  

Researchers at Boston Medical Center released a startling study that found nearly 5 percent of people over the age of 11 in Massachusetts have an opioid use disorder.

The Drug Enforcement Administration also admitted in a Joint Intelligence Report that reducing the supply of prescription opioids in Pennsylvania failed to reduce the state’s soaring overdose rate and may have even increased demand for counterfeit painkillers. Pennsylvania had 5,456 fatal overdoses in 2017, a 65% increase from 2015.  

“Implementation of legislation influencing prescription opioid prescribing has resulted in a decrease in availability; however, a corresponding decrease in demand is less certain,” the DEA report found.

“Practitioners may be offering non-opioid alternatives to pain management to their patients, but this is most likely due to increased scrutiny of prescribing habits, as well as legislated changes, not due to requests from patients seeking non-opioid products.”

Prescription opioids were involved in only 20% of Pennsylvania’s overdoses. Most of the deaths involve a combination of illicit drugs such fentanyl, heroin, cocaine and counterfeit medication.

“The increasing presence of counterfeit opioid CPDs (controlled prescription drugs) in Pennsylvania is an indicator of strong demand for opioid CPDs in the illicit market. Traffickers use substances such as heroin, fentanyl, and tramadol to create tablets that look like the opioid CPDs most commonly purchased on the street (e.g., oxycodone 30 milligram tablets). The tablets are often exact replicas with the shape, coloring, and markings consistent with authentic prescription medications,” the report found.

The DEA said heroin and fentanyl could be found in 97% of Pennsylvania’s counties and called the city of Philadelphia a “wholesale market” for illicit drugs from China and Mexico.

Opioid Use Disorder in Massachusetts

Illicit fentanyl is also blamed for a soaring number of fatal overdoses in Massachusetts, where researchers used a new method to estimate how many people have opioid use disorder (OUD).  

Instead of relying on insurance claims for addiction treatment, researchers used a database that links information from 16 state agencies on other forms of healthcare use. Researchers were then able to identify patients who have OUD and estimate those who have the disorder but aren't seeking treatment. Individuals with substance use disorders are often less likely to seek medical care or be insured. Many are also reluctant to admit they have a drug problem.  

"There are many people with opioid use disorder who do not encounter the health care system, which we know is a barrier to understanding the true impact of the opioid epidemic," said Joshua Barocas, MD, an infectious disease physician at Boston Medical Center, who was lead author of the study published in the American Journal of Public Health.

Barocas and his colleagues found the prevalence of opioid use disorder in Massachusetts rose from 2.72% in 2011 to 4.6% in 2015. People between the ages of 11 and 25 experienced the greatest increase in OUD – a demographic much younger than a typical chronic pain sufferer, who is usually middle aged.

In 2012, Massachusetts was one of the first states where insurers and healthcare providers took steps to reduce the supply of prescription opioids – measures that have yet to have any meaningful impact on the state’s overdose rate.  

MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

Massachusetts was also one of the first states to use toxicology screens from coroners and medical examiners to get a more accurate assessment of the drugs involved in overdoses.

According to the most recent report from the first quarter of 2018, nearly 90% of Massachusetts overdoses involve fentanyl, 43% percent involve cocaine, 42% involve benzodiazepines and 34% involve heroin. Prescription opioids were involved in only about 20% of the Massachusetts overdoses, the same rate as Pennsylvania.

Preliminary estimates released by the CDC last week show a modest 2.3% nationwide decline in opioid overdoses from September 2017 to March 2018. Over 48,000 people died from opioid overdoses during that period, with most of those deaths involving illicit fentanyl, heroin and other street drugs.

A Pained Life: My Medical Marijuana Experiment

By Carol Levy, Columnist

I just got my medical marijuana ID card.

I never tried marijuana as a teen. The one time someone gave me a sample of their medical marijuana, it made me feel terrible, as though I had taken a large dose of opioid medication -- fuzzy mouthed and cloudy brained.

It made me leery, but once it became legal in Pennsylvania there was no way I would not try it.

First thing you have to do is find a state certified doctor. There are only a few, so you are pretty much stuck with whomever is nearby. Before I could see the doctor, I had to give a urine sample. I have never been asked before to do this. All patients are required to – so they can weed out those who may be abusers.

That does not make it any less uncomfortable. I felt, as many do, as though I had been convicted of something and now had to prove my innocence.

The expense seems to be created to make it very hard to access. I am on a fixed disability income. The first visit with the doctor cost $125. This fee was required at the time of the appointment. The doctor told me that I would have to come in once a month for the first six months of use. This would cost $50 per visit, again payable at the time of the appointment.

Next you must send in $50 to get the state ID card.

Once that arrived, I had to find a dispensary. There was one about a half an hour from my home.  I called first to make sure they were open. They were very nice, but the feeling of doing something untoward was hard to ignore. I watch Law and Order. The drug dealers invariable say they have “product.”

“Are you open yet?” I asked the receptionist at the dispensary. “Yes. But we are out of product at this time.” Product? But this is supposed to be a legitimate medical medication, not something clandestine.

Product? But this is supposed to be a legitimate medical medication, not something clandestine.

I went as soon as they had “product.” When I arrived, another person was waiting outside at the entrance, where there was a security guard. He looked at me and said, “Sorry you have to wait outside. We're only allowed to let one person in at a time.”

A security guard? I get that. You never know who might try to worm their way in. But I had the ID card. Why did we have to wait outside before each person was cleared?

Inside was lovely. Nice personnel, a waterfall, plants, real wood tables, coffee, tea and cookies waiting for us on a sideboard. It almost puts you off balance. A security guard at the door. Only one customer inside a time. Is something nefarious going on? But once inside it is warm, embracing and inviting.

I was escorted to a private room, where I spoke with the dispensary pharmacist. She explained how the medication works and what would be best for me, at least to start with. After the consultation I went back to the dispensary room.

The cost was less than I expected. Again, the fee was required at the time of purchase. It was cash only, no checks and no credit cards. Just like with a drug dealer. Apparently, banks are not able to accept checks or credit card charges because of the federal prohibition against marijuana.

Aside from feeling like I was doing something wrong, because of the urine test, security guard, “product” and cash up front, I am glad I tried it. The product I bought has not helped my pain, but the good thing is there are other concentrates and combinations I can try.

It is ironic that there is this war on opioids, yet marijuana remains a Schedule I controlled substance, making it very hard for researchers to get permission to study it. Studies that are available show it helps many disorders, including some forms of chronic pain  If the government truly wanted to help us get off opioids, they should make marijuana readily available for study and for patients..

Then, for many of us, there would be one more avenue of hope.

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.” Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

How Stem Cells Can Reverse Opioid Tolerance

By A. Rahman Ford, Columnist

On January 10, Pennsylvania Governor Tom Wolf declared a disaster emergency to fight the scourge of heroin and opioid abuse in his state, which has one of the highest overdose rates in the country.

“Pennsylvania’s opioid crisis impacts all areas of the state – including urban, suburban and rural communities and all ages including both young people and older Pennsylvanians – and is unprejudiced in its reach and devastation,” the declaration says. Virginia and other states have issued similar declarations.

Gov. Wolf’s effort comes months after President Trump declared the opioid crisis a national public health emergency and the president’s opioid commission released its final report, recommending more federal funding for addiction treatment, further restrictions on opioid prescribing, and the development of new non-opioid painkillers.

However, the commission’s report spent little time discussing an issue that is key to confronting the problems of opioid addiction and overdose – opioid tolerance.  “Tolerance” is defined as a decrease in effect following repeated or prolonged use of a drug, which can result in the need for higher and higher doses to achieve the same result.  For patients suffering from acute or chronic pain, this means that they need more pills to alleviate their pain. 

Tolerance can lead to a dangerous cascade of consequences. According to researchers at the National Institutes of Health, “the repeated administration of any opioid  almost inevitably results in the development of tolerance and physical dependence.” 

Although not all who become opioid tolerant become addicted, the World Health Organization asserts that people dependent on opioids are the group most likely to suffer an overdose. Given the seriousness of the problem, researchers have been looking for a way to prevent opioid tolerance and keep opioid users in a state of analgesia.  In that quest, some have found an answer in stem cells. 

In a recent study, Dr. Jianguo Cheng and scientists at the Cleveland Clinic and the Affiliated Hospital of Qingdao University in China hypothesized that mesenchymal stem cells (MSCs) could prevent or reverse opioid tolerance and opioid-induced hyperalgesia because of their profound anti-inflammatory properties. 

To prove their hypothesis, they induced opioid tolerance in laboratory mice and rats by injecting them with morphine for four weeks.  Astoundingly, after administering MSC therapy to the opioid-tolerant rodents, tolerance was reversed within as little as 2 days. The injections appeared to be completely safe.  All of the rodents showed normal movement, food and fluid intake, and body weight gain.  Their livers, kidneys and other major organs continued to function normally.

The authors concluded that MSCs have “enormous potential to profoundly impact clinical practice and improve opioid efficacy and safety.”  Their study builds on previous research that found MSC therapy “does not produce unwanted side effects and is well tolerated and safe.”  Rejection of the stem cells was not an issue because MSCs are immune-privileged.

America’s opioid problem is as destructive as ever.  If the states and the president’s commission truly seek novel, innovative and readily-implementable solutions to the opioid crisis, tolerance is a critical target and stem cell therapy may be a viable solution.  Patients in pain need solutions now.

A. Rahman Ford, PhD, is a lawyer and research professional. He is a graduate of Rutgers University and the Howard University School of Law, where he served as Editor-in-Chief of the Howard Law Journal. He earned his PhD at the University of Pennsylvania.

Rahman lives with chronic inflammation in his digestive tract and is unable to eat solid food. He has received stem cell treatment in China.  

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Pennsylvania Overdoses Soar, But Not from Painkillers

By Pat Anson, Editor

A new study by the U.S. Drug Enforcement Agency underscores the changing nature of the nation’s overdose crisis and the diminishing role played by opioid painkillers.

In an analysis of 4,642 drug related overdose deaths in Pennsylvania last year, the DEA found that over half of those deaths (52%) involved fentanyl or fentanyl related substances. In many cases, toxicology reports found multiple drugs in the bodies of those who died.

Heroin was the second most frequently identified drug (45%), followed by benzodiazepines (33%), a class of anti-anxiety medication, and cocaine (27%).  

Prescription opioid medication was the fifth most common type of drug found. Painkillers were involved in 25 percent of the Pennsylvania overdoses, while ethanol (alcohol) was ranked 6th at nearly 20 percent.

Overall, the number of overdoses in the state was 37 percent higher than in 2015, according to the DEA report. Pennsylvania's overdose rate was 36.5 deaths per 100,000 people, twice the national average.

Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine, and is available legally by prescription to treat severe chronic pain. In recent years however, illicit fentanyl has become a deadly scourge across the U.S. and Canada, where it is often mixed with heroin or used in counterfeit painkillers. Illicit fentanyl is believed to be involved in the vast majority of the fentanyl-related deaths in Pennsylvania.    

DRUGS INVOLVED IN PENNSYLVANIA OVERDOSES (2016)

SOURCE: DEA

The DEA report was prepared in conjunction with the University of Pittsburgh’s School of Pharmacy Program Evaluation Research Unit (PERU). Unlike other reports on overdose deaths, the PERU analysis excluded suicides and included toxicology reports, a methodology that is considered more reliable than the ICD codes traditionally used by the CDC and other federal agencies to determine the drugs involved in overdoses.

“The expertise of PERU in the analysis and interpretation of public health data, which is outside of the traditional scope of law enforcement intelligence analysis, resulted in the creation of this comprehensive report that can be used to implement effective strategies to address the overdose crisis,” said Gary Tuggle, Special Agent-in-Charge of DEA’s Philadelphia Field Division.

Perhaps the most striking aspect of the report was the presence of anti-anxiety drugs in so many of the overdoses, and the smaller role played by prescription opioids. Toxicology reports found opioid medication in 1,181 of the overdose deaths, with oxycodone involved in most of them.

Still, more Pennsylvanians died with Xanax (alprazolam) in their system than oxycodone (846 vs. 679). And the anti-anxiety drugs clonazepam (Klonopin), diazepam (Valium), oxazepam and lorazepam (Ativan) were also involved in hundreds of overdoses.

The existence of valid prescriptions was not analyzed in the DEA report, which did not assess whether medications were diverted or obtained fraudulently.

In 2016, approximately 13 people died of a drug-related overdose in Pennsylvania each day. 

Although painkillers were not involved in most of those deaths, efforts at fighting the overdose crisis are still largely focused on reducing access to legally prescribed opioid medication.

Last month, Independence Blue Cross, the largest health insurer in the Philadelphia area, said it would limit the prescribing of opioids in its network to just five days for acute pain. Independence already limits the quantity of opioids that physicians can prescribe. The company claims that policy has reduced "inappropriate" opioid use by its members by nearly 30 percent.

Deaths from prescription opioids in Philadelphia started declining in 2013, a year before Independence started limiting access to painkillers.

A Pained Life: Pennsylvania’s Opioid Law Ignores Us

By Carol Levy, Columnist

Recently I received an email update from my state senator. He wanted to let me know about  efforts in the Pennsylvania legislature to address the "opiate crisis.”

I have written before that I believe some of what has been proposed throughout the country makes sense, a prescription monitoring database, for instance. Much of what is being considered in Pennsylvania also makes sense to me:

• Labels on opioid prescription bottles warning of their addictive nature
• Written consent from parents in order for their children to receive prescription opioids
• A safe opioid prescribing curriculum in Pennsylvania’s medical schools to better educate future doctors about proper opioid prescribing practices
• Insurance plans to provide access and share the cost of abuse-deterrent opioids
• Mandatory reporting of all heroin and opioid overdoses where naloxone was administered
• Implementation of opioid prescribing guidelines developed by a state task force
• Healthcare providers to discuss the risks of opioid addiction and overdose with patients and to receive written consent from a patient before prescribing them

But there are two provisions of the law I find very concerning, one being a requirement that coroners and medical examiners report the death of any person resulting from a drug overdose.

One of the issues surrounding the reporting of deaths arising from opioids is that other medical conditions, such as the use of alcohol or illegal drugs, are often ignored and the death is counted as an opioid overdose.

That is not only poor research, but gives a false picture of what is the effectual cause of the death. Ignoring those other factors means ignoring other issues that the law needs to be addressing.

The second issue I have with the law is alarming: limiting the prescription of opioids to seven days. This ignores chronic pain sufferers and the long-term need for opioid medication, which is often our only or last available treatment.

The change we saw, in many states, was requiring a visit to the doctor for a new prescription every 6 months to needing one every 3 months. That was bad enough.  I recall needing to go only once a year, but that was in the 1970's and 80's.

If you have trouble moving, tolerating the weather or other issues, being forced to go see the doctor every three months is an issue. In addition, co-pays rise, insurance companies pay more for extra visits and may raise your rates as a result, and the cost to the state and federal government through increased Medicaid/Medicare billing soars.

I decided to research this. I found that New York State has imposed a 7-day limit on prescriptions, but the law contains exceptions for those with chronic pain or who are receiving hospice or palliative care for life threatening illnesses. Unfortunately, Pennsylvania legislators have decided to ignore those in chronic pain. The bill includes exceptions only for hospice and patients receiving palliative care.

The government has acted as doctor in many other instances; such as women's health care, declaring some drugs illegal, and allowing certain medications and procedures while denying others. I understand that. There needs to be limitations and oversight.

But this is not oversight or limitation.  This is a frenzied and illogical response to an “epidemic” that is not caused or perpetuated by those of us with chronic pain, but is nevertheless being taken out on us.

Politicians who point at us and claim they are handling the crisis are ignoring the real culprits, which is those who abuse drugs illegally.

The question has to be asked. 

How in the world does this law address the opioid epidemic, as opposed to merely blaming and punishing those with chronic pain?

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.” 

Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.