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Medical Marijuana in Cancer Treatment: No Standards of Care, and So Far, No Coverage

Samantha DiGrande
Over the past decade, both recreational and medical marijuana use in the United States has grown tremendously. However, disputes surrounding the legal and ethical implications, safe administration, dispensing, health consequences, and therapeutic indications– albeit based on very limited clinical data– related to its usage abound. 
Many questions remain unanswered for medical marijuana in terms of insurance coverage, such as:
  • Which conditions would be covered? Do health plans see a difference between covering medical marijuana to treat terminal cancer and covering it to treat chronic back pain?
  • Will coverage extend to patients in taxpayer-funded programs, such as Medicare or Medicaid?
  • Will state-level plans, such as the Blues, cover it?
In a recent case in New Jersey, McNeary v. Township of Freehold, a worker’s compensation judge ruled for at least the second time in the state that an injured worker was entitled to coverage for medical marijuana.13 Steven McNeary, a patient with muscular spasticity, sought a court order to require the insurance carrier for Freehold Township to pay for his medical marijuana treatment. The insurer refused, arguing that the Controlled Substances Act’s (CSA) criminalization of marijuana supersedes state-level laws. New Jersey Workers’ Compensation Judge Lionel Simon disagreed, ruling that New Jersey’s medical marijuana statute is not pre-empted by federal law. In his decision, Simon stated that the CSA and the New Jersey Medical Marijuana Act both seek to deter the distribution and use of illicit drugs.

“I honestly don’t feel in my heart of hearts that this is a conflict. Certainly, I don’t understand how a carrier, who will never possess, never distribute, never intend to distribute these products, who will [merely] sign a check into an attorney’s trust account, is in any way complicit with the distribution of illicit narcotics,” Simon said.

He cited concerns that McNeary could instead become addicted to opioids should he not be able to obtain medical marijuana. He explained that the court is aware of the “explosion” of narcotics in the United States and the related deaths and addiction rates that follow. “I believe, and I think science supports this, that medical marijuana is safer, it’s less addictive, it is better for the treatment of pain,” he said.

However, the Maine Supreme Court reversed a lower court ruling to compel an insurer to pay for medical marijuana, citing the conflict with federal law.14

Evolving Law and Patient Access

The landscape and conversation around marijuana and its potential use for a multitude of treatments in many disease states is evolving in the United States. In 2018, more states have laws on the books that allow patients access to marijuana in some form than those that do not. While the future of such products remains uncertain, the FDA and the WHO have taken steps to further increase patient access.

WHO recently launched a review of the current international classification of marijuana, THC, CBD, and other related compounds and requested input from member nations.15 The FDA has also requested that the public submit comments that can inform the country’s position before provides its opinion to the WHO.16 This public comment period has since closed. While the findings of the WHO’s review were not released at the time of publication, the potential reclassification of marijuana could have implica- tions both at the state and federal levels.

In addition, a panel in the US House of Representa- tives that reviews federal drug enforcement approved a bill on September 13 that will require the Department of Justice and Attorney General Jeff Sessions

to begin issuing more licenses to grow marijuana for research. To date, 1 farm at the University of Mississippi can supply cannabis for research purposes.17 This bill would increase the number of locations able to legally cultivate marijuana for research purposes to 3.

Prior to the vote, a debate broke out regarding a provision of the legislation that prevents anyone with a “conviction for a felony or drug-related misdemeanor”18 from being affiliated with any kind of cannabis research cultivation. While legislation supporters sought to amend the bill to remove this distinction, House Judiciary Chairman Bob Goodlatte (R-VA) shot down a compromise that would have done away with the restrictions on people with drug misdemeanors while maintaining the ban on those with felony convictions. Instead, he made a commitment to work to revise the restrictions before the bill goes to the House floor and indicated that he would “probably not object” to a carve-out designation for individuals with drug possession convictions.

“While there are many varying opinions on the issue of marijuana, one thing we can all agree on is that we need qualified researchers to study the science to determine if there are any potential medicinal benefits to chemicals derived from cannabis,” said Goodlatte in a statement.19

Without insurance, cost considerations keep patients from using vapes, which Medvedovsky said are safer than smoking. Vapes cost $200 to $400, and a typical medical marijuana program will cost $300 to $400 to join and $150 to $200 per month after that for product. 

More patients are asking for medical marijuana as the stigma around it has waned, Medvedovsky said. “By the time I see them, most patients are excited and ready to start. Many people are desperate for relief and will do anything to feel better, especially when dealing with the end of life.”

REFERENCES
  1. Mauro P, Carliner H, Brown Q, et al. Age differences in daily and nondaily cannabis use in the United States, 2002-2014. J Stud Alcohol Drugs. 2018;79(3):423-431. doi: 10.15288/jsad.2018.79.423.
  2. World Health Organization. Management of substance abuse: cannabis. who.int/substance_abuse/facts/cannabis/en. Published 2016. Accessed August 28, 2018.
  3. United States Drug Enforcement Administration. Drug scheduling. DEA website. dea.gov/drug-scheduling. Accessed September 14, 2018.
  4. Governing. State marijuana laws in 2018. Governing website. governing. com/gov-data/safety-justice/state-marijuana-laws-map-medical-recreational.html. Published March 30, 2018. Accessed September 14, 2018.
  5. Oberbarnscheidt T, Miller N. Pharmacology of marijuana. J Addict Res Ther. 2016;S11:012. omicsonline.org/peer-reviewed/ppharmacology-of-marijuanap-84733.html. Accessed September 8, 2018.
  6. Abrams D. Integrating cannabis into clinical cancer care. Curr Oncol. 2016;23(2):S8-S14. doi: 10.3747/co.23.3099.
  7. ACS. Marijuana and cancer. ACS website. cancer.org/treatment/treatments-and-side-effects/complementary-and-alternative-medicine/ marijuana-and-cancer.html. Published March 4, 2015. Updated March 16, 2017. Accessed September 14, 2018.
  8. NCI Cancer Statistics. NCI website. cancer.gov/about-cancer/understanding/statistics. Updated April 27, 2018. Accessed September 14, 2018.
  9. Braun I, Wright A, Peteet J, et al. Medical oncologists’ beliefs, practices, and knowledge regarding marijuana used therapeutically: a nationally representative survey study [published online July 25, 2018]. J Clin Oncol. doi.org/10.1200/JCO.2017.76.1221
  10. Paice JA, Portenoy R, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2016:34(27):3325-3345. doi: 10.1200/ JCO.2016.68.5206.
  11. FDA approves first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy [press release]. Silver Spring, MD: FDA; June 25, 2018. www.fda.gov/NewsEvents/Newsroom/ PressAnnouncements/ucm611046.htm?ref=hvper.com
  12. FDA. FDA and marijuana. FDA website. www.fda.gov/NewsEvents/ PublicHealthFocus/ucm421163.htm. Updated June 25, 2018. Accessed September 15, 2018.
  13. Mckillop D. NJ workers’ compensation judge rules claimant entitled to insurance coverage for medical marijuana. Scarinci Hollenbeck website. scarincihollenbeck.com/law-firm-insights/cannabis-law/insurance-coverage-for-medical-marijuana/. Published August 1, 2018. Accessed September 8, 2018.
  14. Gaetan H. Bourgoin v. Twin Rivers Paper Company, LLC, et al, 2018 ME 77, A3d courts.maine.gov/opinions_orders/supreme/lawcourt/2018/18me077.pdf.
  15. Angell T. Feds want input on marijuana reclassification. Forbes. April 6, 2018. forbes.com/sites/tomangell/2018/04/06/feds-want-input-on-marijuana-reclassification/#4e35da7d13e2. Accessed September 18, 2018.
  16. Office of the Federal Register. International drug scheduling; single convention on narcotic drugs; cannabis plant and resin; extracts and tinc- tures of cannabis; delta-9-tetrahydrocannabinol; stereoisomers of tetra- hydrocannabinol; cannabidiol, request for comments. Federal Register.April 9, 2018. federalregister.gov/documents/2018/04/09/2018-07225/ international-drug-scheduling-convention-on-psychotropic-substances-single-convention-on-narcotic. Accessed September 18, 2018.
  17. Vote in Congress could open up US cannabis research. The Pharma Letter website. thepharmaletter.com/article/vote-in-congress-could- open-up-us-cannabis-research. Published September 11, 2018. Accessed September 13, 2018.
  18. Angell T. Marijuana bill approved by Congressional committee, despite rug conviction restriction dispute. Forbes. September 13, 2018. forbes. com/sites/tomangell/2018/09/13/marijuana-bill-approved-by-con- gressional-committee-despite-drug-conviction-restriction-dispute/#3b9176733482. Accessed September 15, 2018.
  19. Judiciary Committee approves bipartisan bill to improve medical marijuana research [press release]. Washington, DC: House of Representatives; September 13, 2018. house.gov/press-release/judiciary-commit- tee-approves-bipartisan-bill-to-improve-medical-marijuana-research/. Accessed September 15, 2018.
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