51
Clearing the Smoke: Workplace Safety and Medical Marijuana July 24, 2019
Clearing the Smoke: Workplace Safety and Medical Marijuana
July 24, 2019
Speakers
Robert Kruse, MD, MPH
Joanne Harbert, ARNP
MercyOne Occupational Health
Course Objectives:
• Review and describe the emerging science of medical cannabis from a medical/biological and historical perspective
• Recognize and describe the current implementation of the Medical Cannabidiol Program in Iowa
• Identify three ways medical cannabis may impact policies and procedures in a Drug-Free Workplace
National Conference of State Legislatures. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx
Morbidity and Mortality Weekly Report (MMWR) Summary
1. Colorado Department of Public Health and Environment (CDPHE, 2017) showed one in eight adult state residents aged ≥18 years currently used cannabis in 2014 (13.6%) and 2015 (13.4%) note: age of sales in CO = 21
2. During 2014 and 2015, 14.6% of 10,169 Colorado workers surveyed reported current cannabis use, with the highest reported prevalenceamong workers in the Accommodation and Food Services industry (30.1%) and Food Preparation and Serving (32.2%) occupations.
Best Practices from Morbidity and Mortality Weekly Report
1. Motor vehicle crashes are the leading cause of work-related deaths in the United States (Bureau of Labor Statistics. Fatal occupational injuries by industry and event or exposure, 2016).
2. Safety-sensitive industries that have higher prevalence of self-reported cannabis use could consider evaluating current drug testing programs, drug panels used for preemployment screening, and testing frequencies, and develop policies regarding tolerance of drug use.
Cannabinoids
1. Class of chemical compounds that interact with cannabinoid receptors
2. Endocannabinoids • Produced by human body (Zou and Kumar, 2018)
• Anandamide and 2-arachidonylglycerol
3. Phytocannabinoids• Plant derived (Hanus et al., 2016)
• Includes Delta-9-THC, CBD
Active Ingredients in Whole Plant Cannabis
1. Delta-9-tetrahydrocannabinol (THC) is the main psychoactive ingredient in cannabis
2. Plus: • 60-70 other cannabinoids (known as phytocannabinoids i.e. THC, CBD,
CBN, CBC, CBG, etc….)
• 120 terpenoids (i.e. pinene, myrcene, linalool and limonene) 21 flavonoids
• Flavonoids: color of plant, anti-oxidants, anti-inflammatory?
• 11 plant sterols (in the seed)
• 22 fatty acids
Synthetic Cannabinoids
1. Dronabinol (Marinol)
2. THC + CBD (Sativex)
3. CBD (Epidiolex)
Cannabinoid Pharmacology
Acute psychoactive effects:• Euphoria
• Relaxation/Stress Reduction
• Enhanced Perception
Increased Creativity/Abstract Thinking/Sensuality
Illusions/Pseudohallucinations
Time Distortion
Ataxia
Anxiety, Paranoia, Illusions, Depersonalization
Cannabis and Impairment
Cognitive effects:
• Concentration and sustained attention/vigilance
• Fatigue, sleepiness, lethargy, memory problems
• Reaction time
• Difficulty in thinking and problem-solving
• Difficulty in registering, processing, and using information
Cannabis and Impairment
Performance effects:
• Attention- lack of concentration
• Arousal
• Weaving
• Impulsivity
• Reaction Time
• Impaired learning and memory
Physiological Manifestations
1. Conjunctival injection
2. Increase heart rate above base line
3. Dry mouth/throat, increased appetite
4. Vasodilatation
5. Decreased ocular reaction to light
Epidemiology
1. 2.5% of the world’s population consumes cannabis (annual prevalence, WHO, 2016)
• 0.2% consume cocaine
• 0.2% consume opiates
2. 9.5% of Americans use cannabis (NIH)
• North America reports a much higher usage rate (WHO, 2016)
3. 13.6% percent of Colorado adults use cannabis
• (Monitoring Health Concerns Related to Marijuana in Colorado: 2016 report)
Drug test specimen types
Urine
• Easily obtained in large(r) volume and typically not observed collection
• Detection window (THCCOOH) days to weeks (greatly impacted by usage pattern)
• Not correlated with effects/impairment
Oral fluid
• Easily obtained/observed collection (most non-invasive of common specimen types)
• Detection window (THC), 1-2 days
• Not well correlated with effects/impairment • Few controlled studies of THC disposition
• Measures residual THC in oral fluid mucosa • No THC in oral fluid of patients treated with
dronabinol
Hair
• More specialized collection/observed
• Detects pattern of repetitive use (THCCOOH)
• THC at higher concentration (environmental exposure?)
• Not correlated with effects/impairment
Blood
• Specialized/invasive collection/observed
• Best correlation with effects/impairment
• Few “per se” levels and vary by state
Cannabis: It’s Complicated. National Safety Council Symposium Jun 25-26 2019.
Passive Inhalation Study
1. Six active smokers, six non-smokers per session
2. Enclosed room with air flow control, Plexiglas walls for observation
3. Smokers smoked as much as they wanted to without limitation in a “social-like” setting
4. Three exposure sessions:• Session 1: smokers each smoke ad lib MJ cigarettes (5.3% THC) for one
hour, no active air flow
• Session 2: smokers each smoke ad lib MJ cigarettes (11.3% THC) for one hour, no active air flow
• Session 3: smokers each smoke MJ ad lib MJ cigarettes (11.3% THC) for one hour, with active air flow simulating room air conditioning
Passive Inhalation Sessions
Session 1: 5.3% MJ, No Ventilation Session 2: 11.3% MJ, No Ventilation
Session 3: 11.3% MJ, With Ventilation
Passive Study: Conclusions
Extreme passive smoking is a form of drug administration
• Estimated that non-smokers inhaled 5-15% of the amount of THC that smokers did
• Could test positive at lower cutoffs
Urine Oral Fluid Blood
Multiple positives
confirmed at 20
ng/ml cutoff, but
none at 50 ng/ml
Confirmed
positives up to ~3
hours
Up to ~2 ng/ml
DOT Drug and Alcohol Testing
Marijuana Use is Prohibited for DOT-Covered Employees and is Tested For in DOT Drug Tests:
1. Pre-Employment
2. Post-Accident
3. Reasonable Suspicion
4. Random
5. Return To Duty/Follow-Up
Federal Enforcement of the Controlled Substances Act
• Marijuana is still illegal under federal law (Schedule I drug)
• 2016 DEA denied petition to reschedule; agreed to increase access for research
• Aug. 2018: DEA announced proposal to significantly increase amount permitted for research in 2019
• Medical Marijuana is NOT a legitimate medical explanation under U.S. DOT drug testing
House File 524 – Iowa Code 124E Iowa Medical Cannabidiol Act
A person may knowingly or intentionally:
• recommend,
• possess,
• use,
• dispense,
• deliver,
• transport, or
• administer cannabidiol
if the recommendation, possession, use, dispensing, delivery, transporting, or administering is in accordance with the provisions of Iowa Code Chapter 124E and 641 Iowa Administrative Code 154.
HF 524 was enacted on 5/12/2017
Medical Cannabidiol
Defined as:
• any pharmaceutical-grade cannabinoid found in the plant Cannabis sativa L. or Cannabis indica; or
• any other preparation thereof that has a tetrahydrocannabinol (THC) level of no more than 3%; and
• is delivered in a form recommended by the Medical Cannabidiol Board, approved by the Board of Medicine, and put into administrative rule by the Iowa State Board of Health
Who is a Patient?
A person who has one or more of the qualifying debilitating medical conditions and:
• Is of any age;
• Is a permanent resident of Iowa;
• Has not been convicted of a disqualifying felony offense (related to possession, use, or distribution of a controlled substance)
* Minor patients will not be given a patient registry number, but will be tied to their designated primary caregiver
Qualifying Debilitating Medical Conditions
1. Cancer, if the underlying condition or treatment produces one or more of the following:
• Severe or chronic pain• Nausea or severe vomiting• Cachexia or severe wasting
2. Multiple Sclerosis with severe and persistent muscle spasms
3. Seizures, including those characteristic of epilepsy
4. HIV/AIDS as defined in Iowa Code Section 141A.1
5. Crohn’s Disease
6. Amyotrophic Lateral Sclerosis
7. Ulcerative colitis
8. Parkinson’s disease
9. Severe, pediatric autism with aggressive or self-injurious behaviors
Qualifying Debilitating Medical Conditions
10. Any terminal illness, with a probable life expectancy of under one year, if the illness or its treatment produces one or more of the following:
• Severe or chronic pain
• Nausea or severe vomiting
• Cachexia or severe wasting
11. Untreatable pain - any pain whose cause cannot be removed and, according to generally accepted medical practice, the full range of pain management modalities appropriate for the patient has been used without adequate result or with intolerable side effects
Is a special certificate or license needed to certify a patient’s condition?
• Patients and primary caregivers must obtain the certification of the patient’s qualifying debilitating medical condition for the application process.
• “Health care practitioner” means individuals licensed under Chapter 148 to practice medicine and surgery or osteopathic medicine and surgery in Iowa.
• “Health care practitioner” shall not include a physician assistant licensed under Chapter 148C or an advanced registered nurse practitioner licensed pursuant to Chapter 152 or 152E.
A health practitioner does NOT:
• Prescribe;• Recommend;• Set dosing recommendations
A health practitioner DOES:
1. Certify that he/she has a relationship with the patient and is involved in the patient’s care;
2. Certify that patient has a qualifying debilitating condition;
3. Provide educational material to the patient as provided by the department;
4. Agree to recertify the patient annually to ensure that program criteria are met;
5. Agree to provide information to the department.
Forms and Quantities
Medical Cannabidiol forms approved (154.14(2)):
1. Oral forms, including but not limited to:
a) Tabletsb) Capsulesc) Liquidsd) Tincturese) Sub-lingual forms
2. Topical forms, including but not limited to:
a) Gels
b) Ointments, cream, or lotions
c) Transdermal patches
3. Nebulizable Inhaled forms4. Suppositories, including but not limited to:
a) Rectal
b) Vaginal
*No forms may be edible (i.e., contained in food) or smoked
Strengths
Employment Protection Laws
• Positive Drug Test Language• 4 states have positive drug test language (e.g., employer may not discriminate
based upon a “patient’s positive drug test for marijuana components or metabolites”) AZ, DE, MN, OK
• Safety Sensitive Positions• 2 states include safety-sensitive positions that may not be performed with
specified amount of active THC in blood; limits vary PA: 10 ng/mL WV: 3 ng/mL
• Exceptions• Most laws contain exceptions (e.g., not required to accommodate use at
workplace, working under influence)
Medical Marijuana: Included as alternative/substitute for prescription opioids and/or for opioid abuse and addiction treatment
2018-2019 Passed legislation
• Colorado
• Illinois
• Pennsylvania
• New Jersey
• New Mexico
• New York
• Utah
2019 Proposed
• Hawaii
• Maryland
• New Hampshire
• North Dakota
• Ohio
• Rhode Island
Iowa Code Section 730.5
An employer that has established a policy and testing program under Section 730.5 of the Iowa Code may test and take
actions against current and prospective employees who have a positive drug test because of their legal use of medical
marijuana
Suspected Impairment Best Practices
1. Evaluation of impaired employee at Occupational medicine clinic or Emergency Dept.• Physical Exam- clinical impairment
• Breath alcohol test
• Urine drug test
2. Employee placed on administrative leave until results return
Drug-free workplace program
Develop and implement chemical impairment policy
• Evaluated by HR Dept
• Consulted with legal, health and safety, and occupational health depts
Content for Developing Workplace Policy for Medical Marijuana
• Whether the policy covers searches and extent
• Observable and measurable behaviors indicative of unsafe job performance
• Referral Mechanism for unsafe work performance
• Purpose/intent of program
• Employees covered by policy
• When policy applies
• Prohibited behavior
• Whether employees are required to inform their supervisor of medical marijuana prescription or drug-related convictions
Content for Developing Workplace Policy for Medical Marijuana-II
• Measures to protect employee confidentiality
• Measures for policy enforcement
• Steps to communicate policy
• Assistance available to treat substance use or abuse
• Requirements for drug testing with input from MRO
• Consequences for policy violation
• Whether return-to-work agreements are needed after an absence related to substance abuse
Conclusions
1. Drug Testing will continue to face difficult and challenging issues related to the changing landscape of marijuana legalization and decriminalization in the federal, state, local, and community levels and at the workplace
2. As states modify marijuana laws, non federal workplaces will need to review and possibly adjust their drug free workplace policies but drugs impair performance in the workplace
3. Discussion needs to be continued about current and future research, policy, and legal issues related to the changing landscape of marijuana legalization and decriminalization efforts and shifting knowledge and findings.
CBD OIL
1. Cannabidiol (CBD)
2. Extracted from cannabis plant
3. Do not get the high of THC
Uses of CBD Oil
1. Inflammation
2. Anxiety
3. Seizures/Epilepsy
4. Arthritis
5. PTSD
6. Pain relief
7. Antidepressant
8. Acne
Quality is Everything
1. Many sellers without regulation
2. Look for reputable sellers that do lab testing on content of THC—should have no THC ideally or <0.03% THC
3. Organically grown without pesticides
4. Transparency with seller
5. Concentration of CBD in product
Quality is Everything
1. Accredited laboratory testing of products
2. Total amount of CBD in product
3. How is CBD extracted? Cheaply done with solvents that can leave chemical residue. CO2 is most ideal way to extract the oil. This leaves more of the product pure without contamination.
Dosing
1. 10-20mg 1-2 times per day typical dosing
2. Some people have good relief with 1-3mg per day.
3. Always consult your doctor before starting.
CBD and positive drug screens
1. Lawsuits are arising from CBD oil converting to THC causing positive tests in oils that were reported to have little or no THC
2. Conversion happening in the acidic environment of the stomach.
To Accept or Not
1. Employer responsible for determining whether or not to accept CBD oil as a reason for a positive THC test result.
2. What’s your policy?
3. CBD may quickly become the excuse for a positive THC test.
Thank you
MercyOne East Des Moines Occupational Health
2525 East Euclid Ave
Des Moines, IA 50317
Phone (515) 261- 3300
MercyOne West Des Moines Occupational Health
1055 Jordan Creek Pkwy, Suite 100
West Des Moines, IA 50266
Phone (515) 358-5950
References
641 Iowa Administrative Code Chapter 154 – Patient and Primary Caregiver Registration Cards, Manufacturing, Dispensing, and Medical Cannabidiol Board
Ashton H (2001) Pharmacology and effects of cannabis: a brief review. Br J Psychiatry 178:201–206
Ed Wood, Ashley Brooks-Russell & Phillip Drum (2016) Delays in DUI blood testing: Impact on cannabis DUI assessments, Traffic Injury Prevention, 17:2, 105-108, DOI: 10.1080/15389588.2015.1052421
Goldsmith R, Targino M, Fanciullo G, et al. Medical marijuana in the workplace: Challenges and management options for occupational physicians. Journal of Occupational and Environmental Medicine. 2015;57(5):518-525. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=n&CSC=Y&PAGE=fulltext&D=ovft&AN=00043764-201505000-00006. doi: 10.1097/JOM.0000000000000454.
Hartman, R. L., and M. A. Huestis. 2013. Cannabis effects on driving skills. Clinical Chemistry 59(3):478-492.
Hanus LO, Meyer SM, Munoz E, Taglialatela-Scafati O, Appendino G. Phytocannabinoids: a unified critical inventory. Nat Prod Rep. 2016 Nov 23;33(12):1357-1392.
Hartman, R. L., and M. A. Huestis. 2013. Cannabis effects on driving skills. Clinical Chemistry 59(3):478-492.
Hartman RL, Richman JE, Hayes CE, Huestis MA. Drug recognition expert (DRE) examination characteristics of cannabis impairment. Accident Analysis and Prevention. 2016;92:219-229. http://www.sciencedirect.com/science/article/pii/S0001457516301191. doi: 10.1016/j.aap.2016.04.012.
Hartman, R. L., T. L. Brown, G. Milavetz, A. Spurgin, D. A. Gorelick, G. R. Gaffney, and M. A. Huestis. 2016. Effect of blood collection time on measured delta9-tetrahydrocannabinol concentrations: Implications for driving interpretation and drug policy. Clinical Chemistry 62(2):367–377.
Havens, Andrew. 10 Things you Need to Know Before You Buy CBD Oil. National Pain Report. 21 Jun. 2018. http://nationalpainreport.com/10-things-you-need-to-know-before-you-buy-cbd-oil-8836542.html. Accessed 10 December 2018.
Hunault CC, Bocker KB, Stellato RK, Kenemans JL, de Vries I, and Meulenbelt J. Acute subjective effects after smoking joints containing up to 69 mg delta9-tetrahydrocannabinol in recreational users: a randomized, crossover clinical trial. Psychopharmacology (Berl). 2014 Dec;231(24):4723-33.
References
Iowa Code 124E – The Medical Cannabidiol Act
Leys, Tony. “Legal Medical Marijuana Use Could Still be Trouble.” The Des Moines Register. 1 December. 2018: A1.
Logan, B., Flegel, R. Weed and Your Workforce: What you need to know. Presentation. National Safety Council. 15 April. 2015.
McAhren, L., Caaniabis for Healthcare Professionals. 13 June. 2018. MARCOEM Webinar Series.
National Academies of Sciences, Engineering, and Medicine. 2017. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press. https://doi.org/10.17226/24625.
Parker, Owen; House File 524- Iowa Code 124E: Iowa Medical Cannabidiol Act, Iowa Department of Public Health, Office of Medical Cannabidiol.
Phillips, et al. Marijuana in the Workplace: Guidance for Occupational Health Professionals and Employers: Joint Guidance Statement of the American Association of Occupational Health Nurses and the American College of Occupational and Environmental Medicine. Workplace Health Saf. 2015 Apr;63(4):139-64.
"Legality of cannabis by U.S. jurisdiction.." Wikipedia: The Free Encyclopedia. Wikipedia, The Free Encyclopedia, 30 December 2018, Web. 3 Jan 2019, en.wikipedia.org/wiki/Legality of cannabis by U.S. jurisdiction.
Smith, R.; Hall, K. et al. Current Marijuana Use by Industry and Occupation- Colorado, 2014-2015. MMWR Weekly Report 2018; 67(No. 14).
Thompson, Dennis. CBD Pil: All the Rage, But is it Safe and Effective? WebMD. 7 May 2018, https://www.webmd.com/pain-management/news/20180507/cbd-oil-all-the-rage-but-is-it-safe-effective#1. Accessed 11 December 2018.
Zou S and Kumar U. Cannabinoid receptors and the endocannabinoid system: Signaling and function in the central nervous system. Int J Mol Sci. 2018 Mar 13;19(3).
