Should insurance companies cover medical marijuana for cancer pain?

Click here to read the Cover Story, “With many cannabis products but limited research, ‘education warranted’ for entire oncology workforce”

Yes.

Cannabis was a legal and popular medicine in the United States until the Marihuana Tax Act in 1937, when it was criminalized, over the vigorous objections of the AMA, primarily for reasons related to racism and competitive commercial interests. Now that it is being relegalized, at the behest of the 94% of Americans who support legal access to medical marijuana, insurance companies are obligated to cover the costs of this versatile and relatively nontoxic medicine.

Without affordable access to cannabis, patients will be relegated to the less expensive but more dangerous illicit market for cannabis, where the products aren’t carefully tested for contaminants such as molds, pesticides and heavy metals. Further, it has been extensively documented that people substitute more dangerous options such as opioids and benzodiazepines for cannabis. Insurance coverage would be a ‘harm reduction’ goldmine and would contribute greatly to public health as people would be able to afford to transition from these medicines to cannabis, which is less toxic. In my clinical practice, I have seen many patients whose kidneys are needlessly failing due to years of overreliance on NSAIDs for chronic pain — this all could have been avoided with use of low-dosage cannabinoids instead.

This ‘substitution effect’ is economically advantageous to insurance companies and is projected to save hundreds of millions of dollars yearly. In a 2016 article in Health Affairs, researchers reported that “the use of prescription drugs for which marijuana could serve as a clinical alternative fell significantly, once a medical marijuana law was implemented.” Insurance companies are reaping the financial benefits of medical cannabis, why shouldn’t they cover it?

Some might counter that there isn’t enough “evidence” for insurance companies to cover medical cannabis or that cannabis isn’t FDA approved. This argument does not work for a variety of reasons. Research into the benefit of cannabis has been curated by the U.S. government, which has been interested only in highlighting harms. There is a relative dearth of randomized controlled trials but abundant ‘real-world evidence,’ such as patient-reported outcomes and patient registries, that cannabis is safe and efficacious for a variety of conditions, especially chronic pain. It is challenging to do randomized controlled trials on cannabis, as it is difficult to blind because of psychoactivity. Also, cannabis often has several effects at once (pain, anxiety, sleep, quality of life), whereas randomized controlled trials typically check for one variable at a time.

Despite these obstacles, the 2017 National Academy of Sciences, Engineering and Medicine study stated, “There is conclusive or substantial evidence that cannabis or cannabinoids are effective for the treatment of chronic pain in adults,” as well as many other conditions. Insurance companies cover off-label uses of medications all the time, so this should not be an obstacle.

There are ethical arguments why insurance companies must cover the costs of medical cannabis. They are avoiding doing so by hiding behind our 50-year War on Drugs and the consequent, ongoing federal illegality of cannabis. The War on Drugs is increasingly thought to be a war on people, especially Black and brown people.

If insurance doesn’t cover medical cannabis, it becomes solely a treatment for the well-to-do, and this perpetuates many of the injustices that we urgently need to be mending.

• References:
• Banerjee R, et al. Ther Innov Regul Sci. 2022;doi:10.1007/s43441-021-00346-0.
• Bradford AC, et al. Health Aff (Millwood). 2016;doi:10.1377/hlthaff.2015.1661.
• Legal cannabis stores linked to fewer opioid deaths in the United States. https://www.bmj.com/company/newsroom/legal-cannabis-stores-linked-to-fewer-opioid-deaths-in-the-united-states/. Accessed March 30, 2022.
• The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. https://nap.nationalacademies.org/resource/24625/Cannabis_report_highlights.pdf. Accessed March 30, 2022.

Peter M. Grinspoon, MD, is a primary care physician at Massachusetts General Hospital, an instructor of medicine at Harvard Medical School, and a board member of the advocacy group Doctors for Cannabis Regulation, which works toward legalizing cannabis with an eye toward social justice. He can be reached at pmgrinspoo@bics.bwh.harvard.edu.

No.

WHO states that the responsible use of medications requires that activities, capabilities and existing resources of the health system stakeholders be aligned to ensure that patients receive the right medication at the right time, using them appropriately and benefiting from them. High-quality medical management requires scientific rigor for quality indicators, which in turn would require insurance financial support and governmental clearance for use.

In the United States, physicians often do not prescribe cannabis, but qualify patients for cannabis based upon a medical condition recognized by the cannabis law of that particular state. Less than half rely on the clinician input (40%), cost (45%) or inventory (12%). The dispensary routinely advises patients about safe storage and common adverse effects, but few advise patients about cannabis abuse disorder, the risk for cannabis withdrawal symptoms and the risk for motor vehicle accidents or psychotic reactions. Although regulatory agency oversight in therapeutic development includes toxicology, screening in multiple species, organ system toxicity, teratogenesis and carcinogenesis, most plant-based cannabis products that reach dispensaries go without due process of testing or regulatory oversight. There has been neglect of the teratogenic and carcinogenic effects noted in the literature.

Having state legislatures make decisions about what is considered “medical” without requiring scientific evidence has left the medical community in the difficult position of dealing with fallout from the promotion of cannabis for a wide variety of disorders with no proof of efficacy. FDA labeling is a rigorous, expensive process but provides for a measure of efficacy and safety. Risk management and mitigation strategies are not in place for cannabis. Belief rather than science has driven policy so far. Physicians do not need specific training or a specialty to recommend cannabis and refer patients to dispensaries. Only a minority of states require cannabis education prior to registration.

The International Association for the Study of Pain Presidential Task Force has stated that due to the lack of high-quality clinical evidence, it “does not currently endorse general use of cannabis and cannabinoids for pain relief.” The remaining important questions about long-term and short-term safety of cannabis and cannabinoids need to be addressed.

Data from the National Health Interview Survey between 1986 and 2011 showed cannabis laws did not reduce opioid-related deaths and there was no protective effect when laws were instituted. Data from the National Epidemiologic Survey on Alcohol and Related Conditions between 2001 and 2002 and 2012 and 2013 showed patients with pain used nonmedical cannabis more frequently and had a higher prevalence of a cannabis use disorder. There was no evidence that cannabis was opioid-sparing in randomized cancer studies.

There is neither a structure nor process within the health care system that supports safety of cannabis therapy. There is no outcome from randomized trials with evidence strong enough to support insurance coverage.

• References:
• Abuhasira R, et al. Eur J Intern Med. 2018;doi:10.1016/j.ejim.2018.01.001.
• Brady KT. Am J Psychiatry. 2020;doi: 10.1176/appi.ajp.2020.20050648.
• Fallon MT, et al. Br J Pain. 2017;doi:10.1177/2049463717710042.
• Fujita K, et al. BMJ Open. 2018;doi:10.1136/bmjopen-2017-020437.
• Haroutounian S, et al. Pain. 2021;doi:10.1097/j.pain.0000000000002001.
• Hasin DS, et al. Am J Psychiatry. 2020;doi:10.1176/appi.ajp.2019.19030284.
• Johnson JR, et al. J Pain Symptom Manage. 2010;doi:10.1016/j.jpainsymman.2009.06.008.
• Kim JH, et al. Int J Drug Policy. 2022;doi:10.1016/j.drugpo.2021.103449.
• Lichtman AH, et al. J Pain Symptom Manage. 2018;doi:10.1016/j.jpainsymman.2017.09.001.
• Mainz J. Int J Qual Health Care. 2003;doi:10.1093/intqhc/mzg084.
• McGlynn EA. Int J Qual Health Care. 1998;doi:10.1093/intqhc/10.6.485.
• Merlin JS, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.24511.
• Portenoy RK, et al. J Pain. 2012;doi:10.1016/j.jpain.2012.01.003.
• Reece AS, et al. Sci Rep. 2021;doi:10.1038/s41598-021-93411-5.
• Rice ASC, et al. Pain. 2021;doi:10.1097/j.pain.0000000000002210.

Mellar P. Davis, MD, FCCP, FAAHPM, is section head of the palliative care department at Geisinger Medical System and professor of medicine at Cleveland Clinic Lerner College of Medicine and Case Western Reserve University. He can be reached at mdavis2@geisinger.edu.