How workers compensation is being dragged into the world of medical marijuana

As Melissa Ellsworth drops several grams of dried cannabis into her Magical Butter machine to be ground into oil, she pauses to reflect on how long it took the Workers' Compensation Board of Nova Scotia to start paying for her medical marijuana.

Five years and one tribunal appeal later, she was finally approved in January 2018. The tribunal decision stated there was "sufficient evidence to conclude that the worker is entitled to medical aid in the form of medical marijuana." 

She says that ruling saved her life.

"I can function every day like a normal human being instead of being crippled up in pain," said Ellsworth. "I went from 26 pills a day to cannabis." 

For almost a decade, Ellsworth was on a mixture of opioids, benzodiazepines and sedatives. 

She suffers from chronic pain in her neck, head, jaw and shoulders after being struck in the head with a chair while working as a licensed practical nurse in 2006 at the Nova Scotia Hospital, a psychiatric facility in Dartmouth, N.S. She has been off work since 2010.

Her tribunal victory comes as workers compensation boards across the country are being forced to revise their restrictive policies around medical cannabis as more patients look for forms of pain relief other than opioids.

Last year, New Brunswick was the first province to introduce cannabis guidelines. It was followed by P.E.I. and Ontario. Nova Scotia is expected to release its guidelines in early April.

Number of claims

But getting cannabis coverage approved through a WCB still isn't an easy process in any province.

Ellsworth is one of 10 workers in Nova Scotia who have qualified. P.E.I. and Alberta have similar numbers. Of the provinces that disclose how many workers are compensated for medical marijuana, New Brunswick has the highest number of claims at 71.

Half of the provincial bodies would not say how many cannabis prescriptions are paid. In all regions, coverage is reviewed on a case-by-case basis. 

In comparison, Veterans Affairs Canada approved more than 7,000 veterans at a cost of $50 million in 2017-18. 

Cannabis guidelines

In Nova Scotia, the chief medical officer for the WCB admits the position on cannabis has traditionally been a firm "no." But that has changed in the last year, according to Dr. Manoj Vohra.

"We're starting to see that more evidence is coming, more workers are asking for it and so now we're starting to develop criteria on guidelines," he said.

Vohra said the medical evidence shows that cannabis, especially cannabidiol (CBD) — the non-impairing compound — can help people with chronic illnesses such as cancer and HIV, as well as those suffering from neuropathic pain. 

"If cannabis does help them in those areas where there is evidence, then we're more than open to trying to see how we can do that," he said. "The challenge always comes in with harm. There's not enough clinical trials that actually go through. What are the side-effects?"

Dr. Vohra said there is a collective fear among his colleagues about overprescribing a medication that hasn't been fully researched. He points to the ongoing opioid epidemic as a prime example.

"What's happened 10 to 15 years down the road is we've realized that there's harm that occurs," Vohra said. "And so we want to make sure we don't repeat those mistakes from the past and that we use it and understand what are the risks, what are the contraindications to using it."

In February 2017, 1,543 workers had the cost of their opioid prescriptions covered by the WCB in Nova Scotia. In February 2019, that number dropped to 1,315 workers.

Long overdue

Dr. Mary Lynch, a pain specialist and cannabis researcher in Halifax, said the introduction of cannabis guidelines for injured workers is "long overdue."

"If first- and second-line treatments aren't working, then we will sometimes recommend a medical cannabinoid, depending on the patient's specific presentation," Lynch said. 

"And for those who do benefit, we have run into difficulties with the workers compensation board agreeing to cover the cost."

Lynch is a founding member of the cannabis research startup Panag Pharma Inc., which she and other academic researchers incorporated in 2014 to access research grants.

She hopes Nova Scotia's new guidelines will give weight to a doctor's prescription.

"I'm hoping that the policy will be written in a way that as long as a physician has recommended it, the access will be reasonable, just like it is with any other prescription medication."

As it stands, only Quebec depends on medical advice from the worker's doctor. All other provinces, including ones with guidelines, have their own team of doctors to evaluate claims from injured workers.

Continuous struggle

For Ellsworth, the struggle continues even though she is one of the few who have successfully lobbied for medical marijuana coverage in Nova Scotia.

She was originally prescribed four grams per day. Last August, her family doctor increased her dose to five grams, but that has not been approved by WCB.

"My only job as an injured worker is to take the best care of myself to prevent further injury. I'm trying to do everything I can possible by avoiding addictive medications and everything else. And they're fighting me. They're making it very hard to do," said Ellsworth.

She has appealed her claim to have that extra gram covered, knowing that it will likely lead to another tribunal — a process she has been through eight times for various issues over the years.

"I mean, I've won eight tribunals. How many more do I have to win?" she said.

"Every time I go through a tribunal, I have to live through all that again. And I will be honest, between my employer, workers compensation and everything ... it was a nightmare. An absolute nightmare that I would rather not relive again."

Varying doses

Guidelines developed by New Brunswick, P.E.I. and Ontario have set a maximum dose of three grams per day. While Lynch agrees that is an appropriate limit, she also believes some patients may need more.

"You do need to take each of these things on an individual basis, and these days many people are using topical products where you put the agent into a cream, and in that case you do need access to a bit more of the product," the pain specialist said.

When it comes to THC levels, the Maritimes set a limit of no higher than one per cent. Ontario allows up to nine per cent. THC is reported to have therapeutic effects but also to be chiefly responsible for the psychotropic effects of cannabis, according to the Workplace Safety and Insurance Board of Ontario.

"I know that each province has to come up with their own answers," Lynch said. 

"One would hope, though, that things will move forward within a reasonable length of time [and] perhaps the wheel doesn't need to be reinvented in every province."