September 25, 2024 • 31 mins
Negatives of Marijuana with Dr. Jeffrey Hazelwood
Shane Dawson of Dinsmore and Shohl, LLP and Jennifer White of Peterson White, LLP interview Dr. Jeffrey Hazelwood, a pain management physician, on the topic of the possible negatives of prescribing medical marijuana for pain management in workers' compensation claims. Dr. Hazelwood discusses recent studies, addiction statistics, the effects of polypharmacy and the expected real life outcomes of continued use of medical marijuana in his field. Dr. Jeffrey Hazelwood is a pain management physician who has offices in Tennessee.
To learn more about DRI and the Workers' Compensation Committee visit www.DRI.org.
#DRILawyer
#DRICommunity
Shane Dawson of Dinsmore and Shohl, LLP and Jennifer White of Peterson White, LLP interview Dr. Jeffrey Hazelwood, a pain management physician, on the topic of the possible negatives of prescribing medical marijuana for pain management in workers' compensation claims. Dr. Hazelwood discusses recent studies, addiction statistics, the effects of polypharmacy and the expected real life outcomes of continued use of medical marijuana in his field. Dr. Jeffrey Hazelwood is a pain management physician who has offices in Tennessee.
To learn more about DRI and the Workers' Compensation Committee visit www.DRI.org.
#DRILawyer
#DRICommunity
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:18):
Welcome back to another episode of Conversations podcast, a podcast
developed through the Defense Research Institute where we discuss the
world of workers compensation, exploring issues involving occupational injuries, treatment, claims, management,
and litigation, as well as future trends and emerging issues
in this area of law. My name is Shane Dawson.
(00:40):
I'm here with Jennifer White, a founding member of the
Tennessee and Kentucky firm of Peterson White. We're delighted to
have doctor Jeffrey Hazelwood with us on today's podcast to
talk about the use of marijuana in the treatment of
workers compensation claims. For regular listeners, you may recall that
a few months that we hosted doctor Scott Rosenthal, who
(01:03):
discussed this topic from the standpoint of advocating for use. Today,
doctor Hazelwood, we'll discuss with the medical literature and various
studies report regarding advocacy, potential concerns, and where we currently
lack information to support expanded treatment. Doctor Hazelwood, welcome to
comp Conversations.
Speaker 2 (01:24):
Thank you. I appreciate the invitation to speak today.
Speaker 3 (01:28):
All right, doctor Hazelwood, can you tell us a bit
about your background and how you became interested in this topic.
Speaker 2 (01:35):
Sure.
Speaker 4 (01:37):
My two board certifications are in physical medicine and rehabilitation
and then the secondary board certification and pain management. I'm
located in Elevenon, Tennessee, just outside of Nashville. I've been
practicing about twenty eight years in a large part of
my practice is the treatment of workers conversation injuries.
Speaker 2 (01:57):
I take care of acute.
Speaker 4 (02:00):
Panels such as Amazon and Nissan, But a large part
of my practice is just chronic pain management in these
open lifetime medical benefit cases. So that's where we are
searching desperately in the future to try to find other options,
alternative treatments to try to mitigate this opioid crisis that
we all know that we have. So I've been asked
(02:22):
to speak several different times on alternative treatments, and certainly
the use of medical marijuana is now considered an alternative treatment.
Speaker 3 (02:32):
Can you please explain the background for your study and
the source materials that you utilized.
Speaker 2 (02:38):
Yeah.
Speaker 4 (02:39):
Fortunately, I'm in a network of about eight physicians across
the nation that really get into studying ebonist based medicine
literature and the most recent studies that have been done
regarding different aspects of pain management, whether it be epidural,
stired injections, spinal words, stimulators, the use of opioids, so
(02:59):
a topic.
Speaker 2 (03:00):
It certainly has come up as the medical marijuana usage.
Speaker 4 (03:02):
In Tennessee where I practice, it is not used medically
for chronic pain. I think the only indication is for
pediatric seizures, so it's probably coming in the future. The
legislation is dealing with these issues now. But with this
group of physicians, I have the access in my research
(03:23):
ability to look at different articles that have been published
that are well done studies. So as I go through
my talk, I will try to reference briefly some articles.
But there's really two big article summary articles that I've
really emphasized, which is the New England Journal and Medicine
article in twenty fourteen that discusses the adverse health effects
(03:45):
of marijuana usage, and then most recently a British Medical
Journal article where they really discuss a review of the
meta analysis of randomized controlled trials and observational studies in
assessing the versus the benefits of marijuana. So those are
the two big studies, but there are many others that
I have if anyone is interested.
Speaker 3 (04:08):
Okay, and we talk about marijuana but as a general term,
but can you explain some of the different terms we
hear such as THHC, cannabis, CBD.
Speaker 4 (04:20):
Right, marijuana and cannabis basically are the same terms. Cannabis
or marijuana really refers to the hemp plant that has
the dried leaves flower stems, and basically the plant contains
both cannabinoid chemicals and non cannabinoid chemicals. So the cannabinoid
(04:41):
chemicals are over one hundred of them, but the two
big ones are THHC, which is the psychoactive chemical, and
CBD or cannaba diol. THC is tetrahydro cannabinol. The CBD
that we hear about is the cannaba diol. So those
are the two big ones. The THHC is the psychoactive chemical,
(05:04):
the CBD is the non psychoactive chemical. Also, cannabis has
non cannabinoids, so you have your terpenes and flavonoids. So
bottom line is it's the THHC and CBD cannabinoid chemicals
that come into play. And then we've heard about the
cannabi diol oils that are used that's extracted from the plant.
(05:27):
And then finally you have your synthetic cannabinoids such as
marinol that is legally used for an FDA approved to
treat nausea and vomiting related to cancer patients with chemotherapy.
But I think the take on messages this is combination
of CBD and THC in these chemicals, and the ratio
(05:48):
of the two is the key. Trying to avoid the
addiction psychoactive part and mitigate it some with the non
psychoactive CBD part. So that's a meltdown basically of marijuana
slash cannabis.
Speaker 1 (06:06):
So doctor focusing just on I guess the THHC, the
psychoactive part. Can you explain what are some of the
body parts and the systems in the body that are
then affected by THC.
Speaker 4 (06:21):
It's amazing how many parts of the body it does work.
But the body has these canbinoid receptors and they're especially
present in the peripheral and the central nervous system, so
all different areas can be affected. The neural development, the
immuan system in the body, cardiovascular effects, then flammatory part
of the body system, digestion, metabolism, bond development, and a
(06:47):
big part is the brain effects with psychiatric issues, psychiatric disease,
psychomotive behavior, and my world of pain. So it does
have receptors as I say, and again the central and
peripheral nervous system that come into impact.
Speaker 2 (07:01):
We use it for the treatment of pain.
Speaker 1 (07:05):
So with all of these different body parts that these
chemicals are acting on. And I think you mentioned before
that at least in Tennessee where it's medically accepted for
use in what pediatric seizures are there are there other
medically acceptable uses for THHC that the literature and medicine
(07:30):
seems to acknowledge.
Speaker 4 (07:32):
Yes, there's several that's used in glaucoma to try to
decrease the intra ocular pressure in the eye. We all
have heard about it being used as an anti nausea
or antiemetic treatment for patients with cancer undergoing chemotherapy. It's
a lot of promising promises and treatment in the future.
Research is being done to look at the inflammatory effects
(07:55):
and conditions such as rheumatorial thrinis aulter to colitis.
Speaker 2 (07:58):
Crohn's disease.
Speaker 4 (08:00):
It's used to improve appetite and weight gain and aids
patients that have anorexia and wasting syndrome. A big area
is multiple sclerosis, so for the neuropathic pain part of MS,
but also the spasticity that occurred with MS, as I
mentioned epileptic epileptic caizuars and children definitely has a effect
(08:23):
on the treatment of that. And then finally different brain
issues postraumatic express disorder is being used Alzheimer's disease alas
patients chiritled withvoalt syndrome. So without a doubt, there are
many different promising effects in the medical system literature.
Speaker 3 (08:45):
Now, doctor, a lot of the uses you just talked
about general medical uses don't necessarily come up in a
worker's compensation situation, and as Burgers attorneys, where we would
like to know where do you see some other medical
professionals advocating for use of marijuana and in workers' comp claims,
(09:07):
specifically that THC.
Speaker 4 (09:09):
I think it's the pain effects that it has as
especially with this chronic pain. I don't think many people
would advocate use in a chronic I'm sorry and acute
injury with pain. But these chronic pain patients that are
so miserable, and you know they've been through so many treatments,
polypharmacy with all different medications, injections. Final words, stimulator so
(09:33):
I think in the work world it's the pain issues,
especially chronic pain, and the problem is that the research
is just lacking as it is and so many things
in pain management. But the research does show that there
is evidence more promising for treatment of chronic pain than
acute pain and especially neuropathic pain. The strongest evidence in
(09:56):
pain is really for cancer pain. The big question is
what did the use allow us to decrease the need
for opioids and avoid opioids and the related problems such
as death with opioids. But in summary, the studies are limited,
they are modest benefit, and there's still a great concern
over harm. So bottom line, in these studies, they emphasize
(10:20):
the need for further investigation regarding the long term efficacy. Yes,
it may help temporarily, but what is the long term effect?
And a big question is what is the safety of
the medication, especially used in.
Speaker 2 (10:35):
The work world.
Speaker 4 (10:37):
And another aspect is what is the best route of administration.
They're different ways to administer THC. So The Anals of
Internal Medicine had a good review article August of seventeen
in which the take on message was there's just limited evidence,
but it may be does help neuropathic pain. There's insufficient
(10:58):
evidence about other times of pain such as no susceptive
pain that's muscle ligament joint pain. And then there is
limited evidence that there is concern over increased risk for
adverse mental health effects. This study mentioned thirty nine percent
of patients on long term opioids also used cannabis. So
the question is what is the ramification, what is the
(11:20):
danger of the mixture of the two. But these studies
are small, they have methodological flaws. But I think the
biggest effect and pain has been beneficial with multiple sclerosis
neuropathic pain, as I've mentioned, So these are interesting things
to consider. The New England Journal Medicine article that I
(11:41):
mentioned earlier twenty eighteen really looks at the pros.
Speaker 2 (11:46):
And the cons of use of marijuana.
Speaker 4 (11:49):
This article actually dealt with complex original pain syndrome patients
the old term RSD, and this is one of the
worst pain syndromes.
Speaker 2 (11:57):
There is.
Speaker 4 (12:00):
Pros where yes, it can help pain, it can help
that alodinio hypersensitivity. Possibly it can replace opioids. Is it
not safer? Is THC not safer than opioids? And we'll
talk about that in a bit. If we need to
the risk of addiction actually has been shown to be
less with THC than with opioids. The cons though, are
(12:23):
the research really is largely anecdotal. There's not well done
research done to show the long term effects and the
safety issues. And there are different risks such as sedation, dizziness,
memory laws, risk of psychiatric disorder increase. There's different various
concentrations and types of cannabinoids. How do we regulate that
(12:46):
in the work pomp system is another question. So we
just need more studies really to look at the long
term benefits and are we doing more harm than good?
And that's where I can get into more discussion here,
at least in the pain literature coming up.
Speaker 1 (13:05):
So, doctor Hazelwood, you mentioned about this being used as
a substitute for opioids and that maybe it has lower
addiction rates than opioids, And I think a lot of
times what we hear, at least from those advocating for
its use is that it will replace opioids. And do
(13:31):
the studies and your experience show that that's actually happening,
that people are not using the opioids and instead are
using a THHC product, or is that just kind of
a false narrative that we're hearing from those advocating.
Speaker 2 (13:50):
Well, I think it's mixed with different patients.
Speaker 4 (13:53):
My concern in my world of pain management is not
just opioids and that that occurs. I think a big
problem is this polypharmacy. And we have utilization and view
companies looking at this, we have imes being done to
look at this. But these patients are miserable. They're treating
(14:13):
their emotional pain so many times with drugs. They're on
so many different mind altering drugs, with muscle relaxers and
sleep aids and anxiety medications and any depressants and your
neurontons and lyricas and then opioids. So my concern is
we're adding potentially another mind altering drug THCHC on top
(14:36):
of all of this. So the million dollar question is
can THCHC replace these My concern is that patients will
just add it on top of the other things, and
then that can escalate the resk. So this pain medicine
commentary study that I have in twenty nineteen said we
got to be careful here because we made a huge
(14:58):
mistake assuming the past that opioids were the cure all
for the future, and we don't want to.
Speaker 2 (15:04):
Make the same mistake again.
Speaker 4 (15:06):
And we know what's happened with opioid crisis thinking it
was the answer.
Speaker 2 (15:11):
So we need.
Speaker 4 (15:11):
To slow down a thing and get more studies and
assess the long term of facts. So I've got several
studies that comment on the pros of just THCHC alone
the negatives of THCHC alone. There's some studies that show
that THC has lowered the opioid prescribing rates. This was
(15:33):
a Gemma Internal Medicine oarcle in twenty eighteen. But then
Lanson had another article in twenty eighteen that says there
was no evidence that there was a reduction in opioid
use or discontinuation of opioids with the use of THCHC.
There was another study of plos one study in twenty
seventeen that was positive and said eighty percent reduce their
(15:55):
daily opioid dosages and forty percent decreased to opioids. But
then we have another study JBJS in twenty eighteen looking
at acute muscular scopal injuries and patients said they marijuana
usage decrease their opioid usage, but when they looked at
the facts they actually had to increase their opioid usage
(16:17):
and they were using them longer. There are other studies
that have looked at the combination of the two opioids
alone versus opiods with marijuana, and the bottom line is
no doubt A supports an enhanced analgesic effect of using
the two together. This was an International Journal Behavioral Medicine
article in twenty nineteen. So a good summary articles GEMMA
(16:39):
Insights in twenty nineteen where they stated basically, there's insufficient
evidence to show that the use of medical cannabis. Cannabis
for most conditions is advocated. Marijuana is not the best
option for chronic pain and workers. They said, more research
is needed, so slow down, watch the literature and let's
(17:00):
see what pans out. And then you have the worry
about addiction. I mentioned earlier that is THCHC less addictive.
So the studies show one study show that cannabis addiction
is nine percent, opioids rangingywhere from four to twenty percent.
So when I see patients on opiods, I administer an
opiate risk tool assessment assess the risk. A low risk
(17:23):
patient only has a three point seven percent chance of
becoming addicted four percent, But your higher moderate tirorisk patients
there's up to a twenty percent chance they could become addicted.
So maybe THC is less addictive. A'l cahol is about
eleven percent, cocaine is fifteen percent, Heroin is twenty four
percent of addiction. Cannabis again nine percent. But the problem
(17:47):
is the studies are just not showing when you add
it with the opioids, that you're able to decrease the opioids.
And my gut failing after twenty eight years of practicing,
is patients will have a to add it on top
of other things, and I am leary that it can
replace all of these other things.
Speaker 2 (18:07):
So that's the major concern.
Speaker 1 (18:09):
Yeah, doctor, it sounds like I mean that that takeaway
from from hearing all of that is just that this
notion that it is it is suddenly suddenly going to
become the silver bullet and replace opioids, which you know,
we've we've seen the result of that, that's just not
(18:30):
playing out, and that the literature is just showing that
we we don't have conclusive evidence that that is in
fact what's happening in practice.
Speaker 2 (18:41):
Is that right, that's absolutely wrong.
Speaker 4 (18:43):
So again it's it's got potential, but as so many
things in chronic pain management, we just need more studies
to help us here, because I think the bottom line
is looking at risk versus benefits of anything we do
with its fusions, whether it's opioids, whether it's or stimulators,
whether it's injections, whether it's marijuana. Are we going to
(19:04):
have a better outcome in terms of quality of life
and function? And I think the last part of our talk,
we're going to talk about the dangers in the use
of THCHC in the employment environment. So that's another concern
that we can talk that.
Speaker 3 (19:21):
Leads into my question Doctor Hazel would just to play
a devil's advocate here a little bit there. You know,
there is this push that THC might be safer for
someone performing rather than opioids. Would you feel more comfortable
sending somebody back to work if they were just on
the THCHC as opposed to OPO's or what kind of
(19:42):
restrictions would you see in that kind of situation.
Speaker 4 (19:46):
Yeah, I think the rese art shows that there are
several areas in the work comp world and employment where
we have to be concerned over what the literature research show.
So big category is cognitive impairment when working around safety
sensitive equipment. Whether it's a commercial bus driver or whether
(20:08):
it's working with a machine. There's definitely effects of cognition
from THC. Of course opioids can do the same thing.
There's literature that shows is increased risk of job laws.
Literature shows increase of rendered injuries, literature shows increase crash
risk car wrecks and these commercial drivers with the use
(20:29):
of THCHC. And then even literature shows decrease surgical outcomes
and fusion patients. So I can quote these articles if needed,
but these are all concerns. The one article show that
mari one increases crash risk up to thirty six percent.
Another article indicated that crash risk with fatality increases in
(20:52):
states that legalize THC, surgical outcomes or decrease. Certainly, look
at all of these factors before one has a fusion
to try to determine and we're going to have a
good outcome or not. There's a good article in twenty
twenty three that showed the use of THCHC and patients
(21:12):
going into surgery had negative outcomes. They had increased preoperative
and long term postoperative opioid usage, it did not decrease,
So it is that a longer length of stay that
increased risk to have to undergo a revision surgery. So
all of these are concerns. There was an article in
JAMA Health Forum twenty twenty four recent article that showed
(21:35):
a ten percent increase in workplace injuries in patients and
states that used legal medical marijuana because of the effects
on cognitive function. So these are all concerns that now
have to admit this concerns are present with the use
of opioids muzzle leactuers, gabapet and Lyrica simbalta. So that's
(22:00):
where we go back to this polypharmacy effect and the
are we doing more harm than good? And is it
going to replace all of these other medications, and if
it is, you solely, the research does show the same
risk and the workplace he says you have with all
of these other mind altering.
Speaker 3 (22:18):
Drugs, And just taking you back to that scenario, if
someone's just on THCHC and assuming y'or not on any
other medication, would it be safe to say that that
THHC would be safer than other medication that they might
be on as far as you're turning to work or functioning.
Speaker 2 (22:37):
I don't say that the literature shows that.
Speaker 4 (22:39):
If anything, it seems to indicate there may be more
risks my world, of course, marijuana is illegal in tendency,
so we do not write it. So I don't see
my interaction with patients where I can give my experience.
But I can tell you that most good folks that
use medicines appropriately, such as muscle actors, especially the torontans,
(23:03):
and lyrics for neuropathic pain, some vaulta for pain, they
manage their jobs well, and very few I think have
true cognitive effects. So I can say my experience is
that's not an issue in most of the patients now opioids.
We're always careful. We try to assess how they look
(23:23):
when they come in the office. What does their family
members say about what they're observing. Am I hearing back
from the employers or the case managers that there's concerns
here over sedation? But in my world I just don't
see that much effect. But now I preach sermons to patients,
we watch them carefully. We're really on top of this,
(23:45):
so my patients know to take them appropriately and we
watch it, but I just don't have the experience myself
of seeing the facts of THC because we don't use
it here. But I think the literature shows that there
certainly no decrease and potential risk I think with THC
alone versus other medications and potentially an increased risk Council.
Speaker 1 (24:08):
Doctor with regard to those effects, I mean, what is
the literature showing in terms of short term versus say,
long term effects of THCHC use.
Speaker 4 (24:21):
Well, that's where a really good article I mentioned initially,
this New England Journal Medicine article in twenty fourteen by
ball cow the title of Oracles Adverse Health Effects of
marijuana usage. So they broke it down effects of long
term use. One is addiction we've talked about. Number two
is altered brain development, especially in adolescence. That's a big
(24:42):
concern and the adolescent population, and that's been well shown
by literature. There's increased risk of poor educational outcome, there's
an increased risk of school dropout rates, lower IQ scores,
are seeing in adolescence, diminished life satisfaction and a one
article even showed psychiatrically that THC can lead to a
(25:04):
quote a motivational state end quote. It just takes away
a desire to succeed. That that's a fact, and that's
not good. There's risk of chronic bronchitis. I think the
lung cancer risk is still unclear on THCHC. A big
part in literature that we haven't gotten into is the
(25:25):
effects on psychiatric conditions. There's a definite increased risk for
increased mental disorders, worsening depression, worsening anxiety, there's impairment in
social functioning. There's a lot of studies that show increase
risk of cardiovascular events. So there are a lot of
long term problems short if one uses it long term usage.
(25:47):
On short term usage, certainly, there's studies that show short
term impaired memory, excuse me, difficulty learning, difficulty retaining information,
impaired coordination. That's where the driving crash rates increase, altered judgment,
altered attention, paranoia, psychosis, social anxiety disorder. So that's just
(26:10):
with short term use. So you've got problems for this
excellent review article on short term use of THC and
long term use of THC.
Speaker 3 (26:21):
Doctor at present, what are some of the challenges to
learning more and getting more scientific research about potential medical
uses of marijuana.
Speaker 4 (26:31):
Well, I think some people would argue that it needs
to be legalized so we can do better studies. So
that's a bomb question there, what do you do with that?
But I think you know, if you look at chronic
pain management and the well done studies, nothing obviously is
supported in chronic pain management at the durals are not
supported for long term use spinal corse stimulator, the cocher,
(26:55):
and reviews recently that have come out have just blown
it out of the water in terms of long term
efficacy fusions that are so often done where surgeons are
operating on the picture quote end quote and not the
patient and looking at psychological factors. So none of the
(27:15):
research really supports much at all chronic pain management. So
I think that's where again this article that talked about
slow down, be careful, let's not develop another crisis for
the future like we did with opioids. But somehow we
need more studies and I don't know how to make
that happen, but I think it's essential, and these articles
(27:37):
push that with this THC before we just open the
floodgates and believe it's the all cure for everything, because
nothing to this point in this long world has shown
anything that has great outcomes and chronic pain.
Speaker 1 (27:55):
So, doctor, with a number of different states making medical
marijuanaly and here in Ohio where I am, it's been
legal for almost eight years now, and other states, my
state included, have just made recreational marijuana legal. Do you
(28:15):
have any predictions as you look at this landscape on
the role and impact that THHC and marijuana may have
in the workers space going forward?
Speaker 2 (28:26):
Yeah, I can't predict it. I just don't know.
Speaker 4 (28:30):
I looked up before we started this, and what I
read now is forty seven states allow the use of
cannabis for medical purposes, thirty eight use it in comprehensive programs.
Recreational use is now legalized in twenty four states. So
when I've done this talk in the past, those numbers
have escalated quite a bit from say, two years ago,
(28:53):
so it's coming more and more. I know the legislation
in Tennessee is wrestling with it every session.
Speaker 2 (29:00):
What do we do?
Speaker 4 (29:01):
So I don't know right now. It's illegal federally, and
that's a big questions. You've got your states versus your
federal levels. And I know there's talk about decreasing it
from level one DEA classification or whatever to legalize usage.
But right now I'm looking on all my drug screens
(29:22):
for THHC. If it's positive, we'll give them one extra chance,
but too strikes, you're out. And my wrestling is this
use of cannabi dial which is legal over the counter
but not FDA regulated, and so if it has more
than zero point three percent THC, which is not supposed
(29:42):
to have, it will light up positive THCHC. And then
we're wrestling with is this recreational use or is this
legal cbd us? But they spiked it illegally and it's
too much THC. But I've seen patients lose their jobs
because of a positive drug screen where they're taking over
the counter legal substance, so something needs to be done.
(30:04):
I think FDA needs to regulate this where then they're
forced to use less than point three percent so you
don't have the psychoactive chemical in there that can impair
patients and lead to job loss. So I don't know
where it's added, but I know it looks like every
state is getting more and more likely to use it.
But I think that's where we just have to be
(30:26):
very careful in the work comp world. That's the world
we're all living in. And bottom line is are we
doing more harm than good? And when I look at
the literature, there's a lot of concerns here, as I've
tried to point out today.
Speaker 1 (30:41):
Doctor Hazelwood, Jennifer, and I want to thank you for
being on here today. I know you've got to run.
Where can folks find you if they have more questions
or they wanted to consult with you?
Speaker 4 (30:53):
Sure, I can give you my email address. I'm fine
to do that and email me with any questions and
I'll do the best I can to answer. But my
email is j h A z L E w O
O D at j E h m D dot com.
(31:13):
So you can reach out to me and I'll try
to answer any questions. But uh, again, I think this
is a big topic and I appreciate so much you
guys having me on today to talk about it.
Speaker 3 (31:26):
Thank you very much, Dot Hazlin, Thanks doctor
Welcome back to another episode of Conversations podcast, a podcast
developed through the Defense Research Institute where we discuss the
world of workers compensation, exploring issues involving occupational injuries, treatment, claims, management,
and litigation, as well as future trends and emerging issues
in this area of law. My name is Shane Dawson.
(00:40):
I'm here with Jennifer White, a founding member of the
Tennessee and Kentucky firm of Peterson White. We're delighted to
have doctor Jeffrey Hazelwood with us on today's podcast to
talk about the use of marijuana in the treatment of
workers compensation claims. For regular listeners, you may recall that
a few months that we hosted doctor Scott Rosenthal, who
(01:03):
discussed this topic from the standpoint of advocating for use. Today,
doctor Hazelwood, we'll discuss with the medical literature and various
studies report regarding advocacy, potential concerns, and where we currently
lack information to support expanded treatment. Doctor Hazelwood, welcome to
comp Conversations.
Speaker 2 (01:24):
Thank you. I appreciate the invitation to speak today.
Speaker 3 (01:28):
All right, doctor Hazelwood, can you tell us a bit
about your background and how you became interested in this topic.
Speaker 2 (01:35):
Sure.
Speaker 4 (01:37):
My two board certifications are in physical medicine and rehabilitation
and then the secondary board certification and pain management. I'm
located in Elevenon, Tennessee, just outside of Nashville. I've been
practicing about twenty eight years in a large part of
my practice is the treatment of workers conversation injuries.
Speaker 2 (01:57):
I take care of acute.
Speaker 4 (02:00):
Panels such as Amazon and Nissan, But a large part
of my practice is just chronic pain management in these
open lifetime medical benefit cases. So that's where we are
searching desperately in the future to try to find other options,
alternative treatments to try to mitigate this opioid crisis that
we all know that we have. So I've been asked
(02:22):
to speak several different times on alternative treatments, and certainly
the use of medical marijuana is now considered an alternative treatment.
Speaker 3 (02:32):
Can you please explain the background for your study and
the source materials that you utilized.
Speaker 2 (02:38):
Yeah.
Speaker 4 (02:39):
Fortunately, I'm in a network of about eight physicians across
the nation that really get into studying ebonist based medicine
literature and the most recent studies that have been done
regarding different aspects of pain management, whether it be epidural,
stired injections, spinal words, stimulators, the use of opioids, so
(02:59):
a topic.
Speaker 2 (03:00):
It certainly has come up as the medical marijuana usage.
Speaker 4 (03:02):
In Tennessee where I practice, it is not used medically
for chronic pain. I think the only indication is for
pediatric seizures, so it's probably coming in the future. The
legislation is dealing with these issues now. But with this
group of physicians, I have the access in my research
(03:23):
ability to look at different articles that have been published
that are well done studies. So as I go through
my talk, I will try to reference briefly some articles.
But there's really two big article summary articles that I've
really emphasized, which is the New England Journal and Medicine
article in twenty fourteen that discusses the adverse health effects
(03:45):
of marijuana usage, and then most recently a British Medical
Journal article where they really discuss a review of the
meta analysis of randomized controlled trials and observational studies in
assessing the versus the benefits of marijuana. So those are
the two big studies, but there are many others that
I have if anyone is interested.
Speaker 3 (04:08):
Okay, and we talk about marijuana but as a general term,
but can you explain some of the different terms we
hear such as THHC, cannabis, CBD.
Speaker 4 (04:20):
Right, marijuana and cannabis basically are the same terms. Cannabis
or marijuana really refers to the hemp plant that has
the dried leaves flower stems, and basically the plant contains
both cannabinoid chemicals and non cannabinoid chemicals. So the cannabinoid
(04:41):
chemicals are over one hundred of them, but the two
big ones are THHC, which is the psychoactive chemical, and
CBD or cannaba diol. THC is tetrahydro cannabinol. The CBD
that we hear about is the cannaba diol. So those
are the two big ones. The THHC is the psychoactive chemical,
(05:04):
the CBD is the non psychoactive chemical. Also, cannabis has
non cannabinoids, so you have your terpenes and flavonoids. So
bottom line is it's the THHC and CBD cannabinoid chemicals
that come into play. And then we've heard about the
cannabi diol oils that are used that's extracted from the plant.
(05:27):
And then finally you have your synthetic cannabinoids such as
marinol that is legally used for an FDA approved to
treat nausea and vomiting related to cancer patients with chemotherapy.
But I think the take on messages this is combination
of CBD and THC in these chemicals, and the ratio
(05:48):
of the two is the key. Trying to avoid the
addiction psychoactive part and mitigate it some with the non
psychoactive CBD part. So that's a meltdown basically of marijuana
slash cannabis.
Speaker 1 (06:06):
So doctor focusing just on I guess the THHC, the
psychoactive part. Can you explain what are some of the
body parts and the systems in the body that are
then affected by THC.
Speaker 4 (06:21):
It's amazing how many parts of the body it does work.
But the body has these canbinoid receptors and they're especially
present in the peripheral and the central nervous system, so
all different areas can be affected. The neural development, the
immuan system in the body, cardiovascular effects, then flammatory part
of the body system, digestion, metabolism, bond development, and a
(06:47):
big part is the brain effects with psychiatric issues, psychiatric disease,
psychomotive behavior, and my world of pain. So it does
have receptors as I say, and again the central and
peripheral nervous system that come into impact.
Speaker 2 (07:01):
We use it for the treatment of pain.
Speaker 1 (07:05):
So with all of these different body parts that these
chemicals are acting on. And I think you mentioned before
that at least in Tennessee where it's medically accepted for
use in what pediatric seizures are there are there other
medically acceptable uses for THHC that the literature and medicine
(07:30):
seems to acknowledge.
Speaker 4 (07:32):
Yes, there's several that's used in glaucoma to try to
decrease the intra ocular pressure in the eye. We all
have heard about it being used as an anti nausea
or antiemetic treatment for patients with cancer undergoing chemotherapy. It's
a lot of promising promises and treatment in the future.
Research is being done to look at the inflammatory effects
(07:55):
and conditions such as rheumatorial thrinis aulter to colitis.
Speaker 2 (07:58):
Crohn's disease.
Speaker 4 (08:00):
It's used to improve appetite and weight gain and aids
patients that have anorexia and wasting syndrome. A big area
is multiple sclerosis, so for the neuropathic pain part of MS,
but also the spasticity that occurred with MS, as I
mentioned epileptic epileptic caizuars and children definitely has a effect
(08:23):
on the treatment of that. And then finally different brain
issues postraumatic express disorder is being used Alzheimer's disease alas
patients chiritled withvoalt syndrome. So without a doubt, there are
many different promising effects in the medical system literature.
Speaker 3 (08:45):
Now, doctor, a lot of the uses you just talked
about general medical uses don't necessarily come up in a
worker's compensation situation, and as Burgers attorneys, where we would
like to know where do you see some other medical
professionals advocating for use of marijuana and in workers' comp claims,
(09:07):
specifically that THC.
Speaker 4 (09:09):
I think it's the pain effects that it has as
especially with this chronic pain. I don't think many people
would advocate use in a chronic I'm sorry and acute
injury with pain. But these chronic pain patients that are
so miserable, and you know they've been through so many treatments,
polypharmacy with all different medications, injections. Final words, stimulator so
(09:33):
I think in the work world it's the pain issues,
especially chronic pain, and the problem is that the research
is just lacking as it is and so many things
in pain management. But the research does show that there
is evidence more promising for treatment of chronic pain than
acute pain and especially neuropathic pain. The strongest evidence in
(09:56):
pain is really for cancer pain. The big question is
what did the use allow us to decrease the need
for opioids and avoid opioids and the related problems such
as death with opioids. But in summary, the studies are limited,
they are modest benefit, and there's still a great concern
over harm. So bottom line, in these studies, they emphasize
(10:20):
the need for further investigation regarding the long term efficacy. Yes,
it may help temporarily, but what is the long term effect?
And a big question is what is the safety of
the medication, especially used in.
Speaker 2 (10:35):
The work world.
Speaker 4 (10:37):
And another aspect is what is the best route of administration.
They're different ways to administer THC. So The Anals of
Internal Medicine had a good review article August of seventeen
in which the take on message was there's just limited evidence,
but it may be does help neuropathic pain. There's insufficient
(10:58):
evidence about other times of pain such as no susceptive
pain that's muscle ligament joint pain. And then there is
limited evidence that there is concern over increased risk for
adverse mental health effects. This study mentioned thirty nine percent
of patients on long term opioids also used cannabis. So
the question is what is the ramification, what is the
(11:20):
danger of the mixture of the two. But these studies
are small, they have methodological flaws. But I think the
biggest effect and pain has been beneficial with multiple sclerosis
neuropathic pain, as I've mentioned, So these are interesting things
to consider. The New England Journal Medicine article that I
(11:41):
mentioned earlier twenty eighteen really looks at the pros.
Speaker 2 (11:46):
And the cons of use of marijuana.
Speaker 4 (11:49):
This article actually dealt with complex original pain syndrome patients
the old term RSD, and this is one of the
worst pain syndromes.
Speaker 2 (11:57):
There is.
Speaker 4 (12:00):
Pros where yes, it can help pain, it can help
that alodinio hypersensitivity. Possibly it can replace opioids. Is it
not safer? Is THC not safer than opioids? And we'll
talk about that in a bit. If we need to
the risk of addiction actually has been shown to be
less with THC than with opioids. The cons though, are
(12:23):
the research really is largely anecdotal. There's not well done
research done to show the long term effects and the
safety issues. And there are different risks such as sedation, dizziness,
memory laws, risk of psychiatric disorder increase. There's different various
concentrations and types of cannabinoids. How do we regulate that
(12:46):
in the work pomp system is another question. So we
just need more studies really to look at the long
term benefits and are we doing more harm than good?
And that's where I can get into more discussion here,
at least in the pain literature coming up.
Speaker 1 (13:05):
So, doctor Hazelwood, you mentioned about this being used as
a substitute for opioids and that maybe it has lower
addiction rates than opioids, And I think a lot of
times what we hear, at least from those advocating for
its use is that it will replace opioids. And do
(13:31):
the studies and your experience show that that's actually happening,
that people are not using the opioids and instead are
using a THHC product, or is that just kind of
a false narrative that we're hearing from those advocating.
Speaker 2 (13:50):
Well, I think it's mixed with different patients.
Speaker 4 (13:53):
My concern in my world of pain management is not
just opioids and that that occurs. I think a big
problem is this polypharmacy. And we have utilization and view
companies looking at this, we have imes being done to
look at this. But these patients are miserable. They're treating
(14:13):
their emotional pain so many times with drugs. They're on
so many different mind altering drugs, with muscle relaxers and
sleep aids and anxiety medications and any depressants and your
neurontons and lyricas and then opioids. So my concern is
we're adding potentially another mind altering drug THCHC on top
(14:36):
of all of this. So the million dollar question is
can THCHC replace these My concern is that patients will
just add it on top of the other things, and
then that can escalate the resk. So this pain medicine
commentary study that I have in twenty nineteen said we
got to be careful here because we made a huge
(14:58):
mistake assuming the past that opioids were the cure all
for the future, and we don't want to.
Speaker 2 (15:04):
Make the same mistake again.
Speaker 4 (15:06):
And we know what's happened with opioid crisis thinking it
was the answer.
Speaker 2 (15:11):
So we need.
Speaker 4 (15:11):
To slow down a thing and get more studies and
assess the long term of facts. So I've got several
studies that comment on the pros of just THCHC alone
the negatives of THCHC alone. There's some studies that show
that THC has lowered the opioid prescribing rates. This was
(15:33):
a Gemma Internal Medicine oarcle in twenty eighteen. But then
Lanson had another article in twenty eighteen that says there
was no evidence that there was a reduction in opioid
use or discontinuation of opioids with the use of THCHC.
There was another study of plos one study in twenty
seventeen that was positive and said eighty percent reduce their
(15:55):
daily opioid dosages and forty percent decreased to opioids. But
then we have another study JBJS in twenty eighteen looking
at acute muscular scopal injuries and patients said they marijuana
usage decrease their opioid usage, but when they looked at
the facts they actually had to increase their opioid usage
(16:17):
and they were using them longer. There are other studies
that have looked at the combination of the two opioids
alone versus opiods with marijuana, and the bottom line is
no doubt A supports an enhanced analgesic effect of using
the two together. This was an International Journal Behavioral Medicine
article in twenty nineteen. So a good summary articles GEMMA
(16:39):
Insights in twenty nineteen where they stated basically, there's insufficient
evidence to show that the use of medical cannabis. Cannabis
for most conditions is advocated. Marijuana is not the best
option for chronic pain and workers. They said, more research
is needed, so slow down, watch the literature and let's
(17:00):
see what pans out. And then you have the worry
about addiction. I mentioned earlier that is THCHC less addictive.
So the studies show one study show that cannabis addiction
is nine percent, opioids rangingywhere from four to twenty percent.
So when I see patients on opiods, I administer an
opiate risk tool assessment assess the risk. A low risk
(17:23):
patient only has a three point seven percent chance of
becoming addicted four percent, But your higher moderate tirorisk patients
there's up to a twenty percent chance they could become addicted.
So maybe THC is less addictive. A'l cahol is about
eleven percent, cocaine is fifteen percent, Heroin is twenty four
percent of addiction. Cannabis again nine percent. But the problem
(17:47):
is the studies are just not showing when you add
it with the opioids, that you're able to decrease the opioids.
And my gut failing after twenty eight years of practicing,
is patients will have a to add it on top
of other things, and I am leary that it can
replace all of these other things.
Speaker 2 (18:07):
So that's the major concern.
Speaker 1 (18:09):
Yeah, doctor, it sounds like I mean that that takeaway
from from hearing all of that is just that this
notion that it is it is suddenly suddenly going to
become the silver bullet and replace opioids, which you know,
we've we've seen the result of that, that's just not
(18:30):
playing out, and that the literature is just showing that
we we don't have conclusive evidence that that is in
fact what's happening in practice.
Speaker 2 (18:41):
Is that right, that's absolutely wrong.
Speaker 4 (18:43):
So again it's it's got potential, but as so many
things in chronic pain management, we just need more studies
to help us here, because I think the bottom line
is looking at risk versus benefits of anything we do
with its fusions, whether it's opioids, whether it's or stimulators,
whether it's injections, whether it's marijuana. Are we going to
(19:04):
have a better outcome in terms of quality of life
and function? And I think the last part of our talk,
we're going to talk about the dangers in the use
of THCHC in the employment environment. So that's another concern
that we can talk that.
Speaker 3 (19:21):
Leads into my question Doctor Hazel would just to play
a devil's advocate here a little bit there. You know,
there is this push that THC might be safer for
someone performing rather than opioids. Would you feel more comfortable
sending somebody back to work if they were just on
the THCHC as opposed to OPO's or what kind of
(19:42):
restrictions would you see in that kind of situation.
Speaker 4 (19:46):
Yeah, I think the rese art shows that there are
several areas in the work comp world and employment where
we have to be concerned over what the literature research show.
So big category is cognitive impairment when working around safety
sensitive equipment. Whether it's a commercial bus driver or whether
(20:08):
it's working with a machine. There's definitely effects of cognition
from THC. Of course opioids can do the same thing.
There's literature that shows is increased risk of job laws.
Literature shows increase of rendered injuries, literature shows increase crash
risk car wrecks and these commercial drivers with the use
(20:29):
of THCHC. And then even literature shows decrease surgical outcomes
and fusion patients. So I can quote these articles if needed,
but these are all concerns. The one article show that
mari one increases crash risk up to thirty six percent.
Another article indicated that crash risk with fatality increases in
(20:52):
states that legalize THC, surgical outcomes or decrease. Certainly, look
at all of these factors before one has a fusion
to try to determine and we're going to have a
good outcome or not. There's a good article in twenty
twenty three that showed the use of THCHC and patients
(21:12):
going into surgery had negative outcomes. They had increased preoperative
and long term postoperative opioid usage, it did not decrease,
So it is that a longer length of stay that
increased risk to have to undergo a revision surgery. So
all of these are concerns. There was an article in
JAMA Health Forum twenty twenty four recent article that showed
(21:35):
a ten percent increase in workplace injuries in patients and
states that used legal medical marijuana because of the effects
on cognitive function. So these are all concerns that now
have to admit this concerns are present with the use
of opioids muzzle leactuers, gabapet and Lyrica simbalta. So that's
(22:00):
where we go back to this polypharmacy effect and the
are we doing more harm than good? And is it
going to replace all of these other medications, and if
it is, you solely, the research does show the same
risk and the workplace he says you have with all
of these other mind altering.
Speaker 3 (22:18):
Drugs, And just taking you back to that scenario, if
someone's just on THCHC and assuming y'or not on any
other medication, would it be safe to say that that
THHC would be safer than other medication that they might
be on as far as you're turning to work or functioning.
Speaker 2 (22:37):
I don't say that the literature shows that.
Speaker 4 (22:39):
If anything, it seems to indicate there may be more
risks my world, of course, marijuana is illegal in tendency,
so we do not write it. So I don't see
my interaction with patients where I can give my experience.
But I can tell you that most good folks that
use medicines appropriately, such as muscle actors, especially the torontans,
(23:03):
and lyrics for neuropathic pain, some vaulta for pain, they
manage their jobs well, and very few I think have
true cognitive effects. So I can say my experience is
that's not an issue in most of the patients now opioids.
We're always careful. We try to assess how they look
(23:23):
when they come in the office. What does their family
members say about what they're observing. Am I hearing back
from the employers or the case managers that there's concerns
here over sedation? But in my world I just don't
see that much effect. But now I preach sermons to patients,
we watch them carefully. We're really on top of this,
(23:45):
so my patients know to take them appropriately and we
watch it, but I just don't have the experience myself
of seeing the facts of THC because we don't use
it here. But I think the literature shows that there
certainly no decrease and potential risk I think with THC
alone versus other medications and potentially an increased risk Council.
Speaker 1 (24:08):
Doctor with regard to those effects, I mean, what is
the literature showing in terms of short term versus say,
long term effects of THCHC use.
Speaker 4 (24:21):
Well, that's where a really good article I mentioned initially,
this New England Journal Medicine article in twenty fourteen by
ball cow the title of Oracles Adverse Health Effects of
marijuana usage. So they broke it down effects of long
term use. One is addiction we've talked about. Number two
is altered brain development, especially in adolescence. That's a big
(24:42):
concern and the adolescent population, and that's been well shown
by literature. There's increased risk of poor educational outcome, there's
an increased risk of school dropout rates, lower IQ scores,
are seeing in adolescence, diminished life satisfaction and a one
article even showed psychiatrically that THC can lead to a
(25:04):
quote a motivational state end quote. It just takes away
a desire to succeed. That that's a fact, and that's
not good. There's risk of chronic bronchitis. I think the
lung cancer risk is still unclear on THCHC. A big
part in literature that we haven't gotten into is the
(25:25):
effects on psychiatric conditions. There's a definite increased risk for
increased mental disorders, worsening depression, worsening anxiety, there's impairment in
social functioning. There's a lot of studies that show increase
risk of cardiovascular events. So there are a lot of
long term problems short if one uses it long term usage.
(25:47):
On short term usage, certainly, there's studies that show short
term impaired memory, excuse me, difficulty learning, difficulty retaining information,
impaired coordination. That's where the driving crash rates increase, altered judgment,
altered attention, paranoia, psychosis, social anxiety disorder. So that's just
(26:10):
with short term use. So you've got problems for this
excellent review article on short term use of THC and
long term use of THC.
Speaker 3 (26:21):
Doctor at present, what are some of the challenges to
learning more and getting more scientific research about potential medical
uses of marijuana.
Speaker 4 (26:31):
Well, I think some people would argue that it needs
to be legalized so we can do better studies. So
that's a bomb question there, what do you do with that?
But I think you know, if you look at chronic
pain management and the well done studies, nothing obviously is
supported in chronic pain management at the durals are not
supported for long term use spinal corse stimulator, the cocher,
(26:55):
and reviews recently that have come out have just blown
it out of the water in terms of long term
efficacy fusions that are so often done where surgeons are
operating on the picture quote end quote and not the
patient and looking at psychological factors. So none of the
(27:15):
research really supports much at all chronic pain management. So
I think that's where again this article that talked about
slow down, be careful, let's not develop another crisis for
the future like we did with opioids. But somehow we
need more studies and I don't know how to make
that happen, but I think it's essential, and these articles
(27:37):
push that with this THC before we just open the
floodgates and believe it's the all cure for everything, because
nothing to this point in this long world has shown
anything that has great outcomes and chronic pain.
Speaker 1 (27:55):
So, doctor, with a number of different states making medical
marijuanaly and here in Ohio where I am, it's been
legal for almost eight years now, and other states, my
state included, have just made recreational marijuana legal. Do you
(28:15):
have any predictions as you look at this landscape on
the role and impact that THHC and marijuana may have
in the workers space going forward?
Speaker 2 (28:26):
Yeah, I can't predict it. I just don't know.
Speaker 4 (28:30):
I looked up before we started this, and what I
read now is forty seven states allow the use of
cannabis for medical purposes, thirty eight use it in comprehensive programs.
Recreational use is now legalized in twenty four states. So
when I've done this talk in the past, those numbers
have escalated quite a bit from say, two years ago,
(28:53):
so it's coming more and more. I know the legislation
in Tennessee is wrestling with it every session.
Speaker 2 (29:00):
What do we do?
Speaker 4 (29:01):
So I don't know right now. It's illegal federally, and
that's a big questions. You've got your states versus your
federal levels. And I know there's talk about decreasing it
from level one DEA classification or whatever to legalize usage.
But right now I'm looking on all my drug screens
(29:22):
for THHC. If it's positive, we'll give them one extra chance,
but too strikes, you're out. And my wrestling is this
use of cannabi dial which is legal over the counter
but not FDA regulated, and so if it has more
than zero point three percent THC, which is not supposed
(29:42):
to have, it will light up positive THCHC. And then
we're wrestling with is this recreational use or is this
legal cbd us? But they spiked it illegally and it's
too much THC. But I've seen patients lose their jobs
because of a positive drug screen where they're taking over
the counter legal substance, so something needs to be done.
(30:04):
I think FDA needs to regulate this where then they're
forced to use less than point three percent so you
don't have the psychoactive chemical in there that can impair
patients and lead to job loss. So I don't know
where it's added, but I know it looks like every
state is getting more and more likely to use it.
But I think that's where we just have to be
(30:26):
very careful in the work comp world. That's the world
we're all living in. And bottom line is are we
doing more harm than good? And when I look at
the literature, there's a lot of concerns here, as I've
tried to point out today.
Speaker 1 (30:41):
Doctor Hazelwood, Jennifer, and I want to thank you for
being on here today. I know you've got to run.
Where can folks find you if they have more questions
or they wanted to consult with you?
Speaker 4 (30:53):
Sure, I can give you my email address. I'm fine
to do that and email me with any questions and
I'll do the best I can to answer. But my
email is j h A z L E w O
O D at j E h m D dot com.
(31:13):
So you can reach out to me and I'll try
to answer any questions. But uh, again, I think this
is a big topic and I appreciate so much you
guys having me on today to talk about it.
Speaker 3 (31:26):
Thank you very much, Dot Hazlin, Thanks doctor
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