Cannabis – How can private health benefits plan sponsors and insurers make the right coverage decisions for plan members?Ruslan Dorfman
The legalization of cannabis poses a challenge for employers and insurers, as they are expected to cover the cost of medical cannabis as a part of their employee health benefits. A recent Deloitte report indicates that 7% of adult Canadian population are daily cannabis users, of which 29% are using cannabis for pain management. Canadian employers and unions have started providing their employees and eligible dependents with access to medical cannabis through their third-party drug plans (Shoppers , Loblaw, and OPSEU for example). The average annual cost of medical cannabis can range from $1 700 to $10 000 per person, and some claimants have been reimbursed up to $100 000 a year, making it as costly as a biologic medication.
Payers expect that the number of medical cannabis users will double with legalization, which will increase the financial burden on drug benefits plans. To combat this, many plan sponsors are implementing Prior Authorization (PA) programs, which are designed to limit access to medical cannabis. Some PA programs require patients with MS, cancer, HIV, and neuropathic pain to show evidence that they went through 3-4 trials of opioids (oxycodone, hydromorphone), tricyclic antidepressants (TCAs), antiepileptics (pregabalin, gabapentin), and/or serotonin-norepinephrine reuptake inhibitors (SNRIs). Each of the trials must be at least 4 weeks long, which leaves thousands of patients, plan members, and claimants without adequate pain control for 3 to 7 months. These requirements may inadvertently increase the risk of addiction to opioids, as well as the risk of adverse side effects triggered by antidepressants.
Management of chronic pain is extremely challenging for all concerned because of the complex nature of the condition. Chronic Pain can be a result of many diseases with varying causes and is typically notoriously resistant to treatment. A study done using Cochrane Review data indicates that only 3-4 patients out of 10 participants with neuropathic pain (caused by postherpetic neuralgia and/or peripheral diabetic neuropathy) saw greater than 50% pain reduction using gabapentin, compared with 1-2 participants out of 10 for placebo. This shows that the majority of trials with these drugs do not work. Gabapentin and pregabalin also do not work for other forms of pain (i.e. non-neuropathic pain). Moreover, due to an elevated risk of GI bleeding and heart failure, the use of NSAIDs should be limited to short-term pain management and people with inflammatory pain such as rheumatoid arthritis. This leaves patients with limited options for pain management.
Many patients take high doses of opioids yet still suffer from pain and nausea. In many cases, pharmacogenetic testing can help identify whether the patient can convert the pro-opioids such as oxycodone, tramadol, codeine to more active metabolites. Patients with absent CYP2D6 function have no pain relief because these drugs are not “activated” by this key liver enzyme. Giving these patients more oxycodone or tramadol would not have any clinical effect. For these patients only morphine, fentanyl, and hydromorphone would be effective. However, this poses a huge risk for opioid addiction. Long term use of opioids is made complicated as the patient develops tolerance, known as opioid-induced hyperalgesia. They may also experience constipation and impaired cognitive function, which also prevent their return to work for those on short or long-term disability. Individuals with this drug metabolic profile, called CYP2D6 Poor Metabolisers, account for 15-20% of general population and cannot receive benefit from alternative pain treatment with TCAs and SNRIs, because these drugs also need to be cleared by the same liver enzyme CYP2D6. Another extreme patient population, CYP2D6 Ultrarapid Metabolisers, are at a substantially increased risk of accidental overdose with pro-opioids, and face the risk of opioid addiction and lack of response to TCAs and SNRIs.
North American news outlets are awash with titles about “the opioid crisis”. The Canadian Institute for Health Information reports that 12.5% of Canadians are being treated with opioids, while 20% of seniors over 65 are being prescribed an opioid. It’s time that Prior Authorization strategies for pain management incorporate evidence-based medicine should and available tools, including pharmacogenetics, to better guide the process. For many people cannabis may be the only therapeutic option. Pharmacogenetics can be used to determine both medical necessity for cannabis, and to establish the risk of side effects for other medications, which can be addressed through dose adjustment. A simple genetic test can take the place of months-long trials of different medication options. Pharmacogenetic testing can help plan sponsors streamline cannabis PA regulations, and help most claimants personalize pain management and reimbursement. While the use of medical cannabis will grow with legalization and greater acceptance by physicians as an effective pain management strategy, pharmacogenetic testing can help plan sponsors and insurers make coverage decisions that are based on medical necessity.
If you are one of the people who is struggling to find an effective pain medication, Pillcheck can help. Pillcheck analyzes your unique drug metabolism and recommends optimal medications and covers opioids, TCAs, SNRIs, NSAIDs, as well as THC and cannabinioids. Using Pillcheck to choose the right analgesic can reduce the risk of adverse side effects and feel better, faster. You should share your Pillcheck report and the pharmacist’s opinion letter with your doctor – that’s the best way to make use of the recommendations. This information can also help secure reimbursement for medical cannabis.