Cannabis for Medical Purposes

Policy

Medical cannabis is not necessary, appropriate, or sufficient health care treatment for most medical conditions due to the lack of strong and consistent evidence of therapeutic efficacy, and the known harms of cannabis use. However, in limited circumstances, medical cannabis may be necessary, appropriate, and sufficient health care treatment as a result of a work-related injury/disease.

When entitlement to medical cannabis is allowed, the WSIB will regularly monitor its use and effectiveness and suspend or discontinue entitlement when it is no longer necessary, appropriate, or sufficient.
 

Purpose

The purpose of this policy is to establish guidelines that govern entitlement to, review of, and payment for medical cannabis.

Definitions

For the purposes of this policy, the following definitions apply:

cannabis for medical purposes or medical cannabis means dried cannabis, cannabis oil, or any other lawful class of cannabis, except cannabis plants and cannabis plant seeds, that an individual is authorized to access for medical purposes. Medical cannabis does not have a drug identification number (DIN) or a natural product number (NPN). Medical cannabis does not include pharmaceutical cannabinoids;

CBD means cannabidiol, a major cannabinoid found in cannabis, reported to have potential therapeutic effects and no obvious psychotropic effects;

contraindication or contraindicated means a situation in which the risks of medical cannabis treatment will generally outweigh any potential therapeutic benefits. For greater certainty and without limiting the foregoing, medical cannabis is contraindicated for individuals who

  • are under the age of 25
  • have a personal or strong family history of psychosis
  • have a current or past cannabis use disorder
  • have a current or past substance use disorder
  • are pregnant, planning to become pregnant, or breast feeding
  • have cardiovascular disease, or
  • have severe liver or kidney disease;

designated condition means one of the following conditions for which there is evidence of the therapeutic efficacy of medical cannabis:

  • neuropathic pain
  • spasticity resulting from a spinal cord injury
  • nausea and vomiting associated with cancer chemotherapy
  • loss of appetite associated with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS), or
  • pain and other symptoms experienced in a palliative setting;

health professional means a physician or a nurse practitioner (also known as a Registered Nurse in the Extended Class);

license holder means the holder of a license for sale of medical cannabis;

medical document means, in accordance with the Cannabis Regulations, the authorization document that a health professional provides to an individual under their professional treatment to support the individual's use of medical cannabis;

neuropathic pain means pain arising as a direct consequence of a demonstrable lesion or disease affecting the somatosensory system (e.g., pain caused by a traumatic nerve injury);

period of use means the number of days, weeks, or months indicated on a medical document that the individual named on the document is authorized to access medical cannabis. Under the Cannabis Regulations, the period of use cannot exceed one year;

pharmaceutical cannabinoids means cannabinoids produced in controlled pharmaceutical manufacturing environments that have been issued a DIN (e.g., Nabilone (Cesamet®)) and Nabiximols (Sativex®));

precaution means a situation in which medical cannabis should only be used with caution because of the risks involved. For greater certainty and without limiting the foregoing, medical cannabis should be used with caution in those individuals who

  • have a current mood or anxiety disorder
  • are heavy users of alcohol
  • are taking opioids or benzodiazepines, or
  • have risk factors for cardiovascular disease;

smoking means a route of administration in which the medical cannabis is ignited or combusted so the resulting smoke can be inhaled;

THC means delta-9-tetrahydrocannabinol, a major cannabinoid found in cannabis, reported to have therapeutic effects and to be chiefly responsible for the psychotropic effects of cannabis;

vapourizing means a route of administration in which air heated to extreme temperatures by a vapourizer device is passed over the medical cannabis so the resulting vapour can be inhaled;

written order means, in accordance with the Cannabis Regulations, written authorization from a health professional practicing in a hospital that a stated amount of medical cannabis be dispensed for an individual under their professional treatment.

Overview of entitlement criteria

Except where otherwise provided in this policy in relation to palliative care, entitlement to medical cannabis for a work-related injury/disease may be allowed if all of the following criteria are met:

  1. The worker has a designated condition.
  2. The worker's treating health professional authorizes medical cannabis to treat the designated condition.
  3. The worker has exhausted conventional treatments for the designated condition.
  4. An appropriate clinical assessment of the worker has been conducted.
  5. The benefits of medical cannabis for the worker outweigh the risks.
  6. The dose and route of administration authorized for the worker are appropriate.
  7. The worker has a valid medical document or a written order for medical cannabis.

Entitlement criteria

1. Designated condition
Entitlement to medical cannabis will only be considered if

  • the worker has a designated condition, and
  • the designated condition is clinically associated with a work-related injury/disease or its treatment.

2. Medical cannabis must be authorized by the treating health professional
The health professional who authorizes the medical cannabis to treat the designated condition should be the health professional responsible for managing the ongoing care of the designated condition and/or the associated work-related injury/disease and for conducting regular clinical reassessments of the worker's response to the medical cannabis treatment.

Where another health professional authorizes the medical cannabis and assumes responsibility for conducting regular clinical reassessments of the worker's response to the medical cannabis treatment, the primary treating health professional must support the use and the continued use of medical cannabis for the designated condition.

NOTE
For information about the choice and change of health professionals, see 17-01-03, Choice and Change of Health Professionals.

3. Exhausting conventional treatments
Except in cases of palliative care, the worker must exhaust conventional treatments before initial entitlement to medical cannabis will be considered. The use of conventional treatments and the worker's response to those treatments must be clearly documented in the worker's medical records.

A worker exhausts conventional treatments when

  • the worker has had adequate trials of appropriate conventional treatments for the designated condition, and
  • the treatments are either ineffective (e.g., fail to alleviate or improve the designated condition) or not tolerated.

NOTE
In this section,
"adequate trial" means the worker has tried a treatment

  • at an appropriate dose for a duration that allows for the proper evaluation of the efficacy of the treatment, or
  • until an adverse reaction prevents continuation.

In the case of neuropathic pain, an adequate trial of a treatment will usually be three months.

"appropriate conventional treatments" means both appropriate pharmaceutical and non-pharmaceutical treatments. Additionally, in the case of neuropathic pain, appropriate conventional treatments means the worker has tried, at a minimum, three first-line and/or second-line treatments, and a pharmaceutical cannabinoid.

4. Clinical assessment
An appropriate clinical assessment of the worker, with measurable findings, must take place before initial entitlement to medical cannabis will be considered. Likewise, subsequent reassessments must be conducted to support ongoing entitlement to medical cannabis. The results of these assessments/reassessments must be clearly documented in the worker's medical records to establish the necessity, appropriateness, and sufficiency of the medical cannabis treatment.

An appropriate clinical assessment/reassessment will generally

  • identify measurable treatment goals that will be used to evaluate the progress of the medical cannabis treatment (e.g., weight gain, cessation of nausea or vomiting, pain relief, improved or sustained function, return to work)
  • evaluate whether any progress towards identified treatments goals has been made as a result of the medical cannabis treatment
  • advise the worker of the potential risks of medical cannabis and about the safe use of medical cannabis
  • assess the worker for contraindications and precautions including, but not limited to,
    • anxiety and mood disorders, and
    • substance use disorders using a validated addiction risk screening tool, such as the CAGE-AID or the Opioid Risk Tool
  • assess the worker for adverse effects, side effects, complications, or any change in function
  • where the worker has neuropathic pain or spasticity, administer both baseline and follow-up pain and functional assessments of the worker using validated measures, such as the Brief Pain Inventory (BPI) and Short Form Health Survey (SF-36)
  • identify a clinical rationale for the daily quantity of dried cannabis, the THC percentage, and the period of use authorized for the worker, and
  • identify the potential impacts to the worker's ability to perform their work duties, in particular, any safety sensitive tasks, such as driving or operating machinery.

5. The benefits of medical cannabis outweigh the risks
Medical cannabis can be considered where the benefits of the treatment for the worker outweigh the risks. Any factors that may increase the risks of medical cannabis will be considered when determining its necessity, appropriateness, and sufficiency. Without limiting the foregoing, such factors include where

  • medical cannabis is contraindicated
  • precautions are present
  • the potential exists for adverse drug reactions/interactions, or
  • the treatment may impede the worker's recovery.

6. Dose and route of administration
Subject to the limits on dosing and administration in this section, an appropriate dose will generally be the lowest safe and effective dose of medical cannabis in terms of both the daily quantity and THC percentage.

Dosing should begin at the lowest possible dose and proceed slowly and cautiously in a gradual fashion.

Limits on dosing and administration
The medical cannabis and route of administration authorized for the worker must satisfy all of the following:

  • The route of administration must not involve smoking.
  • The daily quantity of dried medical cannabis must not exceed three grams per day.
  • The medical cannabis should be CBD-rich with minimal THC.
  • The THC percentage of the medical cannabis must not exceed nine per cent.
  • The milligrams (mg) of THC per day should be no more than 30 mg, but in no case shall exceed 75 mg.

NOTE
Information about how to calculate mg of THC per day can be found in the Appendix.

7. Valid medical document or written order
The worker must have a valid medical document or a written order. A medical document remains valid for the period of use specified on it.

In addition to satisfying the requirements of the Cannabis Regulations, the medical document or written order must comply with the dosing and route of administration criteria in this policy and specify

  • the maximum THC percentage of the medical cannabis authorized for the worker, and
  • a route of administration. (The route of administration must not involve smoking.)

NOTE
The requirements applicable to a medical document under the Cannabis Regulations can be found in the Appendix.

Reviewing and monitoring entitlement

When entitlement to medical cannabis is allowed, the WSIB reviews and monitors the use and effectiveness of medical cannabis and may suspend or discontinue entitlement when it is determined medical cannabis is no longer necessary, appropriate, or sufficient treatment.

Regular review
Except in cases of palliative care, entitlement to medical cannabis will be reviewed no more than three months after the date of initial entitlement or when an adjustment to the worker's dose occurs, and subsequently at regular intervals of no more than six months from the previous review.

Ongoing entitlement may be allowed where

  • the worker has been clinically reassessed, and
  • the clinical reassessment and other relevant evidence support that medical cannabis continues to be a necessary, appropriate, and sufficient treatment for the designated condition.

Material change
A worker must advise the WSIB of any material change in circumstances, e.g., a change in health care status that may affect entitlement to medical cannabis (see 22-01-02, Material Change in Circumstances - Worker).

Suspending or discontinuing entitlement
The WSIB may suspend or discontinue entitlement to medical cannabis where there is evidence it is no longer necessary, appropriate, or sufficient treatment including, but not limited to, where

  • the worker experiences insufficient progress towards identified treatment goals (e.g., weight gain, cessation of nausea or vomiting, pain relief, improved or sustained function, return to work) recognizing reasonable adjustments to the worker's dose may be required
  • the worker experiences adverse effects or substantial side effects
  • the worker develops cannabis use disorder, or
  • the treatment impedes the worker's recovery.

Misuse and diversion
The WSIB will discontinue entitlement to medical cannabis where there is evidence the worker is

  • misusing the medical cannabis, or
  • diverting the medical cannabis (e.g., selling it or providing it to others).

Misuse and diversion may be considered to be a claims-related offence. The WSIB pursues the recovery of funds, equipment, or value of services paid to individuals who claim benefits deceptively. Recovery measures used by the WSIB include charges under the Workplace Safety and Insurance Act, 1997, action in civil court, and/or the creation of a benefit-related debt (see 22-01-07, Offences and Penalties - Worker).

Criteria for payment

The WSIB will generally pay for the reasonable costs of medical cannabis if all of the following criteria are met:

  • The applicable entitlement criteria have been met and entitlement is allowed.
  • The medical cannabis is obtained from a license holder with whom the worker is registered as a client or from a hospital. (No payment will be made where the worker obtains or seeks to obtain cannabis from any other source, e.g., designated production, personal production, or a recreational cannabis retailer.)
  • Itemized invoices or accounts from the license holder or hospital are submitted to the WSIB.
  • The itemized invoices or accounts are in alignment with the authorization in the medical document or written order.

Where the approved route of administration is vapourizing, the WSIB will also cover the reasonable cost of a vapourizer. No other devices or paraphernalia for medical cannabis will be covered. Replacements for vapourizers are generally limited to once every two years. If the vapourizer, paid for by the WSIB, is lost or stolen, the WSIB generally replaces it on a once-only basis. Replacement of the same vapourizer, if it is lost or stolen again, is the worker’s responsibility.

Approval before purchase

Before purchasing medical cannabis or a vapourizer for medical cannabis, the worker must get approval from the WSIB for the purchase.

The WSIB is not responsible for the cost of the medical cannabis or the vapourizer incurred by the worker where

  • entitlement to medical cannabis is not allowed, or
  • the medical cannabis does not meet the authorization in the medical document or written order.

Likewise, the WSIB is not responsible for the cost of the medical cannabis or the vapourizer incurred by the worker above the approved amount.

Application date

This policy applies to all purchases of medical cannabis or vapourizers for medical cannabis made on or after March 1, 2019 for all accidents.

Document History

This is a new document.

Policy review schedule

This policy will be reviewed within two years of the application date.

References

Legislative Authority

Workplace Safety and Insurance Act, 1997, as amended 
Sections 1, 22, 23, 32, 33, 34, 35, 36, 37, 159

Cannabis Regulations (made under the Cannabis Act, S.C. 2018, c. 16)

Minute

Board of Directors #4, December 12, 2018, Page 7621

Appendix

Cannabis Regulations - medical document requirements

The medical document authorizing a worker's access to medical cannabis must indicate the following:

  • the health professional's given name, surname, profession, business address, telephone number, and, if applicable, their facsimile number and email address;
  • the province in which the health professional is authorized to practice their profession and the number assigned by the province to that authorization;
  • the given name, surname, and date of birth of the worker who is under the professional treatment of the health professional; the address of the location at which the worker consulted with the health professional;
  • the address of the location at which the worker consulted with the health professional;
  • the daily quantity of dried cannabis, expressed in grams, that the health professional authorizes for the worker;
  • the period of use, expressed as a number of days, weeks or months, which must not exceed one year.

A medical document must be signed and dated by the health professional who is providing it and must include a statement confirming that the information in the document is correct and complete.

Calculating "milligrams of THC per day”

Milligrams of THC per day are calculated as follows:

Q x P = mg of THC per day

where,

  • Q is the daily quantity of dried medical cannabis expressed in milligrams (e.g., one gram per day equals 1000 mg per day), and
  • P is the THC percentage of the dried cannabis expressed as a decimal (e.g., .02 for two per cent THC)