“We’re going to have to be very careful with these pain pills,” I said to one of my patients who was suffering from intermittent headaches. “There are some new laws in Hawaii that require that we review a few things if you’re going to be on any type of opioid pain medication for more than three months.”

“Well, I don’t know how long this pain is going to last,” she replied.

“And right now, I don’t either,” I said. “But if we get to that three month time frame, we’re going to have to look at a couple more papers together and make sure we have a plan.”

“Can I qualify for medical marijuana if my headaches become chronic, instead of Tylenol with codeine? Would my insurance pay for that instead?” she asked.

Thus we hit an interesting predicament.

Anthony Quintano/Civil Beat

“No,” I told her. “Insurance won’t cover for medical marijuana, but might for other alternative treatments like acupuncture, massage, or other medications.”

In an effort to reduce the use of opiate-based treatments, physicians and patients alike have been forced to look for other options to meet the needs of those who suffer with chronic pain. Recent changes in the law have restricted the quantity of medication that can be given at any one time, and people are looking for other substitutes for pain pills.

What about medical marijuana?

Not enough is known about the use of this for chronic pain, but some of the same conditions that qualify patients to use medical marijuana include those for which they might now be taking painkillers like hydrocodone or oxycodone. Chronic headaches, migraines, fibromyalgia and chronic muscle spasms are on the list.

Could marijuana help to ease the opioid epidemic? Should insurance be required to cover it?

Medicare has taken a firm stance against this. With the current designation of marijuana by the U.S. Drug Enforcement Agency as a Schedule 1 narcotic, research is prohibited that might otherwise determine if there are any viable uses for marijuana to treat chronic pain. But all 30 states that have legalized medical marijuana have listed pain or some medical condition that causes pain as a qualifying condition.

Without the research to support its use, government and commercial insurance plans are not going to budge on their current coverage policies. This leaves patients to pay the difference — those who can afford it.

The research thus far has provided conflicting evidence on the efficacy of medical marijuana in reducing opioid use. The Lancet just published a prospective four-year analysis of patients who self-reported marijuana use in Australia, and found no clear association with the use of this substance medicinally on the overall amount of opioids that were taken, or any reduction in pain.

But earlier studies done in the U.S. have noted significantly lower overdose mortality rates from opioid use in states that have legalized the use of medical marijuana. These studies did not have a definitive explanation on why the overdose rates declined, but rather suggested more research needs to be done to substantiate the findings.

Which brings us back to the coverage of medicinal use of marijuana by commercial insurance companies. Annual expenditures for opioids are generally low, given the generic status of most of the medications in short-acting forms. Insurance does cover for these, along with some of the currently accepted non-opioid alternatives, including nerve medications like nortriptyline, gabapentin, pregabalin and NSAIDs. These are paid for with a drug plan, and may have a copay involved.

Alternatives to medication are also increasingly covered by local commercial insurance plans. Physical therapy, massage therapy, chiropractic care and acupuncture are often covered benefits or additional riders that can be purchased to supplement the primary health insurance plan.

So, with the added restrictions on the use of opiates, should patients be given the option of using their drug benefits on medical marijuana?

Opponents feel that until the research is done, there may not be a role for the use of marijuana to treat chronic pain, and without this peer-reviewed analysis to prove efficacy, there is no need to cover what could be considered “experimental treatment.”

Workers comp plans do not cover this, as proven in the recent case with the Hawaii Employers’ Mutual Insurance Company rescinding reimbursement for medical cannabis, stating it followed the federal Medicare fee schedule, which does not pay for medical marijuana. The case could go all the way to the Hawaii Supreme Court, in an attempt to legislate an answer to what is still not adequately determined in the medical literature.

That leaves patients to pay cash if they do qualify to purchase medical marijuana at the local dispensaries, and it is not cheap. The costs can run into hundreds of dollars a month to treat an illness that might be significantly less expensive if prescription opioids are used instead.

All of this leads to the absolute requirement that marijuana be removed from Schedule 1 status so that research can determine if it’s a viable alternative to the pain medications on the market.

Without the research to support its use, government and commercial insurance plans are not going to budge on their current coverage policies. This leaves patients to pay the difference — those who can afford it.

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