Tag: 2019 News

While state lawmakers are rushing to legalize cannabis for various reasons, including so called “medical reasons,” and courts are moving toward approving none FDA approved cannabis for treatment of workers’ compensation pain management, the medical research is trailing these decisions.

A good metaphor for this approach is “fire, ready, aim” since little is known about the relative harms of edible and inhalable cannabis products. And not all of the emerging medical research is good news for cannabis users

A new study funded by the Colorado Department of Public Health and Environment., and published in the Annals of Internal Medicine, documented a sharp rise in emergency-room visits linked with marijuana following legalization in Colorado. One of the key drivers of the ER visits was a mysterious syndrome characterized by severe nausea and repeated vomiting.

The researchers were tasked to describe and compare adult emergency department (ED) visits related to edible and inhaled cannabis exposure. The study focused on a chart review of emergency room visits between 1 January 2012 and 31 December 2016 at a large urban academic hospital in Colorado.

They found 9973 visits with an ICD-9-CM or ICD-10-CM code for cannabis use. Of these, 2567 (25.7%) visits were at least partially attributable to cannabis, and 238 of those (9.3%) were related to edible cannabis.

Very little is known about the condition, called cannabinoid hyperemesis syndrome, or CHS. Cannabinoid hyperemesis syndrome can occur with cannabis use and is characterized by recurrent nausea, vomiting, and crampy abdominal pain.

The pathogenesis of cannabinoid hyperemesis syndrome is unclear, but it may involve accumulation of exogenous cannabinoids or alterations in the brain’s regulation of body temperature.

The prodromal phase is characterized by subsyndromal symptoms of cannabinoid hyperemesis syndrome, including mild discomfort and nausea upon waking. Prior to the use of compensatory exposure to hot water to treat symptoms, people sometimes increase their intake of cannabinoids in an effort to treat the persistent nausea they experience. This phase can last for months or even years

The hyperemetic phase is characterized by the full syndromal symptoms of cannabinoid hyperemesis syndrome, including persistent nausea, vomiting, abdominal pain, and retching. Retching can occur up to 5 times per hour. It is very difficult to take food or medicine by mouth during this stage, and patients may develop a fear of eating. Weight loss and dehydration due to decreased oral intake and vomiting are possible.

Compensatory exposure to hot water, even for hours at a time, may be attempted for symptomatic relief, resulting in compulsive bathing/showering. People have described the hot water relief as “temperature-dependent,” meaning that hotter temperatures provide greater relief. It is during this phase that people with cannabinoid hyperemesis syndrome are likely to present to the emergency department of the hospital for treatment.

Individual attacks can lead to complications, such as acute kidney injury. In the setting of cannabinoid hyperemesis syndrome, this may be defined as cannabinoid hyperemesis acute renal failure (CHARF).

CHARF occurs through dehydration secondary due to persistent vomiting and hot showers, leading to prerenal azotemia. A case report of acute renal failure, albeit in the setting of rhabdomyolysis, has been reported with the use of synthetic cannabinoids.

While definitive treatment involves abstinence from cannabinoids, various drug therapies have been studied for symptomatic relief in the acute presentation of a patient suffering from cannabinoid hyperemesis syndrome, often in the setting of a hospital emergency department.

Food and Drug Administration Commissioner Scott Gottlieb called for tighter scrutiny of electronic health records systems, which have prompted thousands of reports of patient injuries and other safety problems over the past decade.

“What we really need is a much more tailored approach, so that we have appropriate oversight of EHRs when they’re doing things that could create risk for patients,” Gottlieb said in an interview with Kaiser Health News.

Gottlieb was responding to “Botched Operation,” a report published this week by KHN and Fortune magazine.

The investigation found that the federal government has spent more than $36 billion over the past 10 years to switch doctors and hospitals from paper to digital records systems. In that time, electronic health records have created a host of risks to patient safety.

Patient harm: Electronic health records have created a host of risks to patient safety. Alarming reports of deaths, serious injuries and near misses – thousands of them – tied to software glitches, user errors or other system flaws have piled up for years in government and private repositories. Yet no central database exists to compile and study these incidents to improve safety.

One example, an electronic health records system, or EHR, made by eClinicalWorks (eCW), one of the leading sellers of record-keeping software for physicians in America, currently used by 850,000 health professionals in the U.S. It didn’t take long for Foster to assemble a dossier of troubling reports – Better Business Bureau complaints, issues flagged on an eCW user board, and legal cases filed around the country – suggesting the company’s technology didn’t work quite the way it said it did.

In May 2017, eCW paid a $155 million settlement to the government over alleged false claims and kickbacks – one physician made tens of thousands of dollars – to clients who promoted its product. Despite the record settlement, the company denied wrongdoing

Signs of fraud: Federal officials say the software can be misused to overcharge, a practice known as “upcoding.” Some doctors and health systems are alleged to have overstated their use of the new technology, a potentially enormous fraud against Medicare and Medicaid likely to take years to unravel. Two software makers have paid a total of more than $200 million to settle fraud allegations.

Gaps in interoperability: Proponents of electronic health records expected a seamless system so patients could share computerized medical histories in a flash with doctors and hospitals anywhere in the country. That has yet to materialize, largely because officials allowed hundreds of competing firms to sell medical records software unable to exchange information.

Doctor burnout: Many doctors say they spend half their day or more clicking pulldown menus and typing rather than interacting with patients. An emergency room doctor can be saddled with making up to 4,000 mouse clicks per shift. This has fueled concerns about doctor burnout, which in January the Harvard T.H. Chan School of Public Health and Massachusetts Medical Society called a “public health crisis.”

Web of secrets: Entrenched policies continue to keep software failures out of public view. Vendors of electronic health records have imposed contractual “gag clauses” that discourage buyers from speaking out about safety issues and disastrous software installations – and some hospitals fight to withhold records from injured patients or their families.

For an in-depth examination of electronic health records, read “Death By 1,000 Clicks: Where Electronic Health Records Went Wrong.”

Many gig workers, whether in new occupations such as ride-hail driver, or traditional ones such as janitor or truck driver, could soon become employees in California after a ground breaking state Supreme Court ruling last year.

The Dynamex case implemented a simple criteria called the ABC test under which someone is an employee if a company controls what they do; if their work is linked to a company’s primary business; and if they do not have an independent business performing that work.

Assemblywoman Lorena Gonzalez, D-San Diego, is sponsoring a labor-backed bill that would codify that test. But numerous companies have lined up against it, saying it would undermine the flexibility that both they and gig workers value.

A separate case based on different criteria was decided in the U.S. Supreme Court this week. The high court declined to hear an appeal by the California Trucking Association, leaving intact a decision that could result in widespread reclassification of state truck drivers as employees.

Gig workers lack a whole list of protections afforded employees, including minimum wage, overtime, paid breaks, family and medical leave, paid sick leave, unemployment insurance and workers’ compensation. Those costs would add about 41 percent on top of the cost of wages, according to Bureau of Labor Statistics studies.

A new report from the UC Berkeley Labor Center examined demographics and wages, as well as employers’ classification practices, with an eye to the impact that changing workers’ status might have. Independent contractors – the status most gig workers have – don’t get benefits and must pay their own employment taxes, among other differences.

According to the summary prepared by the San Francisco Chronicle “These industries that are some of the worst offenders in California (for misclassification) have a disproportionate share of workers of color, immigrants and low-wage workers,” said Sarah Thomason, a research and policy associate at the Labor Center who co-authored the report. “These workers are in vulnerable positions and being exploited.”

Contracted janitors, for instance, make a median hourly wage of $12.22, and are 80.9 percent Latino and 3.7 percent black. Almost half live in households defined as low income (below 200 percent of the federal poverty line).

The report estimated that 19 percent of California janitors are independent contractors, without suggesting how many are misclassified.

Among truck drivers, the median hourly wage was higher at $19.70 but drivers have high expenses, with many having to purchase a truck and pay for fuel, insurance, maintenance and repair. About 60 percent were Latino and 6 percent were black. About a fifth live in low-income households.

The report quoted a National Employment Law Project report that about four-fifths of drivers at ports are classified as independent contractors, with the majority misclassified.

For construction workers, median hourly pay is $14.98 with 73.2 percent being Latino and 2.3 percent black. About 40 percent live in low-income households.

If the ABC criteria becomes more widely applied, “definitely misclassification would not happen as frequently,” Thomason said.

More than 100 insurance-fraud bills are pending state action. Major state supreme court cases also could have a dramatic impact on fighting fraud. Privacy of consumer data – and how it affects fraud investigations – should be also be closely watched this year.

The California legislature rushed through AB 375, the nation’s most sweeping data privacy law last June. The California Consumer Privacy Act of 2018 (CCPA) takes effect Jan. 1, 2020.

The CCPA applies to insurers and all other businesses in the state and has very severe restrictions on the use of private data. It is not clear what impact it might or might not have on an insurer’s ability to even report fraud.

California legislators rushed a bill through to avoid a ballot initiative proposed by Alastair Mactaggart. Mactaggart agreed to withdraw the initiative if a law was signed by the Governor. Legislators in other states will watch closely for how California’s more-sweeping law moves forward.

The NAIC approved its model data security law. The model already was adopted last year by South Carolina, Ohio, and Michigan. Many other states will likely debate adopting versions of the NAIC model this year.

And there is relentless push back from the applicant/plaintiff attempting to impose personal bad-faith liability. Insurer employees can be sued personally for bad faith in Washington state, a lower court ruled.

Keodalah v. Allstate Insurance arose from a motorcycle collision with a pickup truck in Seattle, resulting in an uninsured motorist claim. The appeals court ruled that Tracey Smith, the Allstate adjuster, can be sued personally, including claims for treble damages and attorney fees. Liability also would extend to outside experts who assist insurers, such as IME physicians, third-party investigators and defense attorneys.

Keodalah addressed a split of authority in Washington. Several federal court judges issued rulings from 2005 through 2016 that non-insurer entities were exempt from bad faith claims and Consumer Protection Act claims.

In 2017, another Division of Washington’s Court of Appeals in Merriman v. American Guarantee & Liability Ins. Co., held that Washington’s generalized statute requiring good faith in the “business of insurance” applied to the insurer’s third-party administrator.

The Keodalah case has been appealed to the Washington state Supreme Court, and will be closely watched..

Courts in Montana, Texas, Mississippi and Kentucky, have long recognized claims against adjusters for bad faith and violations of statutes governing claim-handling practices. In contrast, numerous other courts – including in Oklahoma, Indiana, Hawaii, Alabama, Tennessee, New Mexico, West Virginia, California, New York and Pennsylvania – have held that adjusters generally cannot be liable for bad faith. Many other jurisdictions are undecided.

The plaintiffs bar has also sought to apply RICO laws as a penalty in workers’ compensation claims in a number of jurisdictions for at least a decade with poor results. The 9th Circuit Court of Appeals just affirmed the dismissal of a California effort in the unpublished case of Black v CorVel Enterprises Comp Inc.

Many countries have legalized or decriminalized cannabis use, leading to concerns that this might result in an increase in cannabis use and associated harm.

Indeed, when it comes to “medical marijuana” the litigation and legislative trend seems to focus on the question of “cannabis – yes or no, – without contemplating the related questions of “how long” and “what kind.”

As the following study points out, there are highly potent forms of cannabis available in pot shops where an injured worker might fill a prescription. The legislators and litigation outcomes make no reference whatsoever to potent and dangerous types of cannabis which may sit side by side with other types in a pot shop.

Currently, cross-sectional and prospective epidemiological studies as well as biological evidence support a causal link between cannabis use and psychotic disorder. Meta-analysis shows a dose-response association with the highest odds of psychotic disorder in those with the heaviest cannabis use.

Nevertheless, it is not clear whether, at a population level, patterns of cannabis use influence rates of psychotic disorder.

For that reason, researchers aimed to identify patterns of cannabis use with the strongest effect on odds of psychotic disorder across Europe and explore whether differences in such patterns contribute to variations in the incidence rates of psychotic disorder.

To accomplish this mission, they targeted 901 patients aged 18 – 64 years who presented to psychiatric services in 11 sites across Europe and Brazil with first-episode psychosis and recruited controls representative of the local populations. The results of the study were published online this month in the Lancet Psychiatry.

Differences in frequency of daily cannabis use and in use of high-potency cannabis contributed to the striking variation in the incidence of psychotic disorder across the 11 studied sites. Given the increasing availability of high-potency cannabis, and the researchers say “this has important implications for public health.”

Daily cannabis use was associated with increased odds of psychotic disorder compared with never users increasing to nearly five-times increased odds for daily use of high-potency types of cannabis.

Use of high-potency cannabis was a strong predictor of psychotic disorder in Amsterdam, London, and Paris where high-potency cannabis was widely available, by contrast with sites such as Palermo where this type was not yet available. In the Netherlands, the THC content reaches up to 67% in Nederhasj and 22% in Nederwiet; in London, skunk-like cannabis (average THC of 14%) represents 94% of the street market whereas in countries like Italy, France, and Spain, herbal types of cannabis with THC content of less than 10% were still commonly used.

Researchers concluded that their findings are consistent with previous epidemiological and experimental evidence suggesting that the use of cannabis with a high concentration of THC has more harmful effects on mental health than does use of weaker forms.

If high-potency cannabis were no longer available, 12·2% of cases of first-episode psychosis could be prevented across the 11 sites, rising to 30·3% in London and 50·3% in Amsterdam.