APPEALS RESOLUTION OFFICER DECISION

DECISION NUMBER:

20250052

OBJECTING PARTY:

WORKER

REPRESENTED by:

WORKER REPRESENTATIVE

RESPONDENT PARTY:

EMPLOYER (NOT PARTICIPATING)

HEARING:

HEARING IN WRITING

HEARD by:

DATED:

E. PARSONS, APPEALS RESOLUTION OFFICER

MARCH 17, 2025

ISSUE

The worker, through their representative, is objecting to the Nurse Consultant’s decision dated October 11, 2019, which denied entitlement to medical cannabis.

BACKGROUND

On August 3, 2012, this Truck Driver sustained injuries in an assault and attempted robbery. Initial entitlement to health care benefits was allowed for strain/sprain, contusion, and abrasion injuries to the chest, right elbow, and right hand. Entitlement was later expanded to include posttraumatic stress disorder (PTSD) and cervical radiculopathy, cubital tunnel syndrome, and ulnar transposition surgery. A permanent impairment was accepted for both physical and psychological injuries, and the worker received a combined non-economic loss award of 24%.

In May 2019, the worker requested coverage and reimbursement for medical cannabis. In a decision dated October 11, 2019, the Nurse Consultant denied entitlement to medical cannabis because there had not been an appropriate clinical assessment, nor sufficient trials of conventional treatments for neuropathic pain. The decision was reconsidered on January 2, 2020, and December 17, 2020, however the original decision was upheld.

The worker disputes the decision dated October 11, 2019, and the matter has been referred to the Appeals Services Division for further review.

AUTHORITY

Operational Policy Manual

Published

17-01-10 Cannabis for Medical Purposes

March 1, 2019

ANALYSIS

I have carefully considered all of the available information, legislation and relevant operational policies in reaching this decision.

For the reasons outlined below, I find there is no entitlement for medical cannabis.

Worker’s Position

In the submissions dated May 28, 2020, November 18, 2024, and February 19, 2025, the worker representative submitted that entitlement to medical cannabis should be granted, and the worker should be reimbursed for medical cannabis related expenses to date. The representative contends that the worker’s medical cannabis is necessary, appropriate, and sufficient, pursuant to policy 17-01-10 (Cannabis for Medical Purposes). They referenced several decisions from the Workplace Safety and Insurance Appeals Tribunal (WSIAT) and submitted various medical documentation in support of their position.

Employer’s Position

The employer is not participating in the appeal and did not provide any submissions for my review.

Assessment and Findings

I find entitlement to medical cannabis remains denied. My reasons for why are outlined below.

In the submission dated May 28, 2020, the worker representative referenced several WSIAT decisions which addressed the issue of entitlement to medical cannabis. Prior to March 1, 2019, there was no policy that applied specifically to medical cannabis coverage. As a result, the WSIAT developed and applied 6 requirements to determine entitlement to medical cannabis before March 1, 2019. The worker representative requested these guidelines be applied when determining the merits of this case as the WSIAT guidelines are reasonable, relevant, and applicable to the worker’s situation.

I found it appropriate to rely on policy 17-01-10 (Cannabis for Medical Purposes) which establishes guidelines that govern entitlement to, review of and payment for medical cannabis after

March 1, 2019. The case falls within the application period as the worker sought entitlement for medical cannabis after the policy came into effect. Furthermore, the policy was developed through careful consideration of the existing scientific evidence on medical cannabis and adopted many of the criteria used by the WSIAT.

Policy 17-01-10 (Cannabis for Medical Purposes) provides that medical cannabis is not necessary, appropriate, or sufficient health care treatment for most medical conditions due to the ack 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.

To allow entitlement to medical cannabis for a work-related injury/disease, all of the following criteria must be 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.

As part of my review, I considered each criterion separately to arrive at my conclusion.

1. Does the worker have a designated condition?

I find the worker has entitlement for a designation condition.

Policy 17-01-10 (Cannabis for Medical Purposes) provides a 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 state.

In this case, the worker has entitlement for cervical radiculopathy and ulnar neuropathy. I relied on Memo 34 dated December 12, 2012, which first confirmed entitlement to these conditions and established compatibility to the accident history. As such, I find the first criterion has been met.

2. Did the treating health care practitioner authorize medical cannabis to treat the designated condition?

I find the treating practitioner authorized medical cannabis to treat the designated condition.

The Cannabis Initial Assessment Form completed on September 25, 2019, confirms medical cannabis was being prescribed for neuropathic pain. As noted above, this is a designated condition, and the worker has entitlement to neuropathic pain within the scope of the claim. Therefore, I find this criterion is met.

3. Has the worker exhausted conventional treatments for the designated condition?

I find the worker did not exhaust conventional treatments before turning to medical cannabis.

Policy 17-01-10 (Cannabis for Medical Purposes) provides that 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 workers’ 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.

The policy further clarifies that “adequate trial” means the worker has tried treatment at an appropriate dose for a duration that allows for the proper evaluation of 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.

With respect to “appropriate conventional methods”, this refers to both appropriate pharmaceutical and non-pharmaceutical treatments. Additionally, in the case of neuropathic pain, appropriate conventional treatments mean the worker has tried, at a minimum, three first line and/or second-line treatments, and a pharmaceutical cannabinoid.

In the correspondence dated February 19, 2025, the worker representative indicates the worker tried various pharmaceutical and non-pharmaceutical treatment modalities before resorting to medical cannabis. The worker tried but did not tolerate Tramadol, Tramacet, Tylenol 3, Oxycodone/Percocet, and Nabilone. The worker representative contends many of the prescribed medications resulted in the worker feeling impaired to the degree that they were not able to drive and remain independent. Other medications caused stomach upset, brain fog, insomnia, and paralysis. Cannabidiol (CBD) is the only medication that effectively manages their pain symptoms without side effects.

In reviewing the medical evidence, I find there is insufficient evidence the worker exhausted conventional treatments as defined by the policy. While the representative contends the worker has trialed sufficient first- and second-line treatments, the contemporaneous medical documentation does not reflect this.

Moreover, the medical documentation does not show that all medications tried were ineffective or not tolerated.

First line treatments for neuropathic pain include Tricyclics, Serotonin-norepinephrine reuptake inhibitors (SNRI’s), and Gabapentinoids. I was unable to find sufficient medical evidence to support the worker trialed these options. There is no evidence the worker tried Tricyclics (such as amitriptyline or nortriptyline). There is no evidence the worker tried SNRI’s (such as venlafaxine or duloxetine).

With respect to Gabapentinoids, I found two undated clinical chart notes which indicate the worker was prescribed Lyrica and later reported they did not tolerate it. There is no detailed information with respect to when the worker was prescribed Lyrica, how long the worker trialed the medication, or what the side effects were. In my view, the available information is insufficient to support the worker completed adequate trials of front-line treatments.

Turning to second-line treatments, the worker was prescribed Percocet for pain control following the right ulnar nerve transposition surgery on May 21, 2014, as confirmed by the operative report. There is no clinical information confirming the worker did not tolerate the medication, that it was ineffective, or that it was prescribed beyond the acute post-surgical recovery period.

I found no detailed medical information on the worker’s use of Tramadol. The only mention of this medication is in the Cannabis Initial Assessment Form completed on September 25, 2019, and a report from cannabis consultants dated November 26, 2024 report. Both reports indicate the worker did not tolerate it but do not provide further information.

The worker was prescribed Tramacet during a follow up assessment on November 24, 2014, after undergoing a facet joint injection on October 28, 2014. On January 5, 2025, and April 13, 2015, the worker attended additional follow up visits and reported some good effect with Tramacet. There was no reporting of an inability to tolerate the medication, and the prescription was renewed. No other interventions for pain control were recommended other than oral analgesics.

On November 14, 2017, the worker attended a WSIB arranged comprehensive assessment at Hospital A. The report indicates the worker reported they were taking Tylenol #3 as needed but not too often. The worker reported they felt their pain was well managed and that they did not use street drugs. The worker reported they had tried other medications but stopped due to irritability. The names of the medications, duration of trial periods, and timing of cessations were not provided. In my view, the available information is insufficient to support the worker completed adequate trials of second-line treatments, and that these trials were unsuccessful.

Turning to third-line treatments, I find there is insufficient evidence the worker trialed a pharmaceutical cannabinoid. There is a mention of Nabilone in the June 17, 2021 psychologist report. The worker reported the medication helped to some degree, but they felt groggier and unsure of their ability to drive. There is also a single undated clinical chart note from the family doctor indicating the worker did not tolerate Nabilone. There is no further documentation to confirm when the mediation was prescribed, the duration of the trial, and the timing and reason for discontinuation.

Having considered the available evidence, I find the worker did not exhaust conventional treatment methods before turning to medical cannabis. In my view, there is insufficient information to support the worker trialed sufficient first line and second line treatments, and a pharmaceutical cannabinoid.

Furthermore, I found insufficient evidence that many of the second line treatments tried were ineffective or not tolerated. Thus, I find the criterion is not met.

4. Has an appropriate clinical assessment of the worker been conducted?

I find the available evidence does not support an appropriate clinical assessment was conducted.

Policy 17-01-10 (Cannabis for Medical Purposes) provides an appropriate clinical assessment of the worker, with measurable findings, must take place before initial entitlement to medical cannabis will be considered. The results of the assessment mut 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 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 treatment goals has been made as a result of the medical cannabis treatment
• advise the worker of the potential risks of medical cannabis including any risks associated with the route(s) of administration (e.g., vapourizing, ingestion) 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-ID 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 class(es) of cannabis, route(s) of administration, daily quantity of dried cannabis (or it’s equivalent), milligrams of delta-9-tetrahydrocannbinol (THC) per day, maximum THC concentration and the period of authorization 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.

I find the Cannabis Initial Assessment Form completed on September 25, 2019, did not confirm a comprehensive assessment was completed. The information gathered by this form was sparse, and it did not identify known precautions and considerations for medical cannabis use. Additionally, there is no evidence the prescribing physician administered a pain and functional assessment of the worker using validated measures, nor used validated addiction risk screening tools to review for contraindication.

I reviewed the report from the cannabis consultant dated November 26, 2024. I find this report does not satisfy all of the information and considerations specified above by policy 17-01-10 (Cannabis for Medical Purposes). The report does not confirm the health provider assessed the worker for substance use disorders using a validated addiction risk screening tool, nor administered a pain and functional assessment of the worker using validated measures. Lastly, the report confirms the worker was prescribed 6g of cannabis per day. The report does not contain a clinical rationale for the daily quantity of cannabis, the THC percentage, and the period of use authorized for the worker.

Given the above, I find the available evidence does not support an appropriate clinical assessment was conducted. The criterion has not been met.

5. Do the benefits of medical cannabis for the worker outweigh the risks?

I find there is insufficient evidence to support the benefits of medical cannabis outweigh the risks.

Policy 17-01-10 (Cannabis for Medical Purposes) provides that 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 risk for adverse drug reactions/interactions, or
• the treatment may impede the worker’s recovery.

The policy defines a contraindication as a situation in which the risks of medical cannabis treatment 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 breastfeeding
• have cardiovascular disease, or
• have severe liver or kidney disease

The policy defines a precaution as 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

While the worker does not have any of the contraindications specified by the policy, they do have medical precautions and the potential risk for adverse drug reactions/interactions.

There is consistency across medical reports that the worker has high blood pressure and dyslipidemia. Both conditions are risk factors for cardiovascular disease. The worker also smokes cigarettes, which is also a significant risk factor for cardiovascular disease. As noted in the policy, risk factors for cardiovascular disease are considered a precaution.

The worker takes medications which can interact with medical cannabis. The worker takes medications for high blood pressure and to lower cholesterol levels. Both medications have potential for adverse drug reactions/interactions, and this was identified in the cannabis consultant report dated November 26, 2024.

The worker was diagnosed with PTSD and depressive disorder not otherwise specified. The worker representative contends that PTSD is distinguishable from the contraindications and precautions outlined in the policy. They submit the worker does not have an anxiety, mood, or substance disorder. The worker is not psychotic, and they do not have any emotional-neuro-chemical dysregulations. They submit the PTSD symptoms are the result of external stimuli and the potential for new exposures, and the condition is not mood or personality based.

Furthermore, the worker representative asserts the worker’s psychologist did not indicate any concerns about potential adverse effects of medical cannabis. They contend the absence of reported concerns by the psychologist should be viewed as tacit support and afforded significant weight.

I am not persuaded by the worker representative’s arguments. As stated above, the worker’s PTSD clinical presentation and symptomology has consistently featured significant anxiety related symptoms. In making my findings, I carefully reviewed the available psychological reports that coincide with the worker’s referral to a medical cannabis clinic.

The Community Mental Health Program (CMHP) Initial Assessment Report dated February 2018, confirms the worker continued to endorse symptoms of PTSD including insomnia, nightmares, anger and irritability, flashbacks, intrusive thoughts, hypervigilance, increase startle response, issues with memory and concentration. The psychologist noted the worker had clinically significant elevation on anxiety scale.

CMHP progress reports dated April 24, 2018, June 25, 2018, August 2018, and November 5, 2018, confirm the ongoing diagnoses of PTSD and depressive disorder not otherwise specified. The psychologist specifies that the worker’s ongoing anxiety was significant to the extent that it resulted in functional impairment and prevented a return to truck driving. The worker was reported to be anxious when people are behind or around them and had difficulty being in crowds. The worker was noted to have irritability and anger which impacted interpersonal relationships. They had a lack of emotional regulation.

A narrative psychological progress report dated May 23, 2019, notes that while the worker’s PTSD symptoms were usually under control, the worker remains unable to tolerate people coming up behind them and has little patience during interpersonal interactions.

In my view, the worker’s PTSD and depressive disorder not otherwise specified represent additional precautions due to their longstanding hypervigilance, panic, and anxiety. I do not accept the position that

the worker’s psychologist was supportive of the use of medical cannabis. Psychologists are not medical doctors. They do not prescribe medications. While they can work effectively with medical professionals to deliver comprehensive care, commenting on efficacy or contraindications of medical cannabis, or any pharmacological interventions, is considered outside their scope of practice.

Having considered the evidence, I am unable to conclude the benefits of medical cannabis outweigh the risks. The worker has several clinical precautions, and there is a significant risk for adverse interaction with their prescription medications for high blood pressure and cholesterol. There is no documented clinical rational that addresses the appropriateness of medical cannabis despite presence of the known precautions and risks. As a result, I find the criterion is not met.

6. Are the dose and route of administration authorized for the worker appropriate?

I find the route of administration appropriate, however the authorized dosage is outside the policy guidelines.

In accordance with Policy 17-01-10 (Cannabis for Medical Purposes), the medical cannabis and route(s) 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 (or its equivalent) must not exceed three grams.
• The medical cannabis should be cannabidiol (CBD)-rich with minimal THC.
• The THC concentration of medical cannabis that is intended for inhalation must no exceed 90 milligrams of THC per gram (i.e., nine per cent THC by weight)
• The milligrams of THC per day must not exceed 30 milligrams.

In all cases, the classes of medical cannabis, the types of products within a class, and/or the specific cannabis products must be necessary, appropriate and sufficient in the circumstances.

In their submission dated November 18, 2024, the worker representative confirmed the worker uses approximately 6g of cannabis per day. This amount is consistent with the November 24, 2024 report from the cannabis consultant, which confirms the worker was being prescribed 6 grams per day.

I find that a prescription and usage of 6g per day exceeds the accepted daily maximum quantity of 3g. As the worker’s daily quantity exceeds the policy guidelines, I find the criterion has not been satisfied.

7. Does the worker have a valid medical document or written order?

I find the worker has a valid medical document or written order.

Policy 17-01-10 provides 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 milligrams of THC per day approved for the worker, and
• The route(s) of administration. (The route of administration must not involve smoking)

I find the Cannabis Initial Assessment Form completed on September 25, 2019, is considered a valid medical document, and complies with the dosing and route of administration criteria. Thus, I find this criterion has been met.

In conclusion, in accordance with Policy 17-01-10 (Cannabis for Medical Purposes), I find medical cannabis is not considered to be necessary, appropriate, and sufficient treatment for the worker’s neuropathic pain. As outlined above, all of the requisite criteria of the policy were not satisfied based on the available information. Thus, I find there is no entitlement to medical cannabis.

CONCLUSION

I conclude there is no entitlement to medical cannabis. The worker’s objection is denied.

DATED MARCH 17, 2025

E. Parsons

Appeals Resolution Officer Appeals Services Division