Hi, everyone. Thank you for joining our webinar. Today we're going to talk about cannabis for pain, what the ACON Clinical Guideline Recommendations talk about. There are two features available to communicate with the panelists and other attendees. You may post general messages in the chat feature. Questions can be shared with either the panelists or all participants. Use the drop-down box to select who you want to share your message with. Why don't you now try to test it by introducing yourself to the panelists and attendees. Let us know your role and where you're from. If you have any questions during the webinar, they should be submitted in the Q&A box. Panelists are monitoring this box for questions, so please be sure to post all questions here and not in the chat box. ACON is a membership organization that provides leadership to promote optimal health and safety for workers, workplaces, and environments. So if you're not currently an ACON member, this is a plug that is a great organization and please consider joining. Just a reminder, as we are recording the session today and it will be emailed out as a link to as a recording for all registrants after the webinar. These are our speakers. Hi, my name is Carrie Wiesner. I am the head of epidemiology at MD Guidelines. I'm going to be your moderator today. Our first speaker is Dr. Goldberg, who is a board-certified specialist in occupational environmental medicine. He currently serves on the ACON Chronic Pain Guideline Committee and has served as the president of ACON and WOMA, as well as on numerous committees and councils. Dr. Goldberg has presented nationally on medical marijuana and its potential uses, the workplace safety issues, and public health issues. He was the chief medical officer for Healthy Systems, during which time he developed the MD Guidelines formulary based on the ACON guidelines. He has also been the health service clinical professor of medicine and residency program director at the division of OEM at the University of California, San Francisco. Our second speaker is Dr. Bruns, who is a fellow of the American Psychological Association, the Society for Healthy Psychology, and of Qualitative and Quantitative Methods. He is a practicing pain psychologist in Greeley, Colorado, where he specializes in the psychological assessment and treatment of injured workers with chronic pain and traumatic injuries. He has participated in developing over 30 medical guidelines, mostly for chronic pain and injury. Dr. Bruns is a current and past chair of ACON's Depression, Anxiety, and PTSD Guidelines, and a past chair of the Colorado Medical Treatment Guidelines. He also served as a technical expert for the Centers for Medicare and Medicaid Services, an educator for SAMHSA's Opioid Response Network, and as a co-developer of APA's curriculum for addressing pain and related opioid dependence. Our third speaker is Dr. Hartenbaum, who is president and chief medical officer at Ocumetics, Inc., an occupational medicine consulting firm in Dresser, Pennsylvania, and serves as a chief medical officer of Norfolk Southern Railway. Dr. Hartenbaum is faculty at Penn's OCMED residency program. She is also the editor of the DOT Medical Examination, a guide to commercial driver medical certification, and is the course director for ACON's National Registry of Certified Medical Examiners training program. She chaired ACON's task force on cannabinoids in the workplace and has given numerous presentations on drug testing, fitness for duty, and regulatory issues, including on cannabinoids. Dr. Hartenbaum is past president of ACON and a former member of the board of trustees of the American Board of Preventative Medicine. So we're very excited to have these three speakers here to talk about the cannabis pain guidelines. Just some background about how ACON clinical guidelines are made. These are authored by ACON subject matter experts and supported by a research team. They're published on MD guidelines with a core audience of occupational health clinicians, disability case managers, and utilization reviewers. This specific guideline, which was published in January 2025, has 141 references and focuses on the evidence for treatment of acute, subacute, chronic, and post-operative nonmalignant pain. It also focuses on the impact on workers performing safety-sensitive jobs and dose response related to fatalities, overdoses, and adverse effects. These are all available on MD guidelines right now. If you want to go ahead and read them, or we hope that you've already read some of the details available on MD guidelines about the ACON guideline. Just some general background information about policies in the U.S. You can see this map where the states are color coded. 24 states have legalized and regulated marijuana for adults that are 21 plus. 39 states have medical use approved, and six jurisdictions require work comp to reimburse for medical cannabis. This is to the tune of $45 billion expected to be spent in the year 2025. This is a very important topic and relevant to current policies that are in place and being worked on by government policies. Some general background, you can see from the image on the right that usage is going up, but it differs by age group, sex, ethnicity, education, and income. We're going to talk more about this today, but there are a lot of adverse effects which are outlined in the guideline, and they broadly include dependency, motor vehicle crashes, accidental injuries, work absences, and schizophrenia. This is extra important to consider as we see these general trends are going up in usage as we expect to see more of these in the future as more people potentially can be using marijuana or cannabis in the U.S. And with that, I'm going to turn the slides over to Dr. Goldberg. Good morning, everyone, if you're in my time zone or anything other than the East Coast. So let's start with some history. This goes back 12,000 years or so to the Altai Mountains in Eurasia, where our use is first described. And then coming forward into time in ancient Egypt around 1500 BCE, cannabis was used to treat inflammation. In China, various healers used this for medicinal purposes around starting 800 BCE. And in the last century, marijuana was legal up until 1973. Until that time, its use was pretty widespread, both recreationally and medicinally. And particularly in the first half of the century, it was supported by the AMA, and they actually opposed any taxation on cannabis or medical marijuana. In the 60s and 70s, of course, we had the Civil Rights Movement, we had anti-war demonstrations and a lot of chaos on campuses and the streets of America. And the Nixon administration thought that a strategy to deal with it would be to criminalize marijuana and cannabis. And so Richard Nixon decided to direct the DEA to reclassify this unclassified substance to Schedule I to criminalize its possession and use as a strategy to deal with all the social issues in the country. For 23 years, use continued. Despite the DEA classification, various states dealt with it in the 90s, and California, not surprisingly, was first to legalize it for medical uses in 1996. As Carrie's already described, many states have followed ever since in various ways, shapes, and forms. It was a move over the last 10 or 12 years to reclassify from Schedule I, one to decriminalize possession and use, but maybe more importantly, to allow legitimate research with standardization of dosing and manufacturing. And that proposal finally was taken up by the DEA last year, and that proposal is probably dead in the water now. Next. So the mechanisms of action, there are endocannabinoid and cannabinoid receptors throughout the body, including the brain, the muscles, various organs, and glands. There's two types of receptors. Type I is targeted by THC, and it's in the neuromuscular system and the central nervous system, thereby producing the psychogenic effects of the substance. Type II are in the immune system and throughout the rest of the body, and these are targeted primarily by the cannabinoids or CBD. Next. Routes of administration are several. Over time, smoking and inhalation have been the predominant routes and usages, and onset is very rapid, within minutes for most users, particularly experienced users. Duration, about four hours unless there's repeated administration. After four hours, blood levels start to drop, but effects can linger for 12 to 24 hours and potentially even longer, depending on how often people use cannabis. With ingestion, let's go back for a minute. With ingestion, there's slower onset through the GI system, and so dosing is variable and can be fraught with overdosing because people aren't waiting for the onset and they perhaps ingest too much. Duration is definitely longer because of the slower onset and slower excretion. Okay, next. I'm going to go through a variety of physical adverse effects. So starting with the respiratory system, with anything that's smoked, be it tobacco or cannabis, it's going to affect tracheobronchial tree, and certainly people with COPD and asthma can have acute and chronic aggravations of their disease. For users, we'll have an increased risk of bronchitis and pneumonia. In the cardiovascular system, cannabis produces systolic blood pressure elevation, and people can just get a tachycardia that can be quite high and alarming, but also can be at risk for various tachyarrhythmias, including ventricular arrhythmias, which of course potentially could be fatal. There's increased risk demonstrated for myocardial infarction, as well as cerebrovascular accident or stroke. In the GI system, with most substances and medications, the typical side effects can be nausea, vomiting, and diarrhea, and unique to cannabis, hyperemesis has been reported in a small percentage of users. Okay. Interesting finding is that in the perioperative period, there's elevated risk of myocardial infarction for people that are recent or regular users, and there's increased airway resistance, which is important both perioperatively in the operating room with inhalational anesthesia and postoperatively, and this increases the risk of complications postoperatively in patients that use marijuana regularly. Cancer is a significant risk for regular users. This is due to a number of mixed carcinogens in the smoke of cannabis, and compared to cigarette smoke, there's actually elevated tar and PAHs, which are polyaromatic hydrocarbons, compared to what people get out of standard cigarettes. Primarily the issue is that something's burning, but it's not being filtered the way a cigarette is, and so this increased tar and PAH and other carcinogens starts to elevate the risk of cancer, and the risk of cancers from oral, oropharyngeal, and laryngeal cancer can be anywhere from 2.5 to 8.5 times risk for non-users, and there's a report of other cancers, including bladder cancer, that may exist, but the evidence is less well-defined. So now we're getting towards the guidelines and potential for medical use. So early on, there was some promise that cannabis could be something that could treat a variety of conditions, and the best early evidence, which was still limited, but it was the best early evidence, was for treatment of spasticity and multiple sclerosis. Along the same time, over the last 10, 20 years, there were some lower quality publications that suggested pain reduction, as well as reduced use of opioids, and so there was promise that if people use cannabis, they might either avoid the use of opioids or at least reduce their dose of prescription opioids. There was also potential for treatment for neuropathy, particularly diabetic neuropathy, and as I mentioned earlier, truly effective research has been hampered by the ongoing Schedule 1 DEA classification, and you'll see in a minute that that's had a tremendous impact on what's been published and what our recommendations are. So with all the ACOM guidelines, we have a ranking of recommendations based on evidence, and it goes from strongly recommended down to strongly not recommended, with gradations in between, and the gradations essentially are based on the evidence strength. So evidence A is basically multiple RCTs or randomized control trials. B might have a weaker RCT or case control study or some other epidemiologic study. C may be case reports or other weaker studies. And then when we get to insufficient evidence level I, there will be recommendations made to either recommend something or not recommend something, and when we feel that the evidence is so insufficient that we can't make any recommendation, then we will actually say no recommendation. And basically, insufficient evidence I reflects expert consensus from the guidelines panel and staff. Okay. Okay, now to the real meat of the guideline recommendations. So for chronic pain, as you can see, it's not recommended, and the evidence level unfortunately is only level C. That's because there are really no quality long-term placebo-controlled studies identifiable in the literature. There's also no randomized long-term studies assessing superiority. So what we really want to see is superiority over NSAIDs or other interventions because of the risks and hazards of using cannabis. It should be superior to placebo and ideally superior to standard treatments. There's one high-quality study that we can cite, and I'll describe briefly for you. And that looked at a combination of treatments, including straight THC, tetrahydrocannabinol, CBD or CBD-THC combination, and comparing those against placebo. And after eight weeks of trial, there was no evidence of efficacy for neuropathic pain. Sativex, which is a combination of THC and CBD, was used for placebo trial for diabetic neuropathy, and it was found to be not effective. There are several short-term lower-quality studies that do show improved pain scores of a modest amount for anywhere from two and a half to four hours. But for chronic pain, short-term pain relief is not going to help us in terms of treatment on the chronic basis. And there are no studies showing improved functional outcomes, which for chronic pain is really what we're looking for. We're not trying to just treat pain. What we're really trying to do is improve functional outcomes so people can resume their lives as best they can. Next. For acute and subacute pain, there's very few acute pain studies. One small study with CBD, it was found not to be efficacious. Now looking at post-op pain, it's interesting that there's been a number of studies here and primarily involving post-op pain relating to orthopedic surgery and GYN surgery. The best study is this forearm placebo-controlled study using Nabilone, which is a synthetic substance that's approved only in the United States for treatment of nausea and vomiting secondary to chemotherapy for cancer patients at 1mg and 2mg treatment levels against ketoprofen and placebo, and it was found not to be superior to placebo, and higher doses of Nabilone actually increased patients' pain levels. There have been various dental and oral surgery studies and pain relief has been inferior to standard treatment, and with total abdominal hysterectomy, there's been a study and it's been found that cannabis is not efficacious. So overall, there's a lack of efficacy compared to placebo and cannabis has been found to be inferior to NSAIDs, thereby giving us a moderately not recommended evidence B level. So here's the bottom line. We have a very limited number of high to moderate quality studies. There's very limited, if any, evidence of efficacy for pain control other than very short-term limited response. There's no evidence for improved functional outcomes in injured workers, and there's clear evidence of risks and potential harms, some of which I've covered and the subsequent speakers will further cover. And therefore, the bottom, bottom line is we cannot recommend cannabis at all for any stage of pain in injured workers. So I will end there and turn it over to the next speaker. Hello there, this is Dr. Bruns. It's a pleasure to be here today. Next. Some people use cannabis in a controlled way, but some people don't. And systematic reviews have found that among cannabis users, 22% go on to develop a cannabis use disorder. That's a DSM-5 construct. We're looking at from an ICD-10 perspective, 13% abuse cannabis and 13% become dependent on cannabis. If we lump everything together, the overall rate of problematic cannabis use is as high as 33%, and individuals with pain are at higher risk still for cannabis abuse disorder. Next. Cannabis abuse is associated with several other demographic variables, younger age, genital sex, history of trauma in childhood or elsewhere, history of psychological treatment or drug use, and PTSD, depression, or anxiety. Next. There are various adverse social effects of cannabis use. Difficulty in educational settings, difficulties in work settings, relationship problems, and also aggression and various kinds of criminal behavior. Next. There are also a number of adverse psychological effects of cannabis use. There's a 7.5 times greater risk of psychiatric symptoms. This includes depression, anxiety, mania, and schizotypal personality features. There's also a 5-fold greater risk of brief psychosis. Psychosis is a known effect of cannabis overdose, but the bigger question is, over time, can cannabis cause schizophrenia? The guidelines cite five review studies which explore this, and they look at somewhat different ways. The most recent and most comprehensive study is Grinia in 2024. It's a complicated study. It's an umbrella review, but it does overall find that use of THC is associated with brief reactive psychosis, with later schizotypal personality features, and also with increased risk of the onset of schizophrenia. That stops short of saying causality, saying that we don't have enough evidence to determine causality yet. However, this last study on the bottom, I can't pronounce a person's name, but it's a Danish study, which is also a remarkable study. It's a 50-year-long population study in Denmark. The study concluded 15% to 30% of young males who abuse cannabis may go on to develop schizophrenia, and that we could reduce the prevalence of schizophrenia that much if cannabis abuse was eliminated. This whole study is framed from the perspective of causality, of a causal connection between cannabis and the onset of schizophrenia. Next. This is the DSM-5 criteria for cannabis use disorder. It's pretty detailed, but if you click on the button here, you'll see there's one feature I want to focus on, which is, like most substance abuse disorders, over time, there is an increased desire for a larger dose in order to achieve the desired effect, as tolerance makes a person less sensitive to the substance. Next. Who are the moderators of cannabis use and psychosis? First of all, there's the age of onset. The younger you begin, the more likely psychosis is. And next, how much do you take? If you take, if you use cannabis more frequently and use more potent forms of it, the risk of psychosis increase. Next. This is an interesting study. This is looking at cannabis samples seized by the DEA in drug raids from 1995 to 2022. In 1995, the average percent of THC was 3.96%. In 2022, it was 16.14%. So the THC percent quadrupled over this time period. Are the FETs still not enough? So what do cannabis users do if they want something stronger than standard marijuana? Again, one of the features of a substance use disorder is people progressively want more. Next. The guidelines mention a phenomenon called dabbing wax, but don't really describe what it is. Wax is a concentrated form of THC. Basically, you extract all the cannabinoids out of cannabis and concentrate them. And there's slightly different ways chemically of doing this, and it produces substances which are sometimes called on the street wax, butter, or shutter. The most common name is wax, and so we'll use that. Wax can be up to 90% THC. So far higher than marijuana that you can obtain on the street. Also, it can be used in e-cigarettes. So it's heated, and then the THC is huffed. Now, if you think about it, marijuana in a joint, when it's lit, a lot of it escapes into the atmosphere, a secondhand smoke. With an e-cigarette, it's a more efficient drug delivery system. So when you heat it, pretty much all of it goes through the user's lungs. As a result of this, one dab of wax, dab is kind of a vague term in terms of what a dose is, but the estimate is that a dab of wax can have the equivalent amount of THC to three to six joints. So unlike smoked marijuana, where it may take 20 minutes to smoke that much, a dab is huffed in a single breath. So it's possible to get three to six joints worth of THC in a second, and that causes a spike of THC to hit the brain. So really extreme doses, and overdose happens much more readily here. And we know that higher doses of THC are more likely to cause paranoia and psychosis. Next. What about edibles? As was mentioned previously, they take longer to have an effect. If you think of it like a marijuana brownie may mix marijuana with flour, sugar, chocolate, oil, eggs, walnuts, vanilla, other ingredients, and all of this slows the absorption of THC. It's not uncommon for an effect to take some hours to peak. And so the risk for the user is, unlike smoking where you have immediate feedback, when a person eats a marijuana edible, depending on the type of food it's mixed with, they may not realize for hours that they've overdosed. And then the intoxicating effects last much longer. Another complication is patients who smoke marijuana may get hungry at the knee of marijuana brownie, and that just compounds the risk of overdose. Next. Now there's also something called designer cannabinoids. Now these are not like Christian Dior marijuana. It's much more insidious. Designer cannabinoids are synthetic cannabinoids, and they're collectively often referred to as spice. These were named as an homage to the drug used in the science fiction book, Dune. It has a number of street names, but I'll just refer to it as spice for simplicity. Next. So designer cannabinoids, designed for what? First of all, they're designed to be more potent. Neocannabinoids are partial agonists of cannabinoid receptors, but neocannabinoids are full agonists. They're much more potent, and maybe up to a hundred times more potent than THC, greatly increasing the risk of overdose and toxic side effects. Designer cannabinoids were designed to be difficult to detect. They're not detectable by standard cannabinoid tests. And also, if they make a test for the drugs, they will include a masking agent, which is a drug or a substance which will interfere with the drug test, producing a false negative. But these masking agents can be toxic in and of themselves and cause pulmonary injury. They're rotating chemical formulas for spice to defeat drug tests. They also contain no terpenes, and so they have no odor. There's no marijuana smell, and so they're matched with other components that smell like fruit or incense or potpourri or something. And finally, they're designed to evade legal restrictions. They're synthetic chemicals, so technically cannabis laws or marijuana laws may not apply because they're synthetic chemicals, and they may be sold as potpourri or incense, and may be quasi-legal because the nature of their formulas aren't covered by local jurisdictions. Next. So the scope of the problem. Some neocannabinoids, like HU210, are a hundred times more potent than THC. The number of neocannabinoids is amazing. I just saw this. It's a very recent study from the UN Office on Drugs and Crime. They've cataloged 386 chemical versions of spice, which makes testing for them very difficult. Most recently, in 2023, 122 distinct versions of spice were in circulation around the world. Here's some pictures of spice in its package. It may be sold in gas stations or other places as potpourri, as incense, and they'll have cautions on it to try to evade liability for fragrance purposes only, not for consumption. But it's a drug, and so sometimes if people are vaping something and it smells like strawberries, well, it could be, like here's a version of K2. That's a strawberry version. And these are images from the DEA. The most disturbing thing. Next slide. Scooby snacks. This is a version of spice packaged in a way to appeal to children. What makes that disturbing is what we know is the most dangerous side effect, schizophrenia, happens with younger people. And the younger you are and the greater the dose, the greater the risk. And this seems to be a recipe for disaster. Next. So the trend lines are troubling. On one hand, the social acceptance of marijuana is increasing, as demonstrated by relaxed legal regulations. Marijuana cannabinoids are changing, and they're becoming more concentrated, more potent. There are synthetic versions. And the risks are increasing. And these risks are greater than the public often recognizes. So thank you. And now we'll transition to the next speaker. Okay, good afternoon. I'm Dr. Natalie Hartenbaum, and I'm going to focus really on what are the safety risks that we're worrying about with cannabis and those individuals, primarily in safety-critical positions. So one of the most easy ways that we look at what is the risk of safety is we look at the motor vehicle crashes. And yes, there have been inconsistent findings on whether or not there is an increased risk. However, most of the studies do demonstrate that there is indeed that increased risk. Part of the problem, as was mentioned earlier, is that cannabis doesn't equal cannabis doesn't equal cannabis. It comes in different forms. It's ingested in different ways. It can have a different duration of action. It can have a different component of the psychoactive substances. And for that reason, a lot of these studies are not conducted with uniform systemic methods. And therefore, we do get some potentially inconsistent or confusing results. What cannabis has shown is there is impairment in both the on-road driving as well as the driving simulator studies. There's also been increased evidence of impairment in the psychomotor tests. And the most significant impairment is seen is sedation. And that was mentioned earlier. What's concerning about the motor vehicle crashes is that a lot of Americans will drive under the influence of cannabis. They'll admit that right off, 4.5%. What's more concerning is those that have cannabis use disorder up to 65% will get behind a wheel knowing that they're potentially impaired. Cannabis has been legalized in Canada for a number of years. And if any of you did attend their recent AOHC meeting, Dr. Snyder-Adler gave an excellent presentation on the program in Canada and how they attempt to prevent the unsafe use of cannabis, even though legalized. But what was found is the detectable cannabis in crash was found increasingly with moderate injuries when they're occurring. And traffic accidents increased by 74%. Not necessarily saying that that was caused by, but it certainly was a related finding, which does raise some questions. There have been other studies in the U.S. that also found increased risk of crashes. When you look at the fatality analysis reporting system from 1999 to 2010, it found that the fatality rate nearly tripled, whereas the fatality rate associated with alcohol stayed exactly level. If I can have the next slide. And again, going back to driving, one of my biggest concerns is always when individuals aren't aware that they're impaired. They think they're safe, they think they're safe, and suddenly they're not safe, and by then it's too late to do anything about it. But here was a pretty robust study of 790 cannabis users, and 56 plus percent of them said, yep, I'll go ahead and drive while I'm within two hours of use. I recall a recent trip in Colorado where I got in a Uber and I'm like, okay, this is a little concerning. I smelled the cannabis, wanted to jump out, but wasn't quite comfortable doing that either in the middle of the highway when I realized it. But not just were they willing to drive while they had recently used cannabis, but half of them defined themselves as a little high, thought they were probably good enough and still were driving, and then 21% acknowledged being very high while they were driving. Very commonly with other sources of impairment or incapacitation, individuals don't realize that they're impaired. They thought they're safe, they thought they're safe, and yeah, I know I'm under the influence, but I'm probably okay. Unfortunately, probably okay is probably not good enough, and therefore that does raise some significant concerns. I don't know if there's a slide for it, but accidents have increased, injuries have increased. And for those individuals who are using cannabis on a regular basis, some of the studies on absences shows that cannabis users are about 78% more likely to have absences, and those with cannabis use disorder have an even higher rate of absences, and that also goes up at the higher doses as they're being used. What we're really trying to find and what the real challenge right now is what's the safe level. And there are certainly several studies that suggest lower levels of cannabis are safer. The problem in the US is how are we measuring what's a lower level versus what's a higher level? How are we evaluating how it's being used, when it's being used, how it's being ingested? Is it being inhaled? Is it being smoked? Is it being eaten? Or is it being used in one of the forms like Dr. Bruns mentioned with those very concentrated cannabis products? That's what makes cannabis use so very challenging in identifying what a safe level would be. Yes, there are some studies that show low level probably is okay. Certainly studies that show that as you go above five nanograms per milliliter, you're gonna have increased risk of impairment. However, there was one study that showed even low levels of cannabis in the system is about equal in impairment to moderate use of alcohol. Unlike alcohol where we know if you're drinking a 94 proof glass of bourbon and you know how much alcohol is in there, the challenge with cannabis, we don't know how much is in the product. We don't know what other substances that also may be psychoactive and may impact safety are in that same product. We really have very little control over when that effect is going to hit. And it is very individualized based on how it's used and based on frequency of use, whether that person's gonna be under the influence for four hours, eight hours, 12 hours, or even longer. And as mentioned earlier, they may not even be aware that they're under the influence of that psychoactive potentially hazardous substance. Next slide. So what is the recommendation from the guidelines? Well, it is not recommended and yes, it is an evidence C with a moderate level of confidence. What's interesting is this guideline looks at, should not be recommended in those individuals who are doing safety critical jobs. And they give examples of motor vehicles, forklifts, overhead cranes, heavy equipment, and other modes of transportation. Anyone who's working with sharps, so be knives, that would include your chefs, working with risk of injury. So those are working at high electrical workers, working at poles, those that are working on catwalks, those are working in any location where a fall potential exists. And then very importantly, those tasks involving high levels of cognitive function and judgment. Part of the challenges I'll talk about in the next couple of slides is how do you define safety sensitive may vary. It may be up to the company, it may be up to the individual, it may be up to the state or city. Now, we're gonna separate out the federal drug testing rules because clearly an individual who's covered under federal law at the current time, and we're hoping in the future, cannot use cannabis, cannot use non-FDA approved cannabis. Now what gets interesting, if they are using an FDA approved cannabis product, it is not an automatic disqualifier, it does move a little bit into that safety sensitive, safety critical, safety impairing role, and that's where you need to do that individual assessment. But if they're using cannabis either under medical marijuana or adult use rules in those covered under Department of Transportation and other federal agencies, that would be absolutely prohibited. Now, if we go to the next slides, we're gonna look at some other on the rationale as to why safety critical workers should not be permitted to use cannabis at all. Well, first of all, we've talked about the motor vehicle crashes already. We've talked about accidents and injuries already. We've also talked about performance and attendance. So keep going, please. And the biggest problem we are concerned about really those central nervous system effects. This is not a cannabis specific concern. So really any substance, any situation, whether it's fatigue or it's diabetes or it's sleep disorders, if there is an effect on central nervous system, those individuals should not be performing safety sensitive duties unless it is certain that they are not under any sorts of impairment from whatever condition, medication, or other situation they're dealing with. So these central nervous system effects include cognitive impairment, it includes altered judgment, short-term memory impairment and coordination, impaired attention, dizziness, sedation, vision changes, altered brain development, more of a concern in children than in those that are in the working environment. And it can also affect sleep disorders, which in itself can affect safety. Next slide. So now ACOM has put out a couple of statements. Most recently in 23, there was an update on legalization of cannabis and its implications for workplace safety. And ACOM at that point, again, decided to, let's put out some rough definitions of these are the conditions, these are the working environments where we think any type of impairment could have significant consequences. And that includes working with firearms, whether they're guards, whether they're police officers, or any emergency responders, something that involves very quick, very critical, very multitasking type of decisions, not having any type of cognitive impairments or emergency responders. Whether it's judgment and rapid decision-making, those situations where decisions directly impact the life and health of others. Next slide, I'll go a little bit more on this. And job roles where impairment could impact safety and health risks, looking at not just the individual themselves, but are they putting their coworkers, are they putting the other individuals that are around them, and are they putting the public at risk? Also concerned about will it affect the environment? Is this something that's going to cause significant damage to our air, our water, our soil, fauna? So if this can affect the environment, we want to make certain that person is not impaired. And finally, can it jeopardize the community, causing damage or endangering public safety overall? So when we're looking at safety critical workers, we also then looked at the National Safety Council's Alcohol, Drug, and Impairment Division. And they've done a lot of studies and they've put out some very detailed recommendations, which I just think are worthwhile thinking about. That cannabis and related products can impair numerous aspects of performance. And again, cognitive performance and psychomotor functions. It does affect decision-making, it affects estimating your ability to do things safety, and it affects reaction time. Because of the way cannabis is designed, because of the way cannabis can be altered, the way that cannabis can be produced, the way the cannabis can be ingested, these concentrations do not automatically correlate with the degree of impairment. You can find that someone has a low level, perhaps in their blood and can be very impaired, or can have a very high level and maybe they're not quite as impaired. There's certainly a lot of studies going on, a lot of efforts, I'm sorry, to find the right tool that can best analyze impairment and kind of correlate that with levels, but we are not quite there yet. There's no support from the literature, according to National Safety Council, that higher levels, that there is a threshold concentration where they're safe. Studies are very mixed on that. There are some studies that also suggest that alcohol may play a role as well, but for what we know and what the studies have shown so far, definitely cannabis use does have that impact on safety and performance. The wait times that we were really trying to find, if we could find a great number of hours between cannabis use, X in the end of cannabis use, they can start and do safety-sensitive jobs. The studies just really aren't rigorous enough to be certain that we had that right duration. There's been some thoughts of is eight hours enough? Is 12 hours enough? Is 24 hours enough? And then even some studies suggest that in some individuals, there may be impairment a week or even a month later. Next slide. So what National Safety Council came out to say, and I thought this was an important statement, is there's lack of evidence to show that someone is going to be safe within 24 hours after last use. So here they're saying 24 hours probably is that minimum time of a wait prior to an individual who's used cannabis to perform any safety-sensitive or safety-critical work. Now, the next slide looks at some other studies, and I thought I had a slide on that, but I don't, but there are some studies that suggest people can be impaired from up to, and I didn't have the slide, so that's okay, that they can be impaired for up to a week and others up to a month. So what is that right timeframe? It really depends on what the individual is doing. It really depends on what they're taking, depends on how they're using it, depends on how often they're using it, and that in the workplace, we generally do not have reasonable control over. What I wanted to highlight a bit, especially in those who are not in the federally covered drug testing situation, can you drug test? Can you prohibit cannabis use? And that really depends. A lot of states that have employee-related cannabis use laws will say an employer can't restrict an individual from using cannabis off-duty. There are some locations that say you can't even do pre-employment testing in individuals who are using cannabis, and you can only do post-accident testing in certain circumstances, and random testing may even be more of a problem in those states that have employer laws on cannabis drug testing and cannabis use restrictions. We talk about safety critical, safety sensitive, and that's really what I was trying to cover. It's not a one-size-fits-all. It's not the employer that says, ah, I'm gonna define what's safety sensitive. In many situations, the cannabis laws in the states define what is a safety sensitive position. In others, it defines it, it specifically leaves it to the employer, and in others, which are even more concerning, it's totally silent. So it's very important that when you're dealing with cannabis use, when you're dealing with drug testing, that you're aware of what the laws are in the state where that person is working, being tested, where the company is based, because any of those may impact that individual. It may not just be where he's working, but it may be all those other factors. And finally, that federal testing does override state laws, but it must truly be required testing. Drug-free workplace does not require drug testing. It just requires an employer who's covered under that to have a drug-free workplace program. Doesn't necessarily require testing. Next slide. And I think this slide is just a reminder again of every state is different on what's permitted. There are some states that have a high CBD, low THC program where the amount of THC in their product can be up to five, even to 9%. Certainly enough that is going to cause a positive drug test. Certainly enough of it is going to cause an individual to be impaired. And these are levels are percent by weight, not just a total absolute amount. So a person who takes one gummy may be impaired. A person who takes two or three gummies with a high THC product could certainly be impaired. The other thing to keep in mind is that CBD is not a regulated product. There are certainly that it can contain up to 0.3% by weight to be considered hemp. However, it is frequently mismarked and there are multiple studies that have shown that it can have significantly more THC even when labeled as THC-free. So the couple of references on the bottom and the references on the next slide are ones I would really urge you to look at if you're dealing with cannabis use in the workplace and concerned a bit about what those state laws should be. And you certainly should be concerned about those state laws. Excellent. Well, thank you so much to our speakers. We ask now that you put your questions in the Q&A box. If you have any questions, we're going to go through and answer some of them with the remaining time. And as you type in your questions, I just want to say thank you again for joining us today. There's an evaluation that will be sent in a separate window. So please complete that evaluation in order to claim your CME. You will also be sent instructions about how to do that later. And finally, if you're interested in becoming a Medical Advisory Board member with MD Guidelines, there's a QR code here to get more details about how to join the Medical Advisory Board. And with that, I'm going to end the slides and hand it over to Nikki with ACON to moderate the question. Hello, everyone. I hope everyone's having a good afternoon or morning wherever you're at. We have had a few questions come in through the Q&A chat box. The first one is for Dr. Bruns. Can you clarify that CBD versus THC cannabis and its therapeutic effects for pain side effects? Example, schizophrenia. Okay. Thank you. Somewhat complicated question. First of all, with regard to pain, Dr. Goldberg reviewed that at the start of this. And there's really no evidence that it's effective for pain. There is evidence of problematic side effects. Now, you mentioned schizophrenia. Now, the side effects is broad depression, anxiety, personality change, psychosis. But you mentioned schizophrenia and there's actually the most research on that. Most studies have just looked at cannabis use and its relationship to schizophrenia without breaking it down into the agents is THC or CBD. But some studies have. And of those studies, it looks like the problem of schizophrenia is associated with THC. Not CBD. And it makes sense because THC is more likely to act on the brain versus CBD. So with regard to the risks for schizophrenia and probably other mental health side effects, it's probably more closely associated with THC as opposed to CBD. And lastly also, it's not just a THC but also the spikes of THC that you get with some types of drug delivery systems like Dabby. Okay. Thank you. Thank you for answering that. And excuse me for sneezing. This one is for Dr. Goldberg. With all these bad side effects and guidelines not recommending use of cannabis and showing minimal medical value, why has America Society allowed state approved recreational or medical use of this product? The second part of this question, is it due to racially based policies of prison incarnation? Or why isn't the general medical community pushing back on this? So that's a great question. I can get on my soapbox in a minute, but you could ask the same question about alcohol. And I could just stop there with all the risks and public health issues. Relating to alcohol use and abuse. And we're starting to learn that alcohol probably has no lower limit of safety in terms of regular use. But setting that aside, because people reject comparisons between alcohol and cannabis. Nonetheless, I think there's a lot of cultural reasons. One reason is that prohibition really doesn't work with socially acceptable substances. Alcohol was a good example in the 20s. And I think cannabis was made illegal by schedule one for social engineering and response reasons. And I think the incarceration and the war on drugs became a political thing. And I think there's a lot of reasons why people have rebelled against the prohibition. I think there's also a belief in natural products. And so if it grows, it must be good. And so it can't be bad. And then I think, I mean, there's centuries, if not millennia of use of cannabis. And so to pass a DEA regulation or a law to outlaw something really doesn't work. And so I think that's one half of it. The other half, I believe, is we're going through a public health natural experiment right now. And so because we didn't get to do the prospective research on a DEA scheduled substance before legalization, society decided. So a lot of these were state initiatives, ballot measures, and then politicians in various states responding to the populace. And so, I mean, that's how it works in our democratic society. But I think what we're learning post legalization is that there are a lot of risks, both to individuals and to public health and public safety. And those studies are coming out more and more. But again, this isn't a natural experiment that's coming and will continue. But I guess you could say, why is the medical world not coming out against it? Well, I think we need more evidence, we need more time. And the other issue is, we haven't started a movement to ban alcohol either. So I'll stop there. And if I can just add two things, first of all, I remember that cocaine was legal many years ago, was very commonly found in the elixirs and good old Coca-Cola. So a lot of things were anecdotally felt to be beneficial. This, I think, is where cannabis started. It was anecdotally felt to really help anxiety and pain. Everybody felt really good afterwards. And unfortunately, there wasn't sufficient studies to begin. There were a lot of anecdotal studies, a lot of smaller, not really well-controlled studies, which were suggesting that benefit. And I think that the ACOM guideline was a really good, very detailed evidence-based review. The groups that are looking at this are more and more coming out with some different guidance. I know Canada just came out with new guidelines just published this month, and I've been in the process of trying to get a copy of it. And they're lengthening the duration of between use and stopping. So it's really that attempt, what I think a lot of the medical community is saying right now is slow down, not so much stop, but we need better research. I know back with the descheduling hearings of the groups that were submitting comments that were hoping to be designated parties to that product, it was not a we're in favor or we're against. We're just saying slow down and let's make sure we understand what we're doing before we go full steam ahead. So hopefully there'll be some movement to at least improve the research in what works, what doesn't work, and what are the outcomes from it. And with that, we are at the top of the hour. So thanks again to our speakers and to our attendees. Again, look out for follow-up emails with recordings and CME instructions. Thank you all for joining. Thank you all. Have a wonderful afternoon.

ACOM Clinical Guideline

cannabis for pain

cannabis legalization

cannabis use disorder

chronic pain

cannabis potency

safety-sensitive jobs

drug testing

mental health issues

pain management