Catching ZZZs

Generally speaking, fundraisers are good, right? And fundraisers for such longstanding and venerable organizations as the March of Dimes are important, we can surely all agree. So when Peter Tripp, a popular radio DJ in the ’50s, came up with a stunt to raise money benefiting the March of Dimes, nearly everyone was on board. Everyone, that is, except doctors and scientists. What Tripp proposed was a record-setting, 201-hour “Wakeathon,” denying himself sleep for more than eight days. By all accounts, it didn’t end well. He hallucinated. He took drugs to stay awake. He suffered long-term psychological effects for years following the stunt. (Adding insult to injury, his accomplishment was a short-lived victory; less than a week later, another DJ beat his time by 24 hours).

Long story short: Bad things happen when you don’t sleep.

Enough is enough — or is it?
The list of reasons sleep is imperative to our functioning is much studied and well established. Without adequate sleep, you are more prone to depression, seizures, high blood pressure, compromised immunity and more. Sleep plays a vital role in steadying our metabolic rate; after just one night of inadequate sleep, an otherwise healthy person will show signs of prediabetes. Perhaps less easy to measure, but of equal importance, is the challenge we face connecting with others and practicing empathy when we’ve not gotten enough sleep.

But how much sleep should you really be getting? Age is one key factor that will affect how much sleep you need. Compare the sleep pattern of a newborn to her grandfather’s and you’ll see that the younger we are, the more sleep we need; as we get older, we need less.

Your teenager will probably not be surprised to learn that research on high school-age students says they’re getting up too early for school and it’s affecting their performance throughout the day; some of those researchers suggest our schools shouldn’t begin before noon.

On average, Americans are getting about six hours of sleep a night. That’s not enough. Sleep is a reboot. During sleep, our muscles, organs and cells repair and rebuild. Without giving our bodies that time to regenerate, our growth hormones go down and our cortisol levels — our stress hormones — rise. Losing sleep also changes our hunger structure (in other words, your chances of gaining the “quarantine 15” are real).

Get better sleep as early as tonight
There are a lot of things you can do to improve your sleep patterns and habits, almost immediately. Here are some ideas you can incorporate — and some habits you can break — to make the most of your body’s circadian rhythm and maximize your sleep time:

• Get natural blue light during the day. Blue light is naturally emitted by the sun, and studies show that 45 minutes of unobstructed (i.e., no windows or glasses) exposure to environmental blue light in the morning will help reset your circadian rhythm. Take a walk or sit on your patio before 11 a.m.
• Then get blue-blockers. All the effects that make blue light a positive at the start of your day can negatively impact your evenings. If working (or scrolling) means you’re looking at screens at night, blue light-blocking glasses can help filter out the blue light they emit.
• Add a pink lamp. Himalayan salt lamps give off the same frequency of light as fire. When the sun goes down, let this be your only light source.
• Create a sanctuary. Your bedroom should be cool, clean, and preserved for sleep only.
• Breathe easier. When you sleep, your whole body goes into recovery mode. If the air quality you’re breathing is poor, a portion of your recovery budget needs to go to cleaning pathogens in your lungs. A good air purifier can be a big game changer in sleep quality.
• Exercise early. Getting your heart rate up helps relieve stress, and less stress means better sleep. Try getting your most strenuous activity in earlier in the day to allow your body enough time to rest and relax at night.
• Avoid alcohol, marijuana and caffeine. These stimulants will deprive your body of its ability to reach a REM level of sleep, keeping you from entering that all-important recovery phase of the sleep cycle.

• Avoid eating late. When your stomach has food in it, your body is working to break down and digest rather than rest and restore. Try to close up the kitchen at least three hours before bedtime.
• Keep it cool. A warm shower can be a relaxing way to wash away the day; just be sure to end it with a cool rinse, easing into sleep by keeping your core body temperature down. A cool room and a cool bed will also help set the stage for great sleep.
• Keep it consistent. As much as we may all wish it were true, there’s no such thing as “banking” sleep. Good sleep hygiene means going to bed and waking up at same time every day. Every time you sleep in on a weekend, your circadian rhythm has to start over.
• Write it down. If you’re feeling particularly anxious — and so many of us are right now — set aside some time each evening to think through what’s causing your stress. Then write it down. Once your mind releases it to paper you can let it go more easily. 

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MEDICAL MARIJUANA, HAZY HEALTH AND CLOUDY COMPLIANCE

As the use of medical and legalized recreational marijuana continues to grow, so do the questions. Before we dive into the debate over health benefits and risks, let’s first make sure we’re all speaking the same language.

A whole new lexicon
Cannabis is a natural substance that’s been consumed for thousands of years via inhalation, oral ingestion or topically. Cannabis is popular for medical uses like pain, nausea, muscle spasms, arthritis, epilepsy, migraines and other medical conditions. It’s available in a variety of forms, from edibles to tinctures to topical creams.

While hemp and marijuana are often referred to as species or strains of cannabis, they actually do not qualify as either one. Both are simply broad classifications of cannabis that were adopted into our culture.

Cannabis contains more than 100 different types of cannabinoids; the two most common are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the major psychoactive component of the plant that gives users a “high,” while CBD is the major non-psychoactive component. THC and CBD levels vary among different strains and between hemp and marijuana. Hemp, which is federally legal, cannot have more than 0.3% THC concentration, whereas marijuana can range from 15-40% of THC.

Potential issues with cannabis
To date, there have been no reported overdoses or deaths related to cannabis use alone, but associated side effects include worsening psychosis, increased depression, increased anxiety, risk of myocardial infarction, stroke, testicular cancer, hyperemesis and cannabis use disorder.

• Dispensaries have a menu of items on their shelves, but what the label indicates is not always what it contains.
• Formulations vary from state to state, and there is no standardized laboratory testing that can verify the strength or strain of a cannabis product.
• There’s been so much cross-breeding in recent years that even cannabis cultivators may have a hard time identifying the type of strains they’re producing.
• Physicians and pharmacists are not given the tools to recommend or dispense the right cannabis strain for a patient.
• Some states require clinicians to fulfill continuing education credits for cannabis, but resources are limited.
• Dosing and frequency is patient-dependent and, due to lack of standardized formulation, getting the same batch of cannabis from the same dispensary can be a problem.
• Drug testing is still in an exploratory phase; since the drug can stay in the fatty tissue and is slowly released into the blood stream, it can be detected in the urine up to five days after a single ingestion, and up to six weeks for regular users.
• State laws and regulations regarding medical cannabis use are constantly evolving, and this poses a challenge for workers and insurance payers.
• While there are no conclusive studies linking marijuana’s legalization to increases in workplace accidents or injuries, THC can lead to intoxication (feelings of euphoria and relaxation), impairing coordination, cognitive flexibility and reaction time, all of which pose safety issues in the workplace.

And potential benefits
THC is known to cause relaxation, and delayed muscle response, and can alter the senses related to smell, sight and hunger. The Food and Drug Administration (FDA) has approved two prescription medications on the market (dronabinol and nabilone) used to prevent chemotherapy-induced nausea and vomiting, and to stimulate appetite in cancer patients. It should be noted, though, that a significant number of users report experiencing more benefit from using cannabis than from pure THC.

CBD is believed to have beneficial effects in treating neuropathic pain, but the evidence is limited and it only shows minimal efficacy with no functional improvement. CBD can help with seizures, and there is an FDA-approved drug, Epidiolex, indicated for the treatment of Lennox-Gastaut syndrome and Dravet syndrome in patients over the age of two. Sativex is a new investigational product composed primarily of CBD and THC. GW Pharmaceuticals plans to seek FDA approval for the drug in the U.S. to treat spasticity and other neurological conditions; it’s already being used in Europe and Canada to treat multiple sclerosis and cancer-related chronic pain.

Controversy remains
Despite its growing popularity and mainstream acceptance, many widely used treatment protocols still discourage the use of cannabis. The Official Disability Guidelines (ODG) do not recommend using cannabinoids to combat pain. The American Society of Addiction Medicine states physicians should not recommend their patients use marijuana for medical purposes. Smaller-scale studies compared cannabis (THC + CBD) against placebo, CBD and low-dose THC and concluded that medical marijuana might be beneficial for pain, but only at higher doses. The risk of side effects like depression and anxiety increase with higher THC doses and there is no functional improvement or quality of life.

Although cannabis has a long history of use and is a natural substance, it’s important to remember that it’s still classified by the U.S. Drug Enforcement Administration as a Schedule I substance. It should be carefully evaluated, taking into consideration patient-individual characteristics, before being recommended to patients for pain management or as an alternative to an opioid therapy.

Compliance and compensability
A total of 34 states and the District of Columbia currently allow medical marijuana use, and beginning with Colorado and Washington in 2012, ten states and the District of Columbia have now legalized recreational use. But marijuana is no longer just a medical or health-related issue; with a trend toward decriminalization across the country comes more widespread use and cultural acceptance. From an economic standpoint, the market for legal retail sales of marijuana and cannabis-related products is currently around $19 billion in the U.S. and the global market is projected to grow: different sources project it reaching anywhere between $60-140 billion by 2025. Not only does that mean legalized marijuana won’t be going away anytime soon, but it also will continue to be something we address in the workplace. The need for coverage in the industry — for businesses from growers to transportation to retail — is creating a new insurance vertical, as well.

How do all of these trends impact the way we manage workers’ compensation claims, treatment, usage and review when marijuana is involved? We must keep our fingers on the pulse. We’re seeing more physicians prescribing because either a patient has requested marijuana as an option in their case, or because they’ve tried and exhausted other options.

A marijuana review process, triggered by a request in a claim, is one tool for making well-reasoned decisions. This can include running a full history of the claim, the individual’s comorbidities and health risks, compared to what we know from clinical studies and evidence-based medicine. Whether marijuana is ultimately allowed in a claim or not, a review process can inform our choices and help show that determinations were based on more than just legality or doctor’s recommendations.

Will carriers or payors be required to cover marijuana as part of the claims process? This is another ambiguous question. Some states have required compensability, some states have explicitly denied coverage, but more have taken a stance that leaves room for interpretation — saying “medical marijuana reimbursement is not required” but may be allowed in a claim. Beyond legislation, court decisions continue to shape the compensability and compliance landscape. State-specific guidelines must be watched carefully as statutes and standards change.

In two other areas of concern for employers — drug-free workplace programs and employment decisions — states and federal guidelines are inconsistent. On a federal level, drug-free workplace programs are promoted and suggest that violators can or should be disciplined for being under the influence. But how is “under the influence” determined in the case of marijuana? Everyone wants a safe work environment, but until testing with better validity becomes available, judging what is considered a level of impairment for those testing positive will remain difficult. The technology is being refined; there have been recent breakthroughs for breathalyzer-type testing or saliva swab tests for point-in-time assessment of impairment. With improvements in testing, more consistent standards may emerge.

Still more factors complicate the situation for employers. On the federal level, the Americans with Disabilities Act (ADA) does not protect employees who choose to use marijuana as a treatment option for a medical condition. However, it’s well established in states where marijuana is legalized that taking employment actions against an employee who tests positive is considered discrimination. The Occupational Safety and Health Administration (OSHA) has flip-flopped; after initially saying employers should not drug test after an accident, reasoning that the practice discouraged individuals from submitting workers’ comp claims, they have since changed stance and now say that employers may drug test after a workplace accident to encourage safety.

Position yourself wisely
The most reasonable way to ensure you will be in a defensible position in the case of any possible legal action or complaint is to follow five best practices:

1. Have a sound drug testing policy
2. Educate all employees regarding the policy on a continual basis
3. Enforce the policy consistently and document your actions
4. Focus on deterring employee drug use while at work
5. Emphasize workplace safety and performing work in a safe manner

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AVOIDING PRESCRIPTION DRUGS AND UNINTENDED CONSEQUENCES

Without question, prescription drugs can play a valuable role in alleviating pain — but they can quickly produce unintended consequences when left unchecked. Far too often, patients don’t understand the side effects associated with prescription drugs, the implications of drug interactions or the availability of alternative pain management therapies.

First, the good news: After decades of battling the opioid epidemic, the U.S. is starting to see numbers level off. Before we get ahead of ourselves, though, it’s important to understand that this battle is far from over. While the rate of drug overdose deaths decreased overall, fatal overdoses involving synthetic opioids (e.g., fentanyl, tramadol) increased by 10% from 2017 to 2018. As the opioid epidemic continues, we’re seeing a slew of alternative drugs surfacing in the workers’ compensation industry.

Safer…but not necessarily safe
Alternatives like gabapentinoids may be safer than opioids, but should not be considered safe for everyone. This past December, the FDA issued a warning about potentially serious breathing difficulties in patients using gabapentin or pregabalin who have respiratory risk factors. Other risk factors include increased age, the use of CNS-depressing medications including opioids, and conditions such as chronic obstructive pulmonary disease (COPD) that reduce lung function. The British Medical Journal found patients taking pregabalin to be at an increased risk of traffic accidents and offenses, unintentional overdoses, head and body injuries, suicidal behavior and deaths from suicide.

Some physicians argue that tramadol isn’t a true opioid and therefore has a safer side-effect profile. It is an opioid, one with multiple pharmacologic properties which could lead to serious side effects such as respiratory depression, hypoglycemia, gastrointestinal (GI) disorders and seizures. Neither the ODG or the American College of Occupational and Environmental Medicine (ACOEM) recommend the use of tramadol over non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of lower back pain or osteoarthritis. A 2020 study published in the Journal of Bone and Mineral Research analyzed the safety of tramadol against NSAIDs and codeine. The tramadol group had a significant increase in emergency room visits, falls and hip fractures, cardiovascular events and all-cause mortality compared to NSAIDs, and a higher rate of falls and fractures compared to codeine.

Sleeping aids, which may be prescribed to cope with pain and help with insomnia during the acute phase of an injury, are not recommended beyond four weeks, when efficacy diminishes and risk of dependence grows. The FDA recently issued a black box warning for a class of drugs called “Z-drugs” (i.e., zolpidem, zaleplon) stating that they were linked to sleep behaviors like sleepwalking, sleep driving and engaging in other activities while not fully awake — and even death.

Antacids or other ulcer medications — often prescribed to help with the GI side effects of NSAIDs or with reflux during an acute hospital stay — may be thought of as relatively safe, since most of them are available over the counter. But chronic use of these medications could lead to serious risk of bone loss and fractures, or cause hypomagnesemia and vitamin B12 deficiencies; these effects could be particularly threatening to the elderly. For the general population, these drugs are also associated with an increased risk for cardiovascular morbidity and mortality and risk of myocardial infarction. Clinicians should monitor patients’ therapy and reevaluate if these drugs are prescribed for longer than eight weeks.

While the use of opioids, gabapentinoids and Z-drugs are FDA approved and recommended by many guidelines for indicated periods of time, prolonged use or misuse can lead to dangerous unwanted and unintentional side effects. Clinicians must perform due diligence when prescribing such medications.

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