Incorporating Medical Marijuana: into Clincal Practice

FP WINTER 2019

MISSOURI FAMILY PHYSICIAN VOLUME 38, ISSUE 1

MEDICAL MARIJUANA INCORPORATING MEDICAL MARIJUANA INTO CLINICAL PRACTICE

MISSOURI ACADEMY OF FAMILY PHYSICIANS'

Advocacy Day 2019

You are the Voice of Missouri Family Physicians

February18-19

Capital Plaza Hotel and Missouri State Capitol, Jefferson City, MO Monday, February 18, 2019 6:30 – 8:30 pm Legislative Briefing of Key Issues and Buffet Dinner, Capital Plaza Hotel Tuesday, February 19, 2019 8:00 am – 1:00 pm Legislative Briefing and Breakfast, Capital Plaza Hotel Visit Legislators’ Offices (appointments to be scheduled for you by MAFP staff) Lunch buffet at hotel 1:30 – 5:00 pm Board of Directors Meeting

Register online at mo-afp.org *There are a limited number of complimentary sleeping rooms available through the MAFP. Contact Kathy Pabst at kpabst@mo-afp.org or call 573.635.0830 for more information and availability.

FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION

BOARD CHAIR Mark Schabbing, MD (Perryville) PRESIDENT Sarah Cole, DO, FAAFP (St. Louis) PRESIDENT-ELECT Jamie Ulbrich, MD, FAAFP (Marshall) VICE PRESIDENT John Paulson, MD, PhD, FAAFP (Joplin) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

CONTENTS 6 MEDICAL MARIJUANA:

INCORPORATING MEDICAL MARIJUANA INTO CLINICAL PRACTICE

BOARD OF DIRECTORS DISTRICT 1 DIRECTOR John Burroughs, MD (Kansas City)

ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Robert Schneider, DO (Kirksville)

ALTERNATE Brooks Biele, DO (Kirksville) DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis)

DIRECTOR Kara Mayes, MD (St. Louis)

ALTERNATE Dawn Davis, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald)

ALTERNATE Kristin Weidle, MD (Washington) DISTRICT 5 DIRECTOR Natalie Long, MD (Columbia)

ALTERNATE Vacant DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville)

ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Wael Mourad, MD, FAAFP (Kansas City)

DIRECTOR Afsheen Patel, MD (Kansas City)

ALTERNATE Beth Rosemergey, DO, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Kurt Bravata, MD (Buffalo)

ALTERNATE Charlie Rasmussen, DO, FAAFP (Branson) DISTRICT 9 DIRECTOR Patricia Benoist, MD, FAAFP (Houston)

ALTERNATE Vacant DISTRICT 10 DIRECTOR Deanne Siemer, MD (Jackson)

ALTERNATE Vicki Roberts, MD, FAAFP (Cape Girardeau) DIRECTOR AT LARGE Jacob Shepherd, MD (Grain Valley)

RESIDENT DIRECTORS Ann Lottes, MD, SLU Misty Todd, MD, UMC (Columbia) (Alternate)

STUDENT DIRECTORS Mimi Liu, SLU Morgan Dresvyannikov, UMKC (Alternate)

AAFP DELEGATES Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE COMMUNICATIONS & EDUCATION MANAGER Sarah Mengwasser MEMBERSHIP & PROGRAMS COORDINATOR Becki Hughes The information contained in Missouri Family Physician is for information purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinion expressed in each article(s) is the opinion of its author(s) and does not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 • f. 573.635.0148 mo-afp.org • office@mo-afp.org

4 A Letter from the Chair Opening remarks

5 President's Column

MAFP continues to provide relative information to its members

25 ABFM to Pilot Alternative to Board Exam

Support your desire for continued learning and practice improvement

27 MAFP Strategic Plan

A three-year road map to success

29 MAFP App Review

The latest apps reviewed for you

32 Members in the News Recognizing our colleagues

34 2019 Family Physician of the Year Nominate a deserving family physician today

36 New Opioid Prescribing Recommendations Better, safer care for your patients

37 Physician Workforce Data

Partnering to meet healthcare needs for Missourians

MARK YOUR CALENDAR 2019 Advocacy Day February 18-19, 2019 Capitol Plaza Hotel Jefferson City, MO Show Me Family Medicine Conference June 21-22, 2019 Tan Tar A Resort Osage Beach, MO

Family Medicine Transition Conference June, 2019 (TBA) Doubletree Jefferson City, MO Annual Fall Conference November 8-9, 2019 Big Cedar Lodge Ridgedale, MO

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A LETTER FROM THE CHAIR

I Mark Schabbing, MD, MAFP Chair

4

t seems like each year moves by more quickly than the last. I would like to take a moment and thank each of you who were able to attend our Annual Fall Conference at Big Cedar Lodge in November.

Our conference was a success once again and was well attended. If you have not been able to attend this conference in the past, I would highly encourage you to consider this event in the future. The location is beautiful and it is an opportunity to meet friends from across the state. I also have to say that our staff arranges excellent educational talks.

I would like to take this moment to summarize what our Missouri Academy has been doing this last year. Our Board of Directors has three meetings each year. In February, we have our first meeting in Jefferson City. Prior to this meeting, we hold our Annual Advocacy Day with the state legislature.

Our Advocacy Commission, along with our lobbyist, plans an informative meeting to educate us on the issues currently affecting us on the state level.

We then meet with our own representatives and senators to discuss issues affecting medicine.

We take that time to help educate them on any issues they may have. Unfortunately, this has not historically been a well attended event. There are typically about 30-40 participants. However, this past year was attended by only 28 physicians.

This year, our Advocacy Commission has continued with a survey to evaluate the opinions of our members. This survey has typically consisted of 25-30 questions. The purpose of this survey is to obtain the pulse of our members. This gives the board a better idea of where our members stand on some of the more controversial issues we are dealing with in politics today. This information can be used on the state level and again on the national level when the MAFP is responding to issues at the AAFP Congress of Delegates. In 2016 only 5% of our members responded. In 2018, that number more than doubled to 11% participation. I encourage you to complete the survey which will be available in July-September 2019.

The Board took action earlier this year by writing a letter to then Governor Eric Greitens and his Health Policy Cabinet members regarding the implementation of the CDC guidelines without a legislative/regulatory process. We submitted comments on the 2019 Medicare Physician Fee Schedule to CMS. We also submitted comments to the Board of Healing Arts on the proposed assistant physician regulations. The Board also endorsed the AAFP and other organizations’ “Shared Principles of Primary Care.” Through advocacy, the MAFP continues to work closely with other organizations

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2019

like MSMA and MAOPS on shared priority legislation and regulatory issues. There are many other groups we have collaborated with, such as, Council for Drug Free Youth, Million Hearts of Missouri, Missouri Hospital Association, and Missouri Healthcare Workforce Coalition, just to name a few.

The MAFP also works to help our members by providing measures to help with practice enhancement. This is performed by our Member Services Commission and Education Commission.

Each year, the MAFP sponsors two educational meetings: The Show Me Family Medicine Conference (formerly the Annual Scientific Assembly) held at the Lake of the Ozarks and the Annual Fall Conference at Big Cedar Lodge. At these meetings, our members can earn up to a total of 25 hours of CME, which is 50% of the required amount by the AAFP for continued membership re-election. These two meetings are also held in conjunction with our board meetings which all of our members are encouraged to attend.

Our current website has resources for members and the public. These pages focus on patient resources, state departments, legislative chambers, and federal departments. Our website also includes a blog started by our current President, Sarah Cole, DO, to discuss her outreach efforts throughout the state. The Education Commission has been working to include updates on policy and state activities.

They were able to do that this year with having Gary LeRoy, MD, FAAFP, AAFP President Elect, speak at the Show Me Family Medicine Conference.

In August, the Board met again for a strategic planning meeting which is completed every three years. Greg Meissen, PhD, facilitated our meeting.

A majority of our board was able to attend and there was great discussion of where the board would like to focus the resources of the MAFP over the next few years. Our Vision Statement is: “Every Missourian has a Family Physician.” Our Mission Statement: “The Missouri Academy of Family Physicians is dedicated to optimizing the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education, and research.” Three strategies were discussed to guide the MAFP over the next few years. These three areas are Advocacy for Family Physicians, Public Awareness about Family Physicians, and Pipeline for Family Physicians. Over the next several months the board will be working on a plan to facilitate these strategies. I discussed some of these ideas in MAFP's December blog, INSIGHTS. I hope you and your family had a very Merry Christmas and have a healthy and Happy New Year.

PRESIDENT'S COLUMN

I

had a crash course in the use of medical marijuana last month when Missouri voters passed Constitutional Amendment 2, which outlines the regulatory framework for supply and use of medical marijuana in our state. With three such initiatives on the ballot, I was unsurprised that one passed. After all, one 2014 New England Journal of Medicine study estimated that 86% of Americans believe physicians should be able to recommend medical marijuana. Missouri voters seemed less enthusiastic with 66% voting in favor of the amendment. Most major medical organizations, conversely, oppose the use of medical marijuana due to lack of research surrounding effectiveness, optimal dosing and delivery. Marijuana is classified as a Schedule I medication by the Food and Drug Administration and remains illegal in all forms under federal law. Until federal guidance is forthcoming or until the FDA reclassifies cannabis to a lesser schedule, significant further research remains unlikely to occur.

"

Missouri Academy of Family Physicians will continue to provide its members with relevant information regarding its [medical marijuana] use as we work toward our shared goal of excellent, effective, and compassionate care for our patients."

So it was that on November 7th, I found myself educating patients who asked, some jokingly, some not, if I would “prescribe” marijuana. Physicians

cannot prescribe marijuana but can certify a patient has one or more condition for which the state has approved the use of medical marijuana.

I have also found myself reviewing best practice data regarding use of medical marijuana. Physicians should perform a comprehensive assessment of a patient prior to certification, including documentation of which first- or second-line therapies have failed for the medical condition(s).

Physicians should review with patients the risks and benefits of medical marijuana, including cost, as insurance carriers and prescription plans do not typically cover medical marijuana. Appropriate patients for certification should not have substance use, psychoses or unstable mood disorders.

Follow-up visits should occur regularly, with some advocating quarterly visits. If a patient is also taking opioids or other controlled medications then the medication management agreement should include parameters for medical marijuana use.

Missouri’s Department of Health and Senior Services has been tasked with implementing the provisions of Amendment 2 and with accepting applications for use of medical marijuana by July 4, 2019. Additional information and FAQs from DHSS have been posted at https://health.mo.gov/safety/ medical-marijuana/index.php. I look forward to further specifics and answers from MO DHSS as I’ve heard a variety of concerns and questions. Some Missouri family physicians, for example, wonder if they have the right to decline writing a certification for medical marijuana if they do not believe it would be helpful. And, if so, they wonder how can they decline in such a way as to maintain therapeutic relationship with patients? Others express concern about the lack of framework surrounding use of medical marijuana in terms of quality and safety, particularly when it comes to rapid testing to determine impairment related to marijuana use, similar to breath or blood testing related to alcohol use.

As Missouri joins the majority of states in legalizing medical marijuana, the Missouri Academy of Family Physicians will continue to provide its members with relevant information regarding its use as we work toward our shared goal of excellent, effective, and compassionate care for our patients.

Sarah Cole, DO, FAAFP, MAFP President

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MEDICAL

MARIJUANA

MISSOURI VOTERS PASS AMENDMENT 2 BY A MARGIN OF 66% TO 34% In the US, Colorado and Washington state in 2012 became the first two states to legalize marijuana for recreational purposes. Several states, from Alaska to California to Maine, have since followed. Now, Missouri allows for the use of medical marijuana. Globally, more countries are considering legalization.

The shift poses an enormous challenge to the regime that has dictated drug policy around the world for decades. For much of recent history, the approach to marijuana was to ban it. Now, states and countries are trying to find a better way to deal with the drug — allowing it for medical use in some cases, decriminalizing it in others, or outright legalizing it. So what do the changes mean for us?

The Missouri Academy of Family Physicians remains neutral on this issue. The views, thoughts, and opinions expressed in the text belong solely to the author, and not necessarily to the author’s employer, organization, committee or any other group or individual.

ADVOCACY SURVEY DEFINES MAFP POSITIONS

T

he MAFP Advocacy Commission provides an annual opportunity for members to voice their opinion on legislative and regulatory issues which impact family physicians and patients. This year’s survey was no exception. With participation increasing significantly this year, we have better data to form our positions on these important issues. Here are the highlights of the results, some may surprise you: • Interestingly with the focus of this issue of the magazine, respondents were split

on whether to support medical marijuana – which is why MAFP did not take a position on this issue, but rather provided information to assist you with discussing this topic with your patients. However, 67% of the respondents opposed recreational marijuana.

• 53% of the respondents precept students and 94% support MAFP pursing a preceptor tax credit in rural and HPSA areas – look for more on this topic over the next year.

• 88% do not support APRN independent practice and 86% agree with the current arrangement of any combination up to 6 mid-level providers (APRN, PA, AP) and maintain the current 75 mileage limitation.

71% of the respondents utilize APRNs in their clinic while only 2.5% utilize assistant physicians. The majority of respondents also supported maintaining

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the current 30-day practice with a physician requirement; as well as maintaining the chart review (10% every 14 days).

• As expected, 92% of the respondents support a prescription drug monitoring program (PDMP) with the physician using their discretion to access the PDMP, rather than making it mandatory.

• Respondents do not support pharmacists prescribing self-administered hormonal contraceptives.

• A small percentage of respondents do not provide immunizations in their clinic; but those that do, they provide the full scope of immunizations available to all ages.

• Over 1/3 of the respondents perform radiologic imaging in clinic and is mostly performed by a registered, licensed, or certified radiologic technician.

Each respondent was given the opportunity to provide additional comments on each topic which we find very helpful as we set our legislative agenda, craft talking points, position statements, and testimony throughout the year.

The survey will reopen July, 2019. If you have a topic you would like to include in the next survey, please email it to MAFP Executive Director, Kathy Pabst, at kpabst@mo-afp.org.

MEDICAL CANNABIS: WHAT EVIDENCE DO WE HAVE?

W

ith the passage of Amendment 2, Missouri has joined 32 other states, and the District of Columbia in legalizing cannabis in some form.

Amendment 2 allows patients with a broad set of qualifying medical conditions to use medical cannabis under the supervision of a physician. This has left many physicians in Missouri struggling to determine which conditions, if any, actually benefit from treatment with cannabis.

Little evidence exists to guide physicians in this decision. As a Schedule I controlled substance, access to cannabis has historically been tightly restricted, making it difficult to conduct research in to its use. The few clinical trials that do exist have a small number of participants and are of short duration. Moreover, the lack of standardization in available cannabis products and the inability to reliably blind trial participants makes it challenging to apply the results of those studies.

Because of these barriers to cannabis research, many clinical trials have relied on pharmaceutical cannabinoids. The term “cannabinoid” generally refers to the biologically active constituents of the cannabis plant, but also includes synthetic versions of those constituents. Two cannabinoid products available in the United States are dronabinol and nabilone, synthetic analogs of ∆-9-tetrahydrocannabinol (THC). Both dronabinol and nabilone are approved by the Food and Drug Administration (FDA) for the treatment of nausea and vomiting associated with cancer chemotherapy, and dronabinol also has FDA approval for the treatment of anorexia associated with weight loss in patients with acquired immunodeficiency syndrome (AIDS).

One additional product, nabiximols, has been approved by Health Canada as a treatment for refractory spasticity in patients with multiple sclerosis, but is not currently available in the United States. Nabiximols is a cannabis extract containing standardized concentrations of THC and cannabidiol that is delivered as an oromucosal spray. It is important to distinguish these pharmaceutical cannabinoids from plant cannabis, since it is not clear how or if the results of trials of cannabinoids can be applied to the use of cannabis.

In 2015, The Journal of the American Medical Association published a systematic review and meta-analysis of randomized clinical trials of cannabis and cannabinoids.1 Investigators identified 79 trials including 6,462 participants.

Most of the trials included in the review employed pharmaceutical cannabinoids. Investigators concluded that cannabinoids compared favorably to placebo in the treatment of many symptoms, including chronic pain, spasticity, and nausea and vomiting due to chemotherapy, but these improvements did not reach statistical significance in all trials.

In the treatment of chronic pain, investigators identified 28 trials with 2,454 participants comparing cannabinoids or cannabis to placebo.

In 8 trials of 1,370 participants with chronic neuropathic or cancer pain, the average number of participants reporting 30% or greater reduction in pain on a numerical rating scale or visual analog score was greater in those receiving a cannabinoid or cannabis (OR 1.41[95% CI 0.99 to 2.00]), however this was not statistically significant.1 In the treatment of spasticity due to multiple sclerosis, investigators identified 14 trials with 2,280 participants comparing cannabinoids or cannabis to placebo. In three trials with 698 participants, cannabinoids produced greater average improvement in spasticity as measured by a numerical rating scale (mean difference -0.76 [95% CI -1.38 to -0.14]), and in three trials with 461 participants, the average number of patients reporting improvement on a global impression of change score was greater in those receiving a cannabinoid (OR 1.44 [95% CI 1.07 to 1.94]).1 In the treatment of chemotherapy-induced nausea and vomiting, investigators identified 28 trials with 1,772 participants comparing cannabinoids or cannabis to placebo. In three trials with 102 participants, the average number of participants reporting a complete response to nausea and vomiting was greater in those receiving a cannabinoid (OR 3.82 [95% CI 1.55 to 9.42]).1 There was also low-quality evidence to support the use of cannabinoids for the treatment of weight loss associated with AIDS, sleep disorders, and Tourette syndrome.1 An additional systematic review published in

Lucas Buffaloe, MD, Associate Professor of Clinical Family and Community Medicine, University of Missouri Health Care, Columbia, MO

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The Journal of Pain, in 2015, focused on the use of inhaled cannabis for the treatment of neuropathic pain.2 A total of five trials with 178 participants with neuropathic pain were included in this review. In all trials, participants were randomized to receive inhaled cannabis or placebo.

Investigators found that the average number of participants reporting greater than 30% reduction in pain on a visual analog scale was greater with inhaled cannabis than placebo (OR 3.22 [95% CI 1.59-7.22]).2 In 2017, the National Academies of Sciences, Engineering, and Medicine published The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research.3 The authors of this publication conducted a comprehensive review of randomized clinical trials, reached conclusions about the benefits and risks of cannabis and cannabinoid use, and provided recommendations for future research. Researchers drew from the reviews described above, but additional randomized clinical trials, systematic reviews, and metaanalyses were also included. Again, most of the included studies investigated pharmaceutical cannabinoids. Authors determined that there was conclusive evidence that cannabinoids are effective anti-emetics in the treatment of chemotherapy-induced nausea and vomiting. They determined that there was substantial evidence that cannabis is an effective treatment for chronic pain in adults, and that cannabinoids are

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effective for patient-reported multiple sclerosis spasticity symptoms. They found moderate or limited evidence to support the use of cannabis and cannabinoids in the treatment of sleep disturbance, weight loss associated with AIDS, Tourette syndrome, anxiety, and post-traumatic stress disorder. For all other investigated uses, cannabis and cannabinoids were either ineffective or had not been adequately studied.

As these reviews suggest, evidence from randomized clinical trials supports the use of cannabinoids in the treatment of some forms of chronic pain, spasticity due to multiple sclerosis, and chemotherapy-induced nausea and vomiting.

Inhaled cannabis may be an effective treatment in chronic neuropathic pain. For some patients with these conditions, cannabis may play a role in their care, although evidence of benefit is only one of several factors that physicians will have to consider when determining if cannabis is appropriate for a patient.

The medical uses of cannabis that are supported by current evidence are much narrower than the qualifying medical conditions included under Amendment 2. Although cannabis may be effective in the treatment of other conditions, there is not adequate evidence to make an accurate assessment at this time. Hopefully, future cannabis research will help to shed light on these problems. Patients will likely wish to discuss cannabis as a treatment for conditions that have not been studied, and it will be important for physicians to help patients understand the limited evidence that currently exists, and how much remains unknown.

References 1. Whiting PF, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015;313(24):2456-2473.

2. Andreae MH, et al. 2015. Inhaled cannabis for chronic neuropathic pain: a meta-analysis of individual patient data. Journal of Pain 2015;16(12):1121–1232.

3. National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence And Recommendations For Research. 2017; Washington, DC: The National Academies Press.

EDUCATION OF OUR MEDICAL COMMUNITY ON CANNABIS

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L

ast month, voters made Missouri the 31st state to allow doctors to recommend medical marijuana to patients with serious and debilitating illnesses.

The initiative was overwhelmingly embraced by Missourians. Since the law went into effect earlier this month, patients now have legal protections to begin discussing medical marijuana as a treatment option with their doctors. Now it is time for the medical community to educate ourselves on the information available on cannabis and the endocannabinoid system.

I believe medical marijuana could relieve the painful symptoms of a wide range of debilitating and chronic illnesses. Candidly, patients have spoken openly to me about their travel to one of the 10 states where adult use is available, or lived in one of the states where medical use is allowed. I believe it has been a compassionate, responsible medicine for these patients. After hearing time and time again from patients who experienced benefit, it was hard for me to ignore that cannabis is a medicine. Thus, I embarked on a journey to read and take courses on cannabis, attend national conferences on the subject, and travel to legalized states to speak to other physicians.

Positive physician perception of cannabis has increased over the past few years mirroring that of the public. A WebMD Physician Survey in 2014 of over 1,500 doctors showed that 67% felt it should be a medical option for patients and this increased to 82% amongst oncologists.

However, many physicians have not been educated on the endocannabinoid system and most Missouri healthcare professionals do not know it exists. This is despite the CB1 receptor being identified at St. Louis University in 1988.

The knowledge of cannabis has expanded over the past few decades but great barriers continue to exist making research difficult due to it being a DEA Schedule I drug. Much of the high-quality research is being done in Europe and Israel.

This has culminated in Epidiolex, a whole plant Cannabidiol Oral Solution, gaining FDA approval in June 2018 as a Schedule V drug.

Currently, articles are available for physicians who seek to self-educate on cannabis. Despite

it being federally illegal, the US government reviewed 10,000 scientific abstracts and published a report in 2017 in the National Academies of Sciences, Engineering, and Medicine. They found clinically significant relief for Chronic Pain and improvement in Multiple Sclerosis related spasticity. Cannabis was also noted to be effective as an anti-emetic for Chemotherapy-induced nausea and vomiting.

Also noteworthy, JAMA has published articles on cannabinoids for medical use, as well as article on the public health potential. A systematic review and meta-analysis was published in JAMA in 2015 that showed evidence to support use of cannabinoids in chronic pain and spasticity that were moderate quality. A JAMA article published earlier this year showed significant reductions in the amount of opioids being prescribed in states implementing medical marijuana laws. More impressively, a 2014 JAMA study showed a 25% reduction in opioid overdose deaths in medical marijuana states.

As implementation of the law rolls out in Missouri, patients may begin to ask questions of their physicians and it is important we begin to educate ourselves as much as possible. The Department of Health and Senior Services will make patient applications available June 4, 2019 and begin accepting them July 4. The best thing we can do to ensure that Missouri has a safe and compliant medical marijuana program is the education of our medical community.

This is why I am the chair of the healthcare and education committee and board member of the Missouri Medical Cannabis Trade Association (MoCannTrade), an association of healthcare providers, business owners, professionals, patients and residents dedicated in ensuring a successful, compliant program where safety is a top priority for our patients.

Medical marijuana can improve the lives of Missouri patients. But it is our responsibility, the medical community, to help patients make informed decisions on all aspects of their healthcare, including whether medical marijuana might play a role. The only way we can do that is to begin educating ourselves and having these important discussions now.

Mimi Vo, MD, Board Certified Internist, Vo Medical Clinic, St. Louis, MO

The best thing we can do to ensure that Missouri has a safe and compliant medical marijuana program is the education of our medical community."

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MEDICAL CANNABIS: PANACEA OF PROMISE

O Patricia Hurford, MD, MS, FAAPMR, FAAPM,

SOAR

Spine Orthopedics and Rehabilitation, Kirkwood, MO

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n November 6, 2018, Missourians passed Amendment 2 with 65.5% of voters supporting the medical use of marijuana in our state. Missouri now joins 32 other states with medical marijuana laws. As a physiatrist and pain management physician, I have been faced with the challenges of caring for patients with disabling conditions and severe pain disorders. Like other physicians, I struggle to find safe and effective ways to improve the quality of my patients lives. The struggle is often how to do this compassionately, ethically, and legally.

I became a proponent of medical marijuana based on an extensive review of the endocannabinoid system, and by reviewing arguments both for and against medical marijuana laws. My patients will attest to my change in attitude after writing an article outlining both positives and negatives of cannabis in 2014. I was neutral in my approach but philosophically held an anti-marijuana bias. My attention was focused on the increasing devastation of the opioid overdoses and abuse. Marijuana was part of the “Just Say No” campaign of my youth.

My intent was to explore safer alternatives to opioids. Cannabis was legal as a medical treatment in 21 states at that time, but was still federally restricted as a Schedule I drug under the Controlled Substances Act. It meant that cannabis had a high potential for abuse with no accepted medical use in the United States, and that there was a lack of safety even with medical supervision. More importantly, it was illegal. After this piece was released, the level of interest and inquiry from patients and other physicians was enormous. Like many other physicians, I struggled with the “if it is so harmless and helpful, why is it illegal?”

Contrary to the current classification of a Schedule I drug, cannabis is CLEARLY accepted for use as a medical treatment. Marinol (dronabinol), Cesamet (nabilone) and Sativex (nabiximols) are all pharmaceutical agents which can be prescribed and have known medical uses. The United States government even has a patent (US 6,630,507 B1) granted to the US Department of Health and Human Services in October 2003 for cannabinoids used as antioxidants and neuroprotectants.

The discrepancy between the legal and medical attitudes are pointedly inconsistent. The shortage

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2019

of clinical data is a peculiar and difficult dilemma imposed again by cannabis’ classification as a Schedule I drug thus making the cultivation, research and testing limited to approval by the federal government. It also authorizes only one research facility in the US for manufacturing of cannabis. Despite these limits, clinical efficacy has been established for several medical conditions.

My patients will attest to my change in attitude after writing an article outlining both positives and negatives of cannabis in 2014.

I was neutral in my approach but philosophically held an antimarijuana bias.."

Cannabis has been around for thousands of years. It has been used as a food, as a medicine, as a religious sacrament and as a fiber. In 1850, the United States Pharmacopeia listed marijuana as a legitimate medical compound. It was a universal medicine used for a variety of ailments. The difficulty in maintaining the integrity of solutions containing cannabis and the variable potency made cannabis popular as an extract or tincture but difficult to supply as a consistent pharmaceutical product. Herbal medical practices, many of which

used cannabis, flourished in the late 1800’s but were restricted and eliminated in the United States in the early 1900’s due primarily to political opposition to alternative and herbal medical training.

In 1937, the Marijuana Tax Act was passed. This Act placed a tax levy on any hemp products and any commercial sales of cannabis products. The term “marihuana” was virtually unknown at that time. Many have suggested that the plan was to subvert the hemp industry which was in direct competition with the oil and paper industries of that time. Others claim a more sinister racist attack by Harry Anslinger, the head of the Federal Bureau of Narcotics in the 1930’s. Racial rhetoric, attributed to Anslinger, was used to frighten the public about the criminal behaviors of marijuana users. Anslinger who led the charge against cannabis at that time is quoted as saying, “The primary reason to outlaw marijuana is its effect on the degenerate races.”

Propaganda films, exemplified in the infamous film, Reefer Madness, were released featuring young people smoking marijuana, killing themselves or killing others after being lured into use. The criminality of marijuana introduced by Anslinger changed the public’s perception of marijuana for the worse.

Physicians were caught off guard. Arguably, many never appreciated the full implications of the tax bill.

Doctors knew marijuana by its botanical name, cannabis.

Few physicians knew that “marihuana” (later called marijuana), a derogatory term at the time, was in fact cannabis sativa, a pharmacologic agent that many used to treat various conditions. In fact, the American Medical Association strongly opposed the 1937 Tax Act. Dr. William Creighton Woodward, representing the AMA in 1937, argued that there was no evidence to support the claims of addiction, violence and insanity purportedly linked to cannabis. And, due to the secret preparation of the bill and confusion of terms, there was no serious opposition. This tax levy placed an undue burden on physicians and pharmacists and led to the defacto prohibition of cannabis and hemp. The perception of marijuana changed as cannabis, an innocuous substance became a stigmatized drug.

What role does cannabis play in the treatment of medical conditions? There are numerous reliable and relevant clinical trials which demonstrate cannabis’ effectiveness in treating many medical conditions. These include decreasing nausea created by chemotherapy, improving spasticity and pain from multiple sclerosis, stimulating the appetites of those who are severely affected by anorexia from HIV/AIDS and certain cancers, improving neuropathic pain conditions by improving

inflammation and pain particularly in combination with other agents leading to both a reduction and pain and significant reduction in side effects. Glaucoma discomfort is reliably decreased with cannabis. Pediatric epilepsy treated with cannabis is a life changing improvement for patients and families. Scientific studies from the US and other countries is overwhelmingly positive. Yet the arguments against the use of medical marijuana persist. The most common argument revolves around the inaccurate classification of cannabis as a Schedule I drug. The potential for misuse is used as an argument against medical use. Thus far, science does not support this opinion.

Working with trained medical professionals, qualified patients in Missouri will now be able to receive qualitycontrolled cannabis products from licensed dispensaries.

Amendment 2 legalized marijuana for medical purposes.

This ballot initiative allows physicians licensed in Missouri to recommend marijuana use to patients with nine qualifying conditions and additional conditions with a doctor's approval. Educating physicians in Missouri on the basics of the cannabis plant, the endocannabinoid system and cannabis dosing is an essential part of this Amendment and will be available for all physicians.

If cannabis was discovered today, it would be hailed as a medical breakthrough. Unfortunately, the medicinal cannabis is still a political controversy rather than a medical issue. Had the cannabis extracts of the early 1900’s been more stable with more reliable pharmacologic responses, their incorporation into early pharmaceutical testing would be history. Experimental clinical studies would be robust and ongoing. Today, federal restrictions make research difficult. Until the DEA allows cannabis to be reclassified as a Schedule II or III drug, we will be limited to only a few quality studies proving or disproving the use of cannabis for certain medical conditions. We will be left reviewing scientific data from other countries. There is no question that more studies are needed. Physicians should play a greater role in understanding the contents, dosages and type of cannabinoids they recommend to patients. The mode of delivery needs to be safe for the patients we treat.

Though other pharmaceutical medications may be more effective and long lasting, medicinal cannabis can provide relief for patients who have exhausted conventional therapies and many times with less side effects. Commercialization and politics should not interfere with science and medicine. Our medical concerns should be influenced by research rather than political posturing.

MO-AFP.ORG 13

CHECKMATING STATESPONSORED MARIJUANA "DR UG CARTELS" AN OPINION PIECE

M David Usher Medical Marijuana Opponent Activist

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issouri is the most recent state to be fooled by the High Times crowd.

They learned a lesson from the Lottery. If you can’t legalize crime, turn it into a state-run monopoly.

Marijuana addiction is coming to Missouri.

Michigan “High Times” activists developed a sneaky model to legalize recreational marijuana under the guise of medicine. Time and time again, states fell for it. The model is a combination of emotional ploys. It began years ago with making everybody feel tragically sorry for those who have painful fatal or debilitating diseases. Veterans with PTSD are another favorite victim-class placed on the pedestal of pot politics.

Pot activists then claimed that marijuana is a great painkiller (so is any other substance that sends you to Tralfamador in a handbasket). Social Justice activists entered the arena with assertions that citizens have a Constitutional right to try any drug they want to fix ailments both real and imaginary.

Fault lines appeared revolving around a combination of professional and ideological lines. Realignments occurred in the medical, psychological, and substance abuse recovery fields.

Before continuing, I will do a brief introduction because I am new to this team of professionals.

I have been involved in family law, family rights activism (including father’s rights and shared parenting), support work running a large divorce support group for over a decade, and lay substance abuse support work with Hazeldenbased programs. This was very successful work helping perhaps 5,000 individuals over the years, and stimulating passage of legislation. We had no arrests, no criminal convictions, no suicides, a number of second marriages, and no second divorces.

Self-trained at the Washington University Law Library, I have done my own legal work for 30 years, won two family law court cases pro-bono, won Constitutional Appeal in the Missouri Supreme Court, and converse regularly with former presiding and Appeals court judges and attorneys on legal matters and legislation I am working on.

Three major Missouri statutes were enacted

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2019

based on my policies, along with a number of tweaks – the first of which was in 1991. Several more policies are in the pipeline, including the first melding of family law and addiction counseling that will positively encourage substance misusers to seriously seek recovery instead of suffering all the ugly consequences we know about (more about this later in this article).

I have worked with many psychological professionals over the years, advised on military court cases, and completed research for peerreviewed academic papers involving psychology and family law.

Now for the confessional: I tend to be years ahead of the game, and that gets me in trouble.

Most folks only care about the problems this month and are not looking five years down the road to see where trends will take us. Inevitably, the world eventually catches up. Folks are nervous until it does, and then the Cassandra syndrome sometimes sets in when I predicted something bad would happen.

I am candid in my work, and say it like it is even if it might ruffle a few feathers in the short run.

“Political correctness” is not my forte, but facts are.

Now, back to the article.

We have several fault lines dividing our ranks and making us weak. I believe we all agree that substance abuse is a big problem harming a lot of Americans. Many of us believe there are probably useful medical uses for marijuana (with or without THC). Most of us agree that medicines should be developed and approved under rigorous testing and safety standards, with full peer review, and sold in drug stores. We are looking for policies that will intervene during the critical (and presently unaddressed) gap between prevention and endstage consequences when full recovery of one’s life is possible.

We have been overwhelmed by the “High Times” medicine show. There are some psychologists, doctors, and hired legal guns who believe that drugs are the answer to every human problem.

They scream about pain and agony, painting images of a pain-free world. The media elevates them as the guardian angels of humanity, while we are considered a bunch of high-Victorian Luddites.

DSM-V brought changes I believe are misleading and counterproductive to recovery. The terms “substance abuse” and “substance dependence” were the descriptor used in law and DSM-IV for decades. Political correctness set in and a major change was made in DSM-V. The term changed to “Substance Use Disorders”. Even more stunning is the fact that DSM-V now classifies cigarettes (which are not intoxicating) in the same category as hard core drugs that blow your head off and can kill you before you finish reading this article.

A well-known leader of a substance abuse recovery organization went into paroxisms because I use the words 'substance abuse'. That is considered a insult now (as if “substance use disorder” is perhaps more complimentary).

is an abdication of duty – 'interventions' require placing the substance abuser in a position of having to choose recovery or 'consequences'.

Left to run its course, drug addiction results in irrecoverable and severe consequences to individuals and extremely high costs to the state.

In 2015, The National Institute on Drug Abuse reported what I discovered in 2010. There is a big policy gap between prevention and chronic-phase consequences. There is no federal or state policy facilitating interventions when troubled families desperately need it. This is a monstrous policy gap the size of the United States.

There continues to be a large "treatment gap" in this country. In 2013, an estimated 22.7 million Americans (8.6 percent) needed treatment for a

"

Marijuana addiction is coming to Missouri."

This leader rejects 12-step recovery programs because they are biblically-based. I spent 30 years around the tables, and saw people successfully turn their will and lives over to ungodly items such as the doorknob, clouds, and a bush in the back yard. I suspect this leader spent too much time studying political correctness and too little time understanding how 12-step programs work.

We must pay careful attention to the real reason for these changes and attitudes. The target, my friends, is how substance abuse is handled before the law. Calling it a “Substance Use Disorder” is a diagnosis calling for years of professional counseling regardless of what a person did. It is also a defense of “mental illness” before the law.

The classic “Officer Krupke” defense has successfully been used for decades to get people off the hook, but is now central to the “empty out prisons” movement, letting drug dealers off the hook. The Drug Policy Alliance (funded by George Soros) is the primary organizer of marijuana initiatives (and the “empty the prisons” political movement).

All professionals have a duty to use all available legal means to achieve their professional goals.

For example, much money is spent discouraging cigarette smoking all up and down education and schools. Those who smoke must pay more for insurance and attend cessation classes. Most public places ban smoking with arrestable criminal or civil penalties attached.

But the leader mentioned above was adamant that courts and legal systems must not be used in any way to intervene in or bring about recovery.

Apparently, substance abuse is a private matter between the mentally-ill and their counselors. This

problem related to drugs or alcohol, but only about 2.5 million people (0.9 percent) received treatment at a specialty facility.

With states operating monopoly drug cartels (and actively addicting their citizens), we must enact policy to tactfully intervene when substance abuse becomes a problem for family members. We have no choice but use courts and social services to help troubled families when they request assistance.

It is up to us to make this happen. I invite all medical and psychological professionals to help us make Missouri the first state to fill the policy gap. We have a 'Family Substance Abuse Order', formerly Missouri House Bill 1070, to be reintroduced in January. It is a simple bill using existing systems: • If you have a family member or child who has a serious addiction problem, you will be able to get a restraining order. The judge removes them from the home until the person has convinced the responsible spouse and/or a state-recognized substance abuse program that they are sufficiently recovered.

• The state backs the responsible spouse to execute the intervention. These are traditionally very difficult to do via informal methods.

• A loan is available for people who cannot pay for services. Low-income Missourians will not fall through the cracks.

• The state has no authority to intervene. Only an adult family member can request intervention assistance from the courts.

• A simple one-page checkbox reporting paperwork system is implemented so recovery counselors can report monthly status to the court. Courts cannot subpoena counselors to testify. The only MO-AFP.ORG 15

information they provide is recovery status. Court forms vetted by counselor will be printed in the statute so the policy works without chance of administrative negation.

• The policy is self-correcting. If a substance abuser get a restraining order to game the system, the recovery center will discover it during the P/I evaluation and interview of the other spouse. The restraining order will be reversed.

• This policy has been developed over the past seven years using some of the finest counselors, legal minds, and policy minds in the nation.

This policy model is the most effective choice to address the 'treatment gap'. Substance abuse intervention is both appropriate and indicated in families when substance abuse is driving family conflict. Three-quarters of serious domestic violence is associated with substance abuse at the time of violence. Our Family Substance Abuse restraining order will encourage recovery at the exact time when recovery is most likely to be triggered, and before irreversible consequences occur.

Physicians and counselors will be able to recommend a good course of action to troubled clients. There are many kinds of substance abuse treatment with substantially different efficacy rates. The Hazelden/Betty Ford model has a longitudinal five-year recovery rate of about 75% -- the best in the recovery field. Hazelden focuses on family intervention and tough-love behavioral modification. I am not a fan of recovery programs pretending that you can treat behavioral problems with a pill. Clearly, substance abuse interventions require positive participation of government and partnerhip with family members and medical professionals to put substance-abusing family members in a mood to choose recovery over 16

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2019

eventual self-destruction.

I believe that all medical associations who opposed the marijuana initiatives in Missouri and other states will want to sign on to our intervention-model legislation. We could not stop legalization. We must now position responsible physicians and psychologists to establish functional government policy that will reverse substance abuse caused by government policy misusing some medical professionals as shills needlessly addicting citizens to drugs.

We will be sending a letter to Missouri state leaders in both parties signed by professionals and activists supporting this bill. I encourage everyone to sign on to the letter.

About 10 professional medical organizations opposed the three marijuana ballot initiatives.

This is a national issue now. This will be the first bill handling the 'treatment gap' in the United States.

When we enact it in Missouri, it will be much easier to get it passed in other troubled marijuana states.

The only way to stop harm going forward is for all who opposed the marijuana initiatives to help enact our substance abuse recovery policy so that recovery is the norm. If you or your organization wish to sign on to our letter, get co-sponsors, lobby, and/or testify in the House and Senate please submit an email to drusher@swbell.net.

David R. Usher is President of the Center for Marriage Policy. Mr. Usher has been a recognized public policy analyst, creator, writer, and activist for over 30 years. ©2018

A TIMELINE OF PROVISIONS OF AMENDMENT 2

The Department of Health and Senior Services is tasked with implementing the provisions of Amendment 2. This includes but is not limited to: • Issuing registrations to qualified patients and their primary caregivers.

• Licensing and certification of medical marijuana cultivation facilities.

• Licensing and certification of medical marijuana dispensary facilities.

• Licensing and certification of medical marijuana-infused products manufacturing facilities.

• Licensing and certification of medical marijuana testing facilities.

The timeline for the provisions included in Amendment 2 began on Dec. 6, 2018.

Important dates to remember are as follows: • Jan. 5, 2019 – Pre-filed application fees will begin to be accepted.

• June 4, 2019 – Application forms and instructions will be available.

• July 4, 2019 – Applications for identification cards will begin to be accepted.

• Aug. 3, 2019 – Facility applications will begin to be accepted.

If you have questions about this program, visit health.mo.gov/safety/medical-marijuana/ or send your comments to MedicalMarijuanaInfo@health.mo.gov

MO-AFP.ORG 17

FAQ'S

ON AMENDMENT 2 FROM THE MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES

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n November 6, 2018, Missouri voters approved Amendment 2 to permit statelicensed physicians to recommend marijuana for medical purposes to patients with serious illnesses and medical conditions. These FAQs are intended to provide clarifying information about Amendment 2 until applicable rules and regulations can be developed and implemented, which will be no later than June 4, 2019.

Can I legally possess medical marijuana now?

No. While the Department understands that Missourians are anticipating this form of therapy, Amendment 2 requires a series of steps be executed before medical marijuana is made available.

When will medical marijuana be available?

The Department will begin accepting applications for cultivation, manufacturing, and dispensing facilities on Aug. 3, 2019 and we anticipate medical marijuana may be available for purchase as early as January 2020.

How do I get medical marijuana?

Step 1: You must visit a state-licensed physician (not a nurse practitioner or physician’s assistant) to obtain a physician certification.

Step 2: Apply for an identification card from the Missouri Department of Health and Senior Services (starting July 4, 2019).

Step 3: Once your application is approved and you receive your identification card, purchase medical marijuana from a state-licensed dispensary.

Will I be able to go to the pharmacy to fill my medical marijuana?

No, only a Missouri licensed dispensary facility.

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Can someone with an out-of-state medical marijuana card or a physician certification possess medical marijuana in Missouri on December 6?

No. The reason is that while the possession is technically allowed, there will be no marijuana available for legal possession. There will not yet be any licensed dispensary facilities to purchase marijuana from; cultivation identification cards will not yet have been issued; and transportation of marijuana into Missouri from another state or purchase of marijuana from street dealers is prohibited under state and federal law.

Can anyone other than a state-licensed physician provide a physician certification?

No.

What conditions qualify?

• Cancer; • Epilepsy; • Glaucoma; • Intractable migraines unresponsive to other treatment; • A chronic medical condition that causes severe, persistent pain or persistent muscle spasms, including but not limited to those associated with multiple sclerosis, seizures, Parkinson’s disease, and Tourette’s syndrome; • Debilitating psychiatric disorders, including, but not limited to, post-traumatic stress disorder, if diagnosed by a state licensed psychiatrist; • Human immunodeficiency virus or acquired immune deficiency syndrome; • A chronic medical condition that is normally treated with a prescription medication that could lead to physical or psychological dependence, when a physician determines that medical use of marijuana could be effective in treating that condition and would serve as a safer alternative to the prescription medication;

• Any terminal illness; or In the professional judgment of a physician, any other chronic, debilitating or other medical condition, including, but not limited to, hepatitis C, amyotrophic lateral sclerosis, inflammatory bowel disease, Crohn’s disease, Huntington’s disease, autism, neuropathies, sickle cell anemia, agitation of Alzheimer’s disease, cachexia and wasting syndrome.

If I have a qualifying condition, how do I apply?

After you have a physician certification, you can apply with the Missouri Department of Health and Senior Services. An application form is being developed and will be available online no later than June 4, 2019.

When can I apply for my identification card?

Application forms and application instructions will be available to qualified patients and their primary caregivers no later than June 4, 2019. The department will begin to accept applications on July 4, 2019. The Department anticipates an online application process.

When will I receive my identification card?

When can I submit my application FEE for a cultivation, manufacturing, testing, transportation, seed-to-sale, or dispensing facility license?

Beginning on January 5, 2019.

Note: The method for application is currently being developed. The fee submission is nonrefundable. Submission of a fee is not a guarantee of a license.

When can I submit my application FORM for a cultivation, manufacturing, testing, transportation, seed-to-sale, or dispensing facility license?

Beginning on August 3, 2019.

When will I receive my cultivation, manufacturing, or dispensing license?

Within 150 days after the application is received, if your application is approved.

What is a primary caregiver?

Are there fees associated with applying to become a cultivation, medical marijuana-infused manufacturing, or dispensing facility?

Someone who is: • Twenty-one (21) years of age or older; • Responsible for managing the well-being of a Qualified Patient; and • Designated on the primary caregiver’s application for an identification card or in other written notification to the Department.

• Cultivation Facilities require a $10,000 non-refundable application fee and a $25,000 annual fee.

• Dispensary Facilities require a $6,000 non-refundable application fee and a $10,000 annual fee.

• Medical marijuana-infused manufacturing facilities require a $6,000 non-refundable application fee and a $10,000 annual fee.

How much does an identification card cost?

How do I get more information?

$25, initially. Approved payment methods are to-bedetermined.

Email your inquiries to MedicalMarijuanaInfo@health.mo.gov

Within 30 days of application, if your application is approved.

Will I be allowed to grow my own marijuana plants for medical use?

Yes, with the appropriate identification card and in an appropriately secured facility.

What is the Department doing to facilitate implementation of Amendment 2?

We are reaching out to stake holders for input and reviewing other states’ regulations to determine best practices. Check back to this website for updates and developments.

All of this information can be found by visiting health.mo.gov/ safety/medical-marijuana/faqs.php MO-AFP.ORG 19

CANNABIS-INFUSED COLORADO: WHAT'S GOIN' ON? " There are three kinds of men: The ones that learn by reading The few who learn by observation The rest of them have to pee on the electric fence."

-Will Rogers

T

Steven Wright, MD, Mountain Medical Injury and Pain Professionals Lakewood, CO

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he history of cannabis is littered with assertions and conjectures often unproven yet advanced by favorable or unfavorable anecdotal experiences and bias. In 2737 BCE mystical Emperor Shen Neng of China recommended cannabis for gout, rheumatism, malaria, and poor memory. Pliny the Elder in first century Rome wrote the earliest known record of adverse reactions. Today, debate is ongoing about these and other benefits, risks, and the rights of individuals and their freedom to choose.1 Emotions often run high, and major questions remain unanswered.

Medical providers rely on the FDA to provide some level of assurance of the safety and efficacy of a substance used as medicine. Although certain individual cannabinoids (dronabinol, nabilone, cannabidiol) are FDA-approved for narrow indications, cannabis whole plant, plant parts, and extraction products are not. Any medical use is not just off-label, it’s OFF off-label. There is no label!

Laetrile is the only other substance to circumvent the FDA and gain approval by individual states as medical treatment … and that didn’t end well.

Without demonstrated efficacy but promoted as a food, vitamin, and nutritional supplement to cure cancer, 24 states permitted use through legislation by 1982. However, when laetrile is metabolized in the body, cyanide is generated and fatalities occur, so states quickly backed off.2 The FDA, after all, does have a valuable role adjudicating the safe and effective use of drugs for medical purposes.

But that’s where we are today. Cannabis remains a Schedule I substance at the federal level: “no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2019

abuse”.3 However, medical use is approved by 33 states, the District of Columbia, and the territories of Guam, Puerto Rico, and the Northern Mariana Islands. Another 14 states permit use cannabidiolenriched products by limiting the allowable concentration of Δ⁹-tetrahydrocannabinol (THC). In addition, ten states, the District of Columbia, and the Northern Mariana Islands permit recreational use.

In this environment, it is not only important to understand what happens to individuals who use cannabis for medical or recreational purposes (described elsewhere)4-6, but also to society as a whole. Data on a range of socioeconomic and public health parameters is limited because long-term trends and outcomes are yet to be determined. Many studies are observational with small sample size, examine smoking rather than other routes of delivery, and are not well controlled for variable dose, concentration, frequency, duration, or inhalation technique. Interpretation of available data requires caution, since association does not necessarily mean causal due to multiple confounding factors and substances. Indeed, just because I have a cup of coffee in the morning, does not mean it caused the sun to rise!

Colorado’s experience can be instructive, though, but is not altogether generalizable as there is wide disparity as to how states regulate cannabis use.7 In 2000, Colorado voters approved an amendment to the state constitution to allow medical use, which was operationalized the following year. The Ogden memorandum (2009) stated that the federal government would not prosecute medical users as long as they followed state law.8 This resulted in a 10-fold increase in Colorado cannabis registrants over a single year and ushered in what has been

called the "commercialization era” (2009-2014) when dispensaries grew exponentially.

In 2012, voters approved recreational use, and upon rule-making, cannabis was fully legalized in 2014. Today, almost one million people used cannabis at least once last year in Colorado (population 5.4 million), and there are over 89,000 Coloradans with “medical cards”, the latter down 25% since peaking in 2014. This decline may, in part, reflect a proportion of “medical users” who had actually been using their cards for recreational purposes, adding evidence to the assertion that medical use pathway was simply a ruse and a strategy to build towards full legalization.

For the state as a whole, 15-18% of adults >18 years old report past month use, exceeding the national average of 8-10%.9-11 Colorado now ranks third in the nation for adult cannabis use.

The percentages of Coloradans using cannabis has been steadily increasing since 2006 for all age groups, excepting youth 12-17 years old who experienced an upward trend that peaked in 2014, now returning to 2006 levels,12 but still 50% higher than the national average.10 Although lower risk perception about cannabis has been associated with increased use13, in Colorado perception of harmfulness in this cohort has not declined.14 Cannabis sales and service is a boom industry in Colorado. Some 41,000 people have licenses to

sell it. Not including the black market and homegrowing operations, the regulated market sold 301.7 metric tons of product (2017)12, equivalent to more than one joint every other day for every Coloradan >18 years old. There are 1,026 cannabis retail and medical outlets15 compared to 600 retail operations for McDonalds and Starbucks combined.16 These operations are not distributed evenly across the state, as 65% of local jurisdictions have exercised their legal right to not allow commercial sales.

Canna-business has realized strong economic gains. Although the “price per serving” has fallen by half since 2014, total annual sales now exceeds $1.5 billion17,18. It is estimated nearly 18,000 are employed full time in the industry, which is credited for 5.5% of the employment growth in the first half of 2017.19 These jobs are typically well paid with good benefits.20 State tax revenue was $247 million (2017)21, which amounts to 0.9% of the state budget. Commercial real estate - warehouse property in particular - is now at a premium, and home values have realized a net gain of $15,600 in local jurisdictions allowing commercial cannabis sales.22 The travel industry experienced a boost from cannabis tourists visiting for an estimated 18 million days and purchasing 19 metric tons of product (2017).12 These benefits, however, appear to be offset MO-AFP.ORG 21

by costs related to legalization. The Centennial Institute performed a thorough and fair-balanced economic analysis while critically evaluating the limitations of its own work and that of the evidence-based investigations upon which it was based. It found that for every dollar generated in cannabis tax revenue, $4.50 was spent to mitigate adverse outcomes.12 Costs related to healthcare and high-school dropouts were found to be the most significant.

A range of research-based, population-level socioeconomic factors and adverse trends have been identified in Colorado: • Reduced educational achievement/income, and higher unemployment among cannabis users.12,13,23,24 • Increased cannabis-related disciplinary incidents among students.12,25 • Increased employer costs: workplace policies and employee cannabis use violations.12 • Income diverted to cannabis use.26 • Increased housing/commercial/rental costs and renter cannabis-related evictions.12 • Increased energy use by the cannabis industry: 4% of total use in Denver metro.12 • Increase CO2 emissions from energy use = CO2 produced by 38,000 cars (2016).12 • Increased water use: 1 gallon/d per 1 lb flower buds or 480 gallons per plant grown.27 • Increased public land plant seizures16 and environmental degradation.28 • Environmental impact of single-use plastic packaging: >18 million pieces (2017).12 • Pet ingestion of cannabis products.29 • Five-fold increase in cannabis-containing parcels seized in the mail service (2013-2017).16 • Increased non-mail-service interdictions of cannabis transported to other states, now trending down - Missouri the #2 destination!16 The effect on crime is more complicated.

Overall in Colorado crime has increased while it has decreased in the nation as a whole. This is probably not related to legalization, since in the Denver metro area (56% of the state’s population) where the majority of cannabis is sold, crime has decreased.12 As expected, total arrests for have plummeted; however, legal actions related to certain cannabis-related offenses, black market production, and enforcement costs along state borders have increased.12,15,30-32 Data on property and violent crime is mixed.16,32-34 There is uncertainty about traffic safely trends due to an increase in officers trained to identify 22

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drug use as well as incomplete testing and data collection, especially in past years. Even so, cannabis-involved DUIs - often in combination with alcohol - have clearly increased, particularly in Denver.16,32,35 One out of five of Coloradans who use cannabis report operating a vehicle intoxicated by it at least once in the last month.36 Many of them feel they are able to compensate37, and others do not recognize their own impairment.38 The known adverse health effects of cannabis4, are beginning to be reflected at the populationlevel in Colorado. There are concerns about the methodology and accuracy of these public health investigations, so some of this early evidence should be considered tentative: • Doubling of cannabis-related poison center calls.12,16,30,32,35,39,40 • Doubling of accidental cannabis ingestions by children41 • Increased cannabis-involved motor vehicle accident fatalities, extent uncertain.12,16,35 • Cannabis-involved injuries, extent unknown.12 • Burns due to THC extraction from cannabis, expected now to decline as CO2 is supplanting butane for extraction.42,43 • Increased cannabis-involved emergency department visits and hospitalizations.12,40,43,44 Cannabis research, however, appears to be subject to extraordinary revision. Data is sifted, tortured, and exported from the truth. “Natural” invokes safety, but seems to forget harm from natural products like tobacco. “Safer than alcohol” has validity45, but overlooks our inability to manage cannabis impairment consequences since THC levels do not reliably relate to sentinel events.46 “Substitute for alcohol” while plausible47, cannot explain the rise in alcohol consumption seen in Colorado post-legalization.16 “No overdose death” implies no related mortality at all when, in fact, cannabis is associated with conditions that can end in demise: motor vehicle accidents48, cardiac disease49, cancer50, and stroke49. Advocates point to the study by Bachhuber et al11 which found that states with medical cannabis laws had lower opioidrelated deaths. However, speculation cannabis might replace opioids for pain and ameliorate the crisis needs to be revisited because overdose mortality is climbing in Colorado again.

On the other hand, strong cannabis opponents have also selected data points to advantage - not quite “reefer madness” but still problematic.

Crime statistics are cherry-picked, and parameters comparing locations with and without concentrated

sales are not addressed. High prevalence of cannabis use among those who are homeless is described52, yet the misconception that homelessness has increased with legalization is not countered.12 Numerically, suicides have increased, but epidemiologic analysis indicating no association with legalization may go unmentioned.53 Canna-bias: it goes both ways. As Anais Nin said, “We don’t see things as they are. We see them as we are.” When bias wrestles with reality to unfairly sort in poor studies or critique the methodology of those fundamentally sound, science is subverted and only delays the development of sound policy.

When we are obliged to our patients, we are obliged to understand the scope and limitations of the evidence. Show me.

In research. Show me even those surprises that challenge long-held assumptions. Spoiler alert: we already know smoked product bronchodilates54,55 and long-term regular use associates with lower diabetes prevalence.56 And it now appears isolated non-psychoactive cannabinoids have a path to medical application. But, in addition, if current neuropharmacologic understanding - the entourage effect57 - translates successfully into clinical practice, that means the whole plant cannabis chemical soup may prove even better than specified cannabinoids in certain, though limited ways.

Until then, states like Missouri do not have to be shocked by future missteps when some of these might be averted by sorting wisdom from folly of states like Colorado. Are current cannabis initiatives appropriate, safe, and even beneficial?

Are they premature and unwise? Are they flawed in ways that can or cannot be fixed? Or are they a catastrophic, misdirected experiment altogether?

These questions outline a system of problems: complex, multi-causal, and resistant to solutions.

A wicked problem that requires fair-balanced observations of outcomes.

We can learn a lot from that.

When we are obliged to our patients, we are obliged to understand the scope and limitations of the evidence. Show me."

Born in Missouri, Steve Wright is family medicine trained and is a consultant in addiction medicine and medical pain management. He has a particular interest in cannabis, opioids, and benzodiazepines.

He has no relevant disclosures.

(Please see References on page 30)

MO-AFP.ORG 23

MAFP WELL REPRESENTED AT 2018 AAFP CONGRESS OF DELEGATES

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he Missouri delegation was very active at this year’s AAFP Congress of Delegates (COD), October 7-10, in New Orleans, LA. Delegates served on reference committees, introduced a resolution, and presented testimony on important issues before the governing body of state chapter delegates, alternate delegates, presidents, and chapter staff. The COD is the body which sets policy for the AAFP Board to implement, and delegates from all 50 states, Armed Forces, Student and Resident Caucus, Puerto Rico, and Special Constituencies assemble yearly to consider and debate issues important to our membership. This year’s delegation consisted of Delegates Todd Shaffer, MD, and Keith Ratcliff, MD, Alternate Delegates Kate Lichtenberg, DO, and Peter Koopman, MD, MAFP President, Sarah Cole, DO, and Executive Director, Kathy Pabst.

In preparation to represent Missouri at this threeday meeting, the MAFP Board of Directors reviewed approximately 70 resolutions and scored each resolution regarding importance and position. All resolutions were referred to a reference committee and hearings were held and testimony presented.

Resolutions addressed AAFP expanding membership categories to non-physicians, rural obstetrical services, reimbursement rates for immunizations, prior authorization, Medicare/Medicaid parity, medical aid in dying, treatment of opioid use disorder, single payer system, women’s health, and many others.

Missouri introduced a resolution, “Assistant Physician Licensure” and MAFP President, Sarah Cole, DO, presented testimony in support of this resolution. This resolution requested that the AAFP shall: - educate state chapters as to the category of “assistant physician” licensure, and encourage state chapters to advocate for safe standards of supervision and oversight of medical school graduates. The reference committee concluded that while the AAFP should tentatively oppose the designation, they should study the issue and provide materials to help family physicians and chapters protect patients by halting its spread into other

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states that do not yet allow for the designation. The Congress adopted a substitute resolution that the AAFP create and deploy a chapter toolkit regarding assistant physician licensure within six months.

Janet Hurley, MD, from Texas, said it was her impression that the intent was for individuals to assist in rural underserved areas. "I would argue that is exactly where they should not be, because someone taking care of patients in a rural underserved area needs a breadth of training - not just four years of medical school."

One hot topic that the MAFP supported was a resolution asking the AAFP to develop a toolkit that would help physicians understand and determine the primary care spending rate in their states. The Congress adopted a substitute resolution that called on the AAFP to update and expand an existing toolkit to include all payers, refine its legislative template and add guidelines on how to determine primary care spending rates.

This annual gathering is also when the new AAFP leadership is elected. Gary LeRoy, MD, of Dayton, Ohio, was elected to be the Academy's presidentelect. Dr. LeRoy is a family physician in Dayton, Ohio, is the associate dean for student affairs and admission at Wright State University, Boonshoft School of Medicine in Dayton, Ohio, where he is also an associate professor of family medicine. Dr. LeRoy presented a CME session at the MAFP Show Me Family Medicine Conference this year and also conferred the Degree of Fellow to Missouri’s recipients. Other elections conducted at this year’s meeting include: • Speaker of the Congress - Alan Schwartzstein, MD, of Oregon, WI • Vice Speaker - Russell Kohl, MD, of Stilwell, KS • Directors - James Ellzy, MD, MMI, of Washington, DC; Dennis Gingrich, MD, of Hershey, PA; and Tochi Iroku-Malize, MD, MPH, MBA, of Islip, NY • New Physician Board member - LaTasha Seliby Perkins, MD, of Alexandria, VA • Resident Board member - Michelle Byrne, MD, MPH, of Chicago • Student Board member - Chandler Stisher, of Brownsboro, AL

ABFM TO PILOT ALTERNATIVE TO BOARD EXAM

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he American Board of Family Medicine (ABFM) announced at this year’s Congress of Delegates, a pilot program to begin in January 2019 which will assess the value and feasibility of a longitudinal assessment option to the 10-year secure examination. In a followup press release, they identified physicians who are current with continuous certification and are due to take the examination in 2019 would be eligible to participate in the pilot. Jerry Kruse, MD, Chair of the ABFM Board of Directors, stated, “based on the

popular Continuous Knowledge Self-Assessment (CKSA) platform, the longitudinal assessment pathway will deliver 25 questions online each quarter to those Diplomates who choose this new option. This approach is more aligned with the ongoing changes in medicine and draws upon adult learning principles, combined with modern technology, to promote learning, retention and transfer of information. Over time, we will be able to assess the core clinical knowledge of board-certified family physicians and recognize the vast majority who work to keep up to date to take care of their patients.”

A combination of physician experience with the CKSA platform, feedback from Diplomates over time, the independent survey, and information gleaned from the experience of other ABMS boards, all contributed to ABFM’s design of the new online, longitudinal assessment process that will serve as the exam option for this pilot. The ABFM has two years of Diplomate experience with the CKSA platform. Feedback from the more than 24,000 family physicians who have participated in CKSA has consistently shown that this model provides continuous, systematic learning and identification of knowledge gaps, and is highly rated as a useful and convenient platform.

This new mode of assessment will “provide questions on a regular, longitudinal basis, in a format that is much more convenient—a few questions at a time, in the place and time of your choice. You may use clinical references during the assessment, much like you do in practice. You will not need to travel to a test center, nor spend additional time and money on preparatory courses. And, we believe that longitudinal assessment will support your desire for continued learning and practice improvement,” said Dr. Warren Newton, incoming President and CEO of ABFM.

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AAFP STATE LEGISLATIVE CONFERENCE HITS KEY ISSUES

I

Dr. Keith Ratcliff presents information on Missouri's assistant physician.

n preparation for Missouri’s 2019 legislative session, Missouri representatives attended the AAFP State Legislative Conference in late October. Missouri was represented by Keith Ratcliff, MD, Executive Director, Kathy Pabst, and Governmental Consultant, Brian Bernskoetter.

This year’s conference format easily blended a national perspective on key issues with state experiences through a panel discussion. Dr. Ratcliff served on a panel discussion on scope of practice and shared the MAFP’s experience and role with the assistant physician legislation and regulatory process.

The Virginia AFP was successful in defeating a bill that would have started this new mid-level provider in their state.

Kathy Pabst participated as a commentator in the #AAFPChat prior to this year’s meeting. Topics that were covered during this one-hour, online discussion included administrative burden, opioid epidemic, scope of practice, Medicaid expansion, public health, healthcare costs, and state level advocacy efforts. This discussion focused on Missouri’s efforts and the state’s environment on these topics, which was aligned with the State Legislative Conference presentations.

AAFP provided resources to the attendees that included issue briefs and other materials on these topics. This conference will undergo a substantial review by AAFP governmental affairs staff and will not be offered in 2019.

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www.clinicalresearchprofessionals.net 26

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2019

MAFP BOARD APPROVES THREE-YEAR ROAD MAP

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t it’s strategic planning session in August, the MAFP Board of Directors discussed the current state of family medicine in Missouri and brainstormed ideas to address some of the challenges that lie ahead. MAFP members were the focal point of all deliberations during this two-day meeting. We celebrated our accomplishments, while looking toward the next three years, and had extensive discussions about our vision and what we should be doing as an organization. The Board of Directors approved the plan at their November board meeting.

The following plan will be the driving force for the MAFP from 2019-2021: Vision Statement: Every Missourian has a family physician Mission Statement: The Missouri Academy of Family Physicians is dedicated to optimizing the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education and research.

2019-2021 Strategies that Guide the Missouri Academy of Family Physicians Advocacy for Family Physicians To powerfully advocate for quality health care for all Missouri families with elected officials and policy makers.

• PAC Development: Assess and develop a plan to increase MAFP PAC investment.

• Governmental Relations: Advocate and lobby for the primary care investment and the preceptor tax credit.

Public Awareness about Family Physicians To develop a public awareness campaign so that all Missouri families recognize the need to have a family physician.

• Develop a capacity building plan for public awareness.

• Partner with other family physician groups.

• Research and select an advertising agency.

• Build a public/patient section of the MAFP website that is outward focused.

• “Find a Family Physician” section of the webpage.

• “Ask a Family Doc?” Question & Answer interactive section of MAFP webpage.

• Connect and like existing blogs, Twitter accounts, email distribution lists to gain followers of MAFP social media.

• Participate in high school career day at the Heartland Conference.

• Create print materials for family physician waiting rooms, board members, and conferences.

• Advertise and promote family physicians via social media, print, billboards, radio, and/or television.

• Develop TED talks.

Pipeline of Missouri Family Physicians To intentionally strengthen the pipeline for the best & brightest Missouri students to become Missouri family physicians.

• Increase the number of summer externships from 4 to 6 per year.

• Develop a set of standard materials and PowerPoint presentation on family physicians to be done more efficiently.

• Schedule a panel of speakers and topics to be made at medical schools and residencies – provide quality incentives.

• Provide mini-grants to FMIGs to further develop their efforts.

• Develop a plan to build a pipeline by reaching out to students in other states, colleges/universities, high schools, and middle schools.

• Explore increasing residency slots.

Capacity Building to Support Strategic Plan Efforts • Write grants for MAFP projects, programs & initiatives.

• Develop list with background materials of possible funders.

• Establish an Ad Hoc Grants Team.

• Research and/or hire a fund development consultant/staff and/or a grant writer/consultant..

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MAFP App Review featured app

ABFM CKSA The American Board of Family Medicine (ABFM) released a medical app in January, 2017 that allows physicians to complete 25 questions each quarter that will count as CME (2.5 hours per quarter) and towards your board certification points. A big advantage by using this app is that you get KSA credit (2.5 points per quarter, 4 quarters is the equivalent of 1 KSA). For those who are recertifying in 2019, the app is the same format as the pilot longitudinal learning option that is overtaking a full exam every 10 years.

Pros 1. Receive CME credit 2.5 hours per quarter credited to you through the AAFP once selected on ABFM portal.

2. Receive 2.5 certifications points per quarter towards your 50 required 3 year stage points.

3. You can complete the questions at your own pace in clinic or at home on your mobile device.

Cons 1. You must be certified by the ABFM. The app is easy to use. Once you login with your ABFM login and password, it pulls up the list of questions. The questions are setup as random topics very similar to how a board exam would test you. There is no time limit on this self-assessment, you can literally answer three questions close the app and come back to them if you want. All questions must be completed within the quarter. There is no grading scale. It will tell you if you got the question right and has the explanation and reference for the correct answer. It references content in the AAFP journals so membership in the AAFP, or subscription to their journals,

is very helpful in general for these quizzes and the board exam of course. The app also gives you feedback based on the ABFM Exam Blueprint. It provides information regarding areas to focus future CME. CME reporting to AAFP seamless The ABFM and AAFP CME Reporting Tool are integrated so reporting CME is seamless. Once you login to your ABFM account, and go to the modules you completed, you can submit a request to report for CME.

Jacob Shepherd, MD, MAFP Director at Large

Note: This app is for awarding KSA points and CME credit only. The longitudinal assessment program that is being piloted for those renewing their certification in 2019 is separate from this KSA opportunity. See article on page 25 that covers the longitudinal certification pilot program.

To download the free app, search for “ABFM CKSA” in the Apple app store or Google Play store. The app has received an overall rating 4.5 stars. ABFM News on the app: www.theabfm.org/about/news011717.aspx Jacob Shepherd, MD is currently serving at Whiteman Air Force Base in Missouri as an Active Duty Family Physician for the United States Air Force. He finished his Residency at UMKC Family Medicine Residency program in June 2018 and is board certified by the ABFM. He is married to Alicia for almost 10 years and has two children, Hailey, age four and Jacob James, age two. He is currently a board member as the director at large on the Missouri Academy of Family Physicians. Questions? Contact Dr. Shepherd drjacobshepherd@gmail.com.

MO-AFP.ORG 29

References from page 20, Dr. Steven Wright's Article: Cannabis-Infused Colorado: What's Goin' On? 1 Blumenson E, Nilsen E. Liberty lost: the case for marijuana law reform. Ind Law J. 2010;85(1):279-99.

2 Lerner IJ. Laetrile: a lesson in cancer quackery. CA Cancer J Clin. 1981;31(2):91-5.

3 Schedules of Controlled Substances. Title 21 Federal Code of Regulations (C.F.R.) §1308. Definition Schedule I substances Exemption of certain cannabis plant material 4 Wright S, Metts J. Recreational cannabinoid use: the hazards behind the “high”. J Fam Pract. 2016;65(11):770-9.

5 Metts J, Wright S. Medical marijuana: a treatment worth trying? J Fam Pract.

2016;65(3):178-85.

6 Stockings E, Campbell G, Hall WD, et al. Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. Pain. 2018;159(10):193254.

7 Pacula RL, Powell D, Heaton P, Sevigny EL. Assessing the effects of medical marijuana laws on marijuana use: the devil is in the details. J Policy Anal Manage.

2015;34(1):7-31.

8 Essentially rescinded by Attorney General Jeff Sessions in 2018, results of which are unknown.

9 National Survey on Drug Use and Health: 2014-2015 to 2015-2016 Substance Use Comparisons for US and by states.

10 Colorado Department of Public Health and Environment. 2017 Colorado Behavioral Risk Factor Surveillance System (BRFSS).

11 Substance Abuse and Mental Health Services Administration. Reports and Detailed Tables From the 2017 National Survey on Drug Use and Health (NSDUH).

Table 1.16B. 12 Centennial Institute: Economic and Social Costs of Legalized Marijuana (Coloardo). November 15, 2018.

13 Azofeifa A, Mattson ME, Schauer G, et al. National estimates of marijuana use and related indicators - National Survey on Drug Use and Health, United States, 2002–2014. Surveillance Summaries. MMWR. 2016;65(11):1-25.

14 Cerdá M, Wall M, Feng T, et al. Association of state recreational marijuana laws with adolescent marijuana use. JAMA Pediatr. 2017;171(2):142-9.

15 Colorado Department of Revenue: Marijuana Enforcement Division Resources and Statistics.

16 Rocky Mountain High Intensity Drug Trafficking Area. The Legalization of Marijuana in Colorado: The Impact. 2018;5.

17 Colorado Department of Revenue: Marijuana Sales Reports.

18 Market Size and Demand for Marijuana in Colorado 2017 Market Update.

Prepared by the Marijuana Policy Group for the Colorado Department of Revenue.

19 Feliz A. The economic effects of the marijuana industry in Colorado. Federal Reserve Bank of Kansas City. April 16, 2018.

20 Walters KM, Fisher GG, Tenney L, Kraiger K. Work and Well-Being in the Cannabis Industry. 2017.

21 Colorado Department of Revenue: Marijuana Tax Data.

22 Cheng C, Mayer WJ, Mayer Y. The effect of legalizing retail marijuana on housing values: evidence from Colorado. Economic Inquiry. 2018;56(3):1585-601.

23 Fergusson DM, Boden JM. Cannabis use and later life outcomes. Addiction.

2008;103(6):969-76.

24 Brook JS, Stimmel MA, Zhang C, Brook DW. The association between earlier marijuana use and subsequent academic achievement and health problems: a longitudinal study. Am J Addict. 2008;17:155-60.

25 Rosa J, Krueger J, Severson A. Analysis of Colorado K-12 student discipline incidents:2015-2016 school year. Colorado Department of Education. Denver, Colorado.

26 Orens A, Light M, Lewandowski B, et al. Market size and demand for marijuana in Colorado 2017 market update. Prepared for the Colorado Department of Revenue but the Marijuana Policy Group.

27 Chaitanya S. Cannabis cultivators’ report on water usage. Marijuana Venture.

September 23, 2105.

28 Hammon J, Rizza J, Dean D. Current impacts of outdoor growth of cannabis in Colorado. Colorado State University Extension. 2015.

29 Meola SD, Tearney CC, Haas SA, et al. Evaluation of trends in marijuana toxicosis in dogs living in a state with legalized medical marijuana: 125 dogs (2005-2010). J 30

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Vet Emerg Crit Care (San Antonio). 2012;22(6):690-6.

30 Davis JM, Mendelson B, Berkes JJ, et al. Public health effects of medical marijuana legalization in Colorado. Am J Prev Med. 2016;50(3):373-9.

31 Colorado Bureau of Investigation and National Incident-Based Reporting System: Public Safety - Marijuana.

32 Colorado Department of Public Safety, Division of Criminal Justice. Marijuana Legalization in Colorado: Early Findings. March 2016.

33 Maier SL, Mannes S, Koppenhofer EL. The implications of marijuana decriminalization and legalization on crime in the United States. Contemp Drug Probl. 2017;44(2):125-46.

34 Shepard EM, Blackley PR. Medical marijuana and crime: further evidence from the western states. J Drug Issues. 2016;46(2):122-34.

35 Colorado Department of Public Safety, Division of Criminal Justice. Impacts of Marijuana Legislation in Colorado. October 2018.

36 Colorado Department of Public Health and Environment. Behavioral Risk Factor Surveillance System and Child Health Survey. 2017 BRFSS summary tables: Marijuana Use. 37 Gunn RL,Skalski L, Metrik J. Expectancy of impairment attenuates marijuanainduced risk taking. Drug Alcohol Depend. 2017;178:39-42.

38 Bartholomew J, Holroyd S, Heffernan TM. Does cannabis use affect prospective memory in young adults? J Psychopharm. 2010;24(2):241-6.

39 Colorado Department of Public Health & Environment. Marijuana health effects: Poison Center Calls 2000-2017.

40 Wang GS, Hall K, Vigil D, et al. Marijuana and acute health care contacts in Colorado. Prev Med. 2017;104:24-30.

41 Wang GS, Le Lait MC, Deakyne SJ, et al. Unintentional pediatric exposures to marijuana in Colorado, 2009-2015. JAMA Pediatr. 2016;170(9):e160971.

42 Bell C, Slim J, Flaten HK, et al. Butane hash oil burns associated with marijuana liberalization in Colorado. J Med Toxicol. 2015;11(4):422-5.

43 Monte AA, Zane RD, Heard KJ. The implications of marijuana legalization in Colorado. JAMA. 2015;313(3):241-2.

44 Wang GS, Davies SD, Halmo LS, et al. Impact of marijuana legalization in Colorado on adolescent emergency and urgent care visits. J Adolesc Health. 2018;63(2):23941.

45 Lachenmeier DW, Rehm J. Comparative risk assessment of alcohol, tobacco, cannabis and other illicit drugs using the margin of exposure approach. Sci Rep. 2015;5:8126.

46 Balíková M, Hložek T, Páleníček T, et al. Time profile of serum THC levels in occasional and chronic marijuana smokers after acute drug use - implication for driving motor vehicles. Soud Lek. 2014;59(1):2-6.

47 Subbaraman MS. Can cannabis be considered a substitute medication for alcohol? Alcohol Alcohol. 2014; 49:292-8.

48 Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis.

BMJ. 2012;344:e536.

49 Thomas G, Kloner RA, Rezkalla S. Adverse cardiovascular, cerebrovascular, and peripheral vascular effects of marijuana inhalation: what cardiologists need to know.

Am J Cardiol. 2014;113(1):187-90.

50 Tomar RS, Beaumont J, Hsieh JCY. Evidence on the carcinogenicity of marijuana smoke. California EPA: Reproductive and Cancer Hazard Assessment Branch of the Office of Environmental Health Hazard Assessment. August 2009.

51 Bachhuber MA, Saloner B, Cunningham CO, et al. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Intern Med. 2014;174(10):1668-73.

52 Stringfellow EJ, Kim TW, Gordon AJ, et al. Substance use among persons with homeless experience in primary care. Subst Abus. 2016;37(4):534-41.

53 Rylander M, Valdez C, Nussbaum AM. Does the legalization of medical marijuana increase completed suicide? Am J Drug Alcohol Abuse. 2014;40(4):269-73.

54 Underner M, Urban T, Perriot J, et al. Cannabis use and impairment of respiratory function. Rev Mal Respir. 2013;30(4):272-85.

55 Pletcher MJ, Vittinghoff E, Kalhan R, et al. Association between marijuana exposure and pulmonary function over 20 years. JAMA. 2012;307(2):173-81.

56 Rajavashisth TB, Shaheen M, Norris KC, et al. Decreased prevalence of diabetes in marijuana users: cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) III. BMJ Open. 2012;2:e000494.

57 Russo EB. Taming THC: potential cannabis synergy and phytocannabinoidterpenoid entourage effects. Br J Pharmacol. 2011;163(7):1344-64.

MEMBERS IN THE NEWS Rues Philanthropists of the Year Award

Dr. Brent Smith, AAFP Foundation President (center) presents Drs. Larry and Jane Rues with their award.

Drs. Larry and Jane Rues were recognized at the AAFP Foundation reception in October as the AAFP Foundation Philanthropists of the Year. Drs. Larry and Jane Rues were honored to commemorate their dedicated and longstanding support of the Foundation and its work. Criteria for the award includes showing financial support to the AAFP Foundation, volunteers and/or is in a leadership role, encourages philanthropy in others, and is philanthropic in his/her community.

Dr. Rues has a passion for policy, students and helping the underserved at home and abroad. This has led him to support the Family Medicine Leads Emerging Leader Institute (FML ELI) which provides an opportunity for medical students and residents to learn firsthand about policy, leadership and how they can make a difference in their careers. In belief and support of this Foundation initiative, Drs. Larry and Jane Rues have funded the FML ELI Best Project Award for the Policy & Public Health Leadership

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Track since inception and have made arrangement to fund this opportunity in perpetuity.

Dr. Rues recently retired as faculty member and former program director at the Research Family Medicine Residency Program and has volunteered to potentially work with the FML ELI program as a mentor or in another helpful capacity. In addition to resident and student support, Dr. Larry Rues, and wife, Dr. Jane Rues who is a retired occupational therapy professor, have hearts for humanitarian work.

They have completed numerous medical mission trips and plan to do even more now that they are both retired.

Drs. Rues’ generosity, hard work, and commitment sets an example for the students and residents he supports and encourages colleagues to pay it forward. Congratulations on being the 2018 Philanthropists of the Year!

DO YOU HAVE NEWS TO SHARE?

Email it to office@mo-afp.org for review.

We love to hear from our members!

Lichtenberg Serving AAFP

Miller Completes MHA Degree

As announced at this year’s AAFP Congress of Delegates, Kate Lichtenberg, DO, FAAFP, was appointed as the chair of the Commission on Quality and Practice for 2018-19. Dr. Lichtenberg’s tenure on this commission began in 2016 and her service ends in 2019.

The Commission on Quality and Practice works to improve the practice environment of family physicians. It directly supports the AAFP’s Strategic Objective on Practice Enhancement. The commission studies and develops recommendations, policies, and programs for family medicine in the following areas: health care delivery systems, performance measurement, practice redesign/ quality improvement, privileging, health information technology, practice management, private sector advocacy, physician payment, and practice environment.

In addition. Dr. Lichtenberg was appointed to serve as the AAFP representative to the Quality Insights, Preventive Care and Screening: Screening for Depression and Follow-up Plan Expert Work Group (EWG). CMS has contracted with Quality Insights to review and update certain measures.

Former SLAFP and FHFM president, and MAFP board member, David A. Miller, MD, FAAFP, recently completed his Masters of Health Administration at Webster University in St. Louis. He is currently an Assistant Medical Director of Affinia Healthcare and Clinical Director of Affinia’s Urgent Care (Affinia Healthcare is the largest federally qualified health center in St. Louis City) after retiring from primary care medicine in Crestwood and Kirkwood, Missouri, after 20 years. He continues to serve his community as a volunteer physician once a week with Volunteers in Medicine – West County in Manchester, Missouri; as a scout leader with a BSA Troop in Wildwood, Missouri, where his two sons both recently received their Eagle rank; and as a Lt. Colonel with the U.S. Air Force Auxiliary as the Missouri Wing’s medical officer and public affairs officer. He and his wife, Nikki, live in Wildwood, Missouri, and are enjoying a sudden empty nest syndrome with two boys off to college.

SLAFP Booth at Sun Run

St Louis Academy of Family Physicians (SLAFP) sponsored a Sun Run 5K in September. SLAFP sponsored the one mile Fun Run portion of the race and had a booth to promote Family Medicine.

Koopman Appointed to AAFP Commission Peter Koopman, MD, FAAFP, has been appointed to the AAFP Commission on Governmental Advocacy. Dr. Koopman's tenure on this commission began in 2018 and his service ends in 2022. The Commission on Governmental Advocacy informs and guides the Academy's federal advocacy program and the AAFP’s support for constituent chapters in their advocacy efforts before state governments.

Correction

The MAFP tries to ensure that all information in the magazine is accurate at the time of publication. However, we need to report that in the OctoberDecember issue of the Missouri Family Physician magazine, there were two additional authors of the article on “Meeting Refugee Immunization Challenges at the Door,” written by David Campbell, MD, FAAFP, who were omitted. Samantha Marquard, MPH, FNP, and Brook Faye, MSN, FNP, were also instrumental in writing this article.

MO-AFP.ORG 33

2019

Family Physician of the Year

An outstanding, caring, family physician in your community deserves the title “Missouri Family Physician of the Year.” The Missouri Academy supports over 2,500 active members in the workforce – doing extraordinary things every day. You know them, and we would like to acknowledge them.

Nominations may be made by the public, as well as by physicians.

Nominees must meet the eligibility requirements to be considered for this award.

The Missouri Academy is accepting submissions up to the deadline of Monday, February 4, 2019.

Visit the MO-AFP website to nominate someone today!

www.mo-afp.org

34 MISSOURI FAMILY PHYSICIAN MO-AFP.ORG 34 JANUARY-MARCH 2019

M

HOSPITALS UPDATE OPIOID PRESCRIBING GUIDANCE FOR PHYSICIANS HOSPITALWIDE

NEWS RELEASE December 3, 2018 Jefferson City, MO — New opioid prescribing recommendations designed to guide hospital-based physicians’ use have been adopted and released by a coalition of health care policy and advocacy organizations. The revised guidance reflects evolving best practices in the use of opioids for pain management and changes in the law designed to reduce the opioid addiction crisis.

In November 2015, the Missouri Academy of Family Physicians, Missouri Association of Osteopathic Physicians and Surgeons, Missouri College of Emergency Physicians, Missouri Dental Association, Missouri Hospital Association, and Missouri State Medical Association jointly recommended a set of hospital emergency department guidelines to reduce variation in opioid prescribing practices. This new recommended guideline expands the recommendations and reflects developments in best practices.

“The guidelines serve to assist physicians in following best opioid prescribing practices while still allowing for individual autonomy and judgement,” said Evan Schwarz, M.D., MOCEP President and Assistant Professor of Emergency Medicine at Washington University School of Medicine in St. Louis.

Hospitals are on the front line of the opioid crisis.

These recommendations provide guidance

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for all hospital-based physicians, rather than just emergency physicians, that are consistent with guidance from the Centers for Disease Control and Prevention and update prescribing limits for firsttime acute pain management to synchronize with Missouri’s new law.

“Opioid abuse prevention is the primary goal,” said Leslie Porth, R.N., Ph.D., MHA Senior Vice President of Strategic Quality Initiatives. “When providers have the knowledge and tools to make informed decisions about patients’ pain management options, patients get better, safer care.”

The guidance includes a new recommendation encouraging physicians to consider prescribing naloxone upon discharge to patients at risk of overdose. Naloxone, an overdose rescue medication, can be used by patients or bystanders to reverse an opioid overdose.

“Missouri's family physicians continue to implement evidence-based strategies that both prevent opioid misuse and reduce harm associated with opioid use,” said Sarah Cole, D.O., Fellow of the American Academy of Family Physicians and MAFP President. “These recommendations are clear and succinct for all physicians who care for people in the emergency department and hospital settings.”

The recommendations are being implemented this month.

MISSOURI BOARD OF HEALING ARTS PARTNERS WITH THE UNIVERSITY OF MISSOURI SCHOOL OF MEDICINE TO COLLECT PHYSICIAN WORKFOR CE DATA Physician data collection project will provide information needed to better meet healthcare needs for Missourians FOR IMMEDIATE RELEASE Date: November 9, 2018 Media Contact: Lori Croy, Director of Communications (573) 751-2562 news@difp.mo.gov Jefferson City, MO – The Missouri Board of Healing Arts and the University of Missouri School of Medicine are collaborating to collect workforce data to better understand the characteristics of the physician workforce in Missouri. The survey results will be used in conjunction with other health care workforce data to inform local and state policymakers, public and private health care providers, and health care workforce training programs to better meet Missourians’ health care needs and to ensure the best possible outcomes for Missouri’s population health.

A November 9th letter to Missouri’s licensed physicians invites them to participate in this data gathering project. The letter explains that in order to meet the healthcare needs of our population, Missouri needs to assess the areas of practice, quantity, demographic characteristics, and practice locations of our physician workforce. Missouri is a diverse state with differing workforce needs in central cities, suburbs and rural areas.

Without such information, Missouri risks seriously misallocating expensive resources, confounding opportunities to improve healthcare access and quality, and jeopardizing economic development initiatives that are highly valued in quality health systems.

“We are excited to partner with the University of Missouri to enhance the healthcare workforce data collection for physicians.”

- Executive Director, Connie Clarkston, MO Board of Healing Arts

“This data is essential to understanding the characteristics of the physician workforce and providing a sound resource to policymakers.”

The collection period will run from November 9, 2018 to January 31, 2019. Data collected through this physician survey will be analyzed by the School of Medicine, and shared with the Board of Healing Arts as well as the Missouri Healthcare Workforce Advisory Group. The next phase for the Board of Healing Arts will begin in the fall of 2019 with the collection of workforce data for physical therapists and physical therapy assistants.

This collection of workforce data was authorized by section 324.001.14 with the passage of HB1816 (merged with SB635) in 2016.

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