May/June 2019 - High Hopes by Advocates for Better Health

May/June 2019

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

High HopeS Physician Perspectives On Medical & Recreational CannabIS

In This Issue: • • • •

Cannabis, THC, Hemp & CBD Colorado’s Experience Senior Physician Spring Gathering Luminary of Twin Cities Medicine

“Your patients will thank you for referring them to Dr. Crutchfield.”

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves. Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column. Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring underrepresented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota in the names of his parents, Drs. Charles and Susan, both pioneering graduates of the U of M Medical School, class of 1963. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRU TCHFIELD DERMATOLO GY

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters. Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild 1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

Contents V O L U M E 2 1 , N O . 3 M AY / J U N E 2 0 1 9

Useful Information to Absorb

By Robert R. Neal, Jr., MD

President’s Message

“Time and Money”

By Ryan Greiner, MD

5 Page 32

In this issue

TCMS in Action

By Ruth Parriott, MSW, MPH, CEO

cannabis 6 • Update on Minnesota’s Medical Cannabis Program

By Tom Arneson, MD, MPH and Chris Tholkes, MPA

8 • SPONSORED CONTENT: Cannabis: What We Know and What We Don’t Know By Arthur P. Wineman, MD

11 14

• Colleague Interview: A Conversation with Tom Arneson, MD, MPH

• Neurodevelopmental Considerations in Cannabis Use By Andria Botzet, MA, LAMFT, Jenna Triana, MD, Katharine Heins, PharmD, and Linda Skalski, PhD

16 Page 5

• SPONSORED CONTENT: Cannabis Use and Psychosis: What’s the Connection?

By Lucien Gonzalez, MD

18 • Minnesota’s Medical Cannabis Solution By Joseph (Jay) Westwater, JD, MD, FACEP 20

• SPONSORED CONTENT: Is Cannabis Good Medicine?

By Joseph Sicora, MD

• CBD From Industrial Hemp — Is It Legal?

Page 11

26 • Lessons Learned from Colorado on the Health Impact of Legalized Marijuana By A. Elyse Contreras, MPH, Katelyn E. Hall, MPH, and Daniel I. Vigil, MD, MPH 29

Page 18 MetroDoctors

Environmental Health — Clean Energy: RX for Health By Mike Menzel, MD

Charles Bolles Bolles-Rogers Award Nomination Form

Spotlight on Books

Senior Physicians Association

Honoring Choices Minnesota

In Memoriam

Career Opportunities

Luminary of twin cities medicine

Neal L. Gault Jr., MD

The Journal of the Twin Cities Medical Society

May/June 2019

By Cody Wiberg, PharmD, MS, RPh

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

High HopeS Physician Perspectives On Medical & Recreational CannabIS

In This Issue: • • • •

Cannabis, THC, Hemp & CBD Colorado’s Experience Senior Physician Spring Gathering Luminary of Twin Cities Medicine

Cannabis — medical and recreational. Articles describe the history, approved uses, benefits and challenges. Articles begin on page 6. MJ Opt1.indd 1

4/1/2019 11:28:25 AM

May/June 2019

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Mac Garrett Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

May/June 2019

May/June Index to Advertisers

TCMS Officers

President: Ryan Greiner, MD President-Elect: Sarah Traxler, MD Secretary: Andrea Hillerud, MD Treasurer: Rupa Polam Austria, MD Past President: Thomas E. Kottke, MD At-large: Matthew A. Hunt, MD

Clinical Scribes, LLC........................................24 Crutchfield Dermatology...................................... Inside Front Cover

TCMS Executive Staff

Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com

Fairview Health Services..................................31

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

HealthPartners.......................................................... Inside Back Cover

Karen Peterson, Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com

MedCraft..............................................................23

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

Minnesota Medical Solutions: a Vireo Health Company................................................24

Trish Greene, Administrative Specialist, Honoring Choices Minnesota (612) 362-3705; tgreene@metrodoctors.com

North Memorial............... Outside Back Cover

Annie Krapek, Program Manager, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com Amber Kerrigan, Project Coordinator, Physician Advocacy Network (612) 362-3706; akerrigan@metrodoctors.com

PNC Bank............................................................13 University of Minnesota Health....................10

NEED HELP? Feeling overwhelmed and turning to alcohol and/or drugs for relief?

Physicians Serving Physicians is an independent, physician-centric organization that was established in 1981 by a group of physicians in recovery to help other physicians and their families struggling with chemical dependency. The core of PSP’s mission is to provide active help and service to physicians (including residents), medical students and their family members affected by alcohol and drug addiction.

Physicians Serving Physicians can help! For confidential assistance: • Call: (612) 362-3747; email: psp@metrodoctors.com • Jeffrey Morgan, MD, Interim Medical Director, (612) 267-8912 • Psp-mn.com

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Useful Information to Absorb

Cannabinoids are the world’s most commonly used substance, used by about 2.5% of the global population. Medical cannabis has been approved in 34 states with recreational in 10. This issue of MetroDoctors provides a broad look at cannabis and should serve as a good base of information for any healthcare provider. Medical cannabis has been approved for use in Minnesota for almost four years, and recreational use will probably be available in the not too distant future. Tom Arneson, MD, Research Director for the Medical Cannabis program at the Minnesota Department of Health (MDH), and his colleague, Chris Tholkes, begin with an update on the progress and success of the program. It is well-designed to monitor product quality, compliance, and outcomes for each of the 13 medical conditions approved for cannabis use. So far, the results are interesting and surprising. Increasing numbers of our healthcare providers are becoming registered to participate in the certification program. With new treatment indications, increased use for chronic pain, and probable cannabis legalization, practicing physicians face a significant learning curve to catch up. Dr. Arneson is also featured as our Colleague Interview. He comments on his experiences and observations on the MDH program over the last four years, and on possible problems we could face with legalization of recreational use. He emphasizes the importance of continued research, good laboratory monitoring, and oversight of cannabis products. Well documented randomized trials of cannabinoids are lacking; however, studies of user populations have shown certain medical benefits which are outlined in an article by Arthur Wineman, MD. He also provides some cannabis history, including some of the things we know and don’t know about the properties of cannabis. Two articles discuss the neuropsychiatric effects of cannabinoids. The first, from the department of Psychiatry at the U of MN, discusses the disturbing effects of cannabinoids on the developing fetal and childhood brain and their apparent increased sensitivity to damage. The second article, by Lucien Gonzales, MD, deals with the increased association of psychosis with cannabis use, noting a six times increased risk with teenage regular use (over 55 times). I personally know of two such cases. Also

By Robert R. Neal, Jr., MD Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

included is a discussion of some of the important components of cannabinoids and the genetics involved in their action. Interestingly, there may also be positive effects of cannabis in certain cases of psychosis. We have included an article by Jay Westwater, MD, JD, CEO of MN Medical Solutions, one of the two licensed cannabis growers and distributors in Minnesota. He explains the operation of their four cannabis Patient Centers. This company provides information on the benefits of cannabis and the function of the program to pharmacists, legislators, regulators and healthcare providers. Included is information on how individual practitioners function as patient certifiers. Joseph Sicora, MD, a family physician who practices hospice and palliative medicine, writes about the benefits, side effects, and costs of medical cannabis as experienced by his patients, and the differences in the effects of CBD and THC compounds. Industrial hemp is a strain of cannabis containing both CBD and THC and has interesting legal ramifications. Cory Wiberg, Executive Director of the MN Board of Pharmacy, explains the problems of hemp product branding, marketing and legal sales. He includes a good discussion of the pharmacologic effects of THC. Medical marijuana was legalized in Colorado in 2001 and recreational use in 2014. Because of this experience, we sought an article from the Colorado Department of Public Health and Environment. The data provided on surveillance, policy, public education and testing should be very useful to the Minnesota endeavor. The data on age, type of product, and duration of use is also quite interesting. Lastly, Dr. Neal Gault, a former U of M Medical School Dean, is featured as this issue’s Luminary of Twin Cities Medicine. Minnesota physicians are presented with a new adjunctive therapy option with medical cannabis, that can be both helpful and harmful. While more research is needed, beneficial effects have been validated in clinical research. It is important for physicians to make use of resources available to educate themselves to appropriately respond to questions from patients. May/June 2019

President’s Message

“Time and Money” Ryan Greiner, MD

What is most important to you as a practicing physician? Why do you show up to work long hours, on weekends, and in the middle of the night? Why do you suffer the angst of a lawsuit or an angry patient and keep going? Is that an easy question to answer? Would all physicians say the same thing? I used to tell administrators that to keep doctors happy you had to ensure and respect two things, “time and money.” Always make sure they get paid and don’t bother them on their time off. If only it was so simple… Recently, I was having lunch with a second-year medical student who expressed concern about burnout and well-being following the tragic suicide of a University of Minnesota medical student. We spoke of her experiences as a student, the pressure of achievement, the fear of failure, the drive to succeed. And, as if out of nowhere, she commented on the importance of “time and money.” Time to live life and money to live it with. I was taken aback. Does this idea of “time and money” start way back in medical school? Is this where it takes root? Or did she somehow pick this up from an attending? It really got me thinking… Why did I choose to go into medicine? I can tell you for certain it was not about “time and money,” or at least not in the beginning. Medicine offered this gateway to a life of imagination, compassion, interpersonal affirmation, and technical expertise. It offered the satisfaction of delayed gratification and the prospects of being and doing something unique and sought after. It brought the pride of one’s family and the acknowledgment of achievement. It accentuated the vulnerability of human life and invited me into its suffering and joy — a far cry from “time and money.” Studies show that medical students enter their training with a wealth of empathy and compassion, but as they transition through their 3rd and 4th year, imbued with the clinical experiences of their peers, mentors, and patients, they quickly begin to lose that reservoir of emotional fortitude and regress into a more cynical application of their experience. What did they experience or what did they learn that drove the loss of such important aptitudes? How do we reverse this trend? Studies have shown the deleterious effect that a lack of empathy has on clinical outcomes. In a 2012 study, published in Academic Medicine, researchers found higher rates of complications among diabetic patients whose doctors had low empathy levels. The open access Public Library of Science (PLoS) published a systemic review and meta-analysis in 2014 showing that patients did better if their doctors were taught empathy-building techniques, like making regular eye contact. Why aren’t doctors making eye contact?!! Oh, that’s right, they’re staring at computer screens. Medicine without empathy and compassion is not medicine at all, it’s just “time and money.” Empathy and compassion are the driving force of everything that we do and are the protection from the cynicism and stress that create burnout and foster mental health disorders. These emotions should be cultivated, admired, taught, reinforced, and celebrated. We should find ways to remove barriers to their expression and cultivation. Most importantly, we should ensure that the learning members of our profession understand the value we place on their vulnerability and the appreciation we have for the innocence of their compassion and empathy. Your Twin Cities Medical Society, in partnership with the Minnesota Medical Association, is placing physician well-being at the forefront of our strategic plan. From the work at the bedside to advocacy at the legislature, together we are working tirelessly to find ways to decrease the burdens of medical practice and create space for empathy and compassion. I encourage you to visit www.mnmed.org/ and www.metrodoctors.com/ to learn about all that is happening on your behalf. As always, if you or someone you know needs peer-to-peer substance abuse support, please contact Physicians Serving Physicians at (612) 362-3747 for confidential, reliable information and support. You can also visit their website at www.psp-mn.com for more information. 4

May/June 2019

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION Ruth Parriott, MSW, MPH, CEO

Spring is a busy time for physician activists as the state legislature is in full swing and local advocacy work continues. TCMS members are speaking out on many medical and public health issues at the Capitol, including gun violence prevention, assured access to no-cost contraception, and tobacco control. A priority issue on which TCMS takes the lead is the continuation of state funding to promote advance care planning, which has allowed Honoring Choices MN to broaden its reach and scope over the past four years. Bills have been introduced to fully fund the program and once again have attracted bipartisan support. The importance of uninterrupted work in emerging partnerships with African American, Native American, and college student communities is central to this year’s request and we would greatly appreciate you urging your legislator to support Senate File 555 and House File 2036. If you would like to learn more or receive assistance in contacting your elected officials, please contact Karen Peterson at kpeterson@metrodoctors.com. While statewide policy debates continue, TCMS physicians played a crucial role in passing two ordinances in the city of Robbinsdale focused on youth tobacco use prevention. Dr. Emily Bannister, occupational medicine specialist with HealthPartners, and TCMS Board President Dr. Ryan Greiner, Medical Director at North Memorial Health, testified in support of measures to raise the age of tobacco MetroDoctors

sales to 21 and restricting the sale of vaping devices and e-nicotine liquids to adult only tobacco shops. When these new laws take effect this summer, they should greatly reduce access to tobacco products for adolescents in the city.

TCMS President Ryan Greiner, MD, and PAN staff Annie Krapek and Kate Feuling Porter celebrate in Robbinsdale.

Budding physician advocates with the TCMS medical student advocacy fellowship are involved in some fascinating projects. Whitney Johnson is partnering with the Minnesota Department of Health to conduct key informant interviews related to challenges primary care providers face when referring patients to the National Diabetes Prevention Program. Diana Rubio partnered with TCMS to host a workshop for medical students on food access and health equity. Event registration filled within 24 hours of announcement, and we learned that “food as medicine” remains a hot topic. Lucas Zellmer partnered with the Minnesota Community Health Worker Alliance to conduct key informant interviews with elected officials about frontline community

The Journal of the Twin Cities Medical Society

health workers and will present the results at a statewide CHW conference. If these examples piqued your interest, you can learn about all the projects at a May 14 year-end celebration. Learn more and RSVP at www.metrodoctors.com/fellowship. On March 15, MetroDoctors editor Nancy Bauer was there to share in the cheers, tears, and general excitement of Residency Match Day at the University of Minnesota Medical School. A total of 230 residencies were announced, with 52% of graduates choosing primary care (family medicine, internal medicine, and pediatrics) and 43% staying in Minnesota for residency. The activism of our members and the priorities of TCMS have always resonated with medical students and we look forward to supporting these future physician leaders as they enter the next phase of their career.

Match Day students active with TCMS: Back from left: Maria Bening, Kevin O’Donnell, Sarah Ringstrom, Taurean Baynard. Front: Kristin Bastug, Mac Garrett, Elizabeth Fairbairn. Not pictured: Ryan Fox.

May/June 2019

Cannabis

Update on Minnesota’s Medical Cannabis Program

innesota’s medical cannabis program was established in 2014 with a goal of providing safe, laboratory tested, extraction-based medical cannabis products to qualified patients within the context of ongoing medical care. In the months after the program became operational in July, 2015 there were some early signs of success in achieving the goal, but enrollment in the program was lower than expected. There were complaints from patients about difficulties finding a healthcare practitioner who would certify them for the program, costs, and exclusion of smokeable and edible cannabis from the program. In this article we provide an update about what has happened in the first 3 ½ years of the program. After a slow first year, growth has picked up and remains steady — both in number of enrolled patients and in number of clinicians enrolled in the program. The legislation that created the program set out nine qualifying conditions and gave the Health Commissioner authority to add additional conditions. Addition of intractable pain as a qualifying condition, effective August, 2016, significantly increased the rate of growth in enrolled patients. The subsequent addition of PTSD in 2017 and, to a lesser extent, autism and obstructive sleep apnea in 2018, have also contributed to an increase in enrolled patients. Re-enrollment is required annually and a substantial proportion of enrolled patients — nearly half of those who enrolled in 2017 — do not re-enroll. Some die during their enrollment year, but we believe most do not re-enroll due to some combination of lack of effectiveness, burden of cost outweighing benefit, and side effects. By Tom Arneson, MD, MPH and Chris Tholkes, MPA

May/June 2019

Though many do not re-enroll, even more enroll for the first time, so the number of active enrolled patients continues to grow very steadily each month; as of December 31, 2018 there were 14,481 patients. Intractable pain is the most common certified condition (64%), followed by PTSD (16%), severe muscle spasms (13%) and Tom Arneson, MD, MPH Chris Tholkes, MPA cancer (9%). The table gives annual cohorts of enrolled patients, and for additional information on patient age and the first five months of patients enrolled for certified conditions. newly-added qualifying conditions. AvailThe number of clinicians registered in able on the OMC’s website are reports for the program continues to grow very steadithe program’s first two annual cohorts and ly; over the past two years, an average of for the early cohort of intractable pain pasix were added each week. Currently there tients. A comprehensive report on the first are 1,450: 75% physicians, 18% advanced five months of patients certified for PTSD practice registered nurses, and 7% physician will be on the website about the time this assistants. Though there are still some comarticle is published. plaints about having difficulty getting cerHere are a few highlights from the intified for the program, the volume of those tractable pain report. At each purchase, pacomplaints has dropped. Over the past four tients completed the composite PEG scale, years staff from the Office of Medical Cana three item scale asking the patient to asnabis (OMC) — mostly Dr. Arneson — have sess, over the past week, pain intensity and given hundreds of presentations to clinician its interference with enjoyment of life and groups on the program and on the science general activity. Using the PEG scale data, of cannabinoids and the endocannabinoid 42% achieved ≥30% reduction in score, and system. We welcome additional requests for 22% both achieved and maintained ≥30% presentations. reduction over four months. Clinicians reUnlike any other state medical cannabis sponding to a survey about patients they program, Minnesota’s is committed to learncertified (40% response rate) indicated a ing from the experience of the participants. reduction in pain scale scores very similar Data is available from three main sources: to the change in patient self-report scores. enrollment, surveys of patients and cliniAccording to the clinician survey results, cians, and patient self-report data at time among patients taking opioid medications of each purchase. The patient self-report at program enrollment, 63% were able to data includes 0-10 scale responses for a set reduce or eliminate opioid usage after six of eight symptoms (example — nausea, anxmonths. About 40% of the patients experiiety, pain) for everyone, condition-specific enced an adverse event, with the vast majorquestions, and side effect type and severity. ity (90%) mild to moderate in severity. The Comprehensive reports are produced for MetroDoctors

The Journal of the Twin Cities Medical Society

most common side effects were dry mouth, drowsiness, fatigue, and mental clouding. Of the 75 patients reporting severe adverse events, meaning “interrupts usual daily activities,” an assessment found no apparent pattern in patient age, primary cause of pain, or type of medical cannabis product used. Readers are encouraged to go to the OMC website, mn.gov/medicalcannabis, to review the full comprehensive reports. The inconvenience of purchasing medical cannabis products in person remains a frequent complaint. By law, products can be sold at only eight retail locations and home delivery of the products is not allowed. Only the patients or their registered caregivers or parents are allowed to purchase the products. These restrictions are a particular burden for citizens of the state that live a long distance from the retail locations: four in the metro area and one each in Rochester, St. Cloud, Moorhead, and Hibbing. Ideas for legislation to increase the number of retail locations and/or allow delivery options have been floated. Cost continues to be a frequent cause of complaint. Costs to patients include product purchases and annual enrollment fee. The enrollment fee is set in statute at $200, reduced to $50 for patients in a variety of medical assistance programs; around half of patients in the program pay the reduced fee. Cost of products is set by the two licensed manufacturers. Monthly product purchase costs are typically a few hundred dollars per month, though they vary greatly. Product costs have come down a bit over the past couple of years, but remain a challenge for many. No insurance covers the product costs, with the exception of workers compensation insurance, which in some cases reimburses patients. Since the medical cannabis program was established, discussions of cannabis adult use legalization have increased greatly. We are often asked what impact cannabis adult use legalization would have on the medical cannabis program. It’s hard to know, but the impact will likely be influenced by details of taxation and other policy issues. All of the states with legalized adult cannabis use had an existing medical cannabis program, and have retained their medical cannabis programs. However, the experience of these states is not directly applicable to MetroDoctors

of Minnesota. He is board certified in Public Health and General Preventive Medicine. Dr. Arneson can be reached at: Tom.arneson@state. mn.us; (651) 539-3005.

Minnesota, as their medical programs sold mostly whole plant cannabis (to be smoked or eaten), unlike Minnesota’s. An important aspect of our state’s medical cannabis program is the laboratory testing that gives patients clear knowledge of the amount and type of cannabinoids they are taking into their body and confidence in the products’ freedom from contaminants and adulteration. It will be interesting to track the nature of testing required in any eventual legislation for cannabis adult use legalization.

Chris Tholkes brings over 20 years experience working in the public and nonprofit sectors. She is currently Acting Director for the Office of Medical Cannabis at the MN Department of Health. Previously she served as Assistant Division Director for the Office of Statewide Health Improvement Initiatives, which includes the Statewide Health Improvement Partnership (SHIP), Tobacco Use Prevention Grants and Tribal Grants. She has additional experience working in county and state public health departments, in tobacco control and HIV/AIDS prevention. She holds a Bachelors in Community Health Education from Minnesota State Moorhead and a Masters in Public Administration from Hamline University. She can be reached at: chris.tholkes@state.mn.us; (651) 539-3002.

Tom Arneson, MD, MPH is the Research Manager at the Office of Medical Cannabis within the MN Department of Health. He provides a clinical and research perspective to implementation of the state’s medical cannabis program and oversees research on the program’s impact. He received his Bachelor of Arts degree from Harvard, his Doctor of Medicine degree from Mayo Medical School, and his Masters of Public Health degree from the University

Breakdown of Active Patients by Age Group and Qualifying Medical Condition, as of December 31, 2018 Age (y)

0-4

5-17

18-24

25-35

36-49

50-64

65+

All Ages

43 (<1%)

456 (3%)

596 (4%)

2,167 (15%)

3,841 (27%)

4,633 (32%)

2,745 (19%)

14,481 (100%)

Intractable Pain

204

1,148

2,515

3,396

1,972

9,267 (64%)

PTSD

168

742

816

432

126

2,323 (16%)

Muscle Spasms

278

574

650

247

1,826 (13%)

Cancer

186

520

488

1,300 (9%)

Seizures

133

100

136

140

616 (4%)

Obstructive Sleep Apnea

162

163

484 (3%)

Inflammatory Bowel Disease

122

145

111

447 (3%)

Autism Spectrum Disorder

211

357 (2%)

Terminal Illness

135 (<1%)

Tourette Syndrome

122 (<1%)

Glaucoma

110 (<1%)

HIV/AIDS

98 (<1%)

ALS

32 (<1%)

All Conditions

The Journal of the Twin Cities Medical Society

Note: 14% of patients qualified for more than one condition

May/June 2019

Sponsored Content

Cannabis: What We Know and What We Don’t Know Contributed by Arthur P. Wineman, MD

annabis — also known as marijuana — has been used in medicine for over two thousand years, beginning in China. In 1839, William O’Shaughnessy, an Irish doctor in the British East India Company, brought it back to England after studying it in India. By the early 20th century, marijuana was widely used in both England and the United States but was often viewed with suspicion. In 1937 the Marijuana Tax Act made its use illegal in most circumstances. The Controlled Substances Act of 1970 classified it as a Schedule 1 drug, meaning it could not be prescribed for any reason. In 1994 California became the first state to legalize the use of marijuana for medical indications, and in 2014 Minnesota became the 22nd state to do so. The medically active substances in cannabis are the cannabinoids, of which two have particular clinical importance. Tetrahydrocannabinol (THC) has analgesic and anti-emetic properties. It’s also the psychoactive substance in the marijuana plant. Cannabidiol (CBD) is not psychoactive. It has anti-inflammatory, anti-epileptic, and analgesic effects, among others. Under Minnesota state law, no smokeable or plant forms of marijuana may be prescribed. Instead, two manufacturers (Leafline Labs and Minnesota Medical Solutions) have been licensed to grow the plant, extract the active components, and put them into various forms. They’re available as oral solutions or capsules, sublingual sprays, vaporization oils similar to e-cigarettes, and, more recently, topical formats. These contain varying amounts and ratios of THC and CBD. Any Health Care Practitioner (HCP) — physician, physician assistant or 8

May/June 2019

nurse practitioner — licensed in Minnesota may participate in the program. They do not prescribe any cannabis. Instead, they may certify online that a patient has one of 13 qualifying conditions. The patient then goes to one of eight distribution centers, four in the Twin Cities and the others in Hibbing, Moorhead, St. Cloud, and Rochester. A pharmacist will then dispense the drug using an algorithm. Once a month the patient must return to the center, where a form is filled out detailing both current symptoms and any side effects. Based on these responses, the dosage of cannabis is adjusted and the patient is given another month’s supply. The patient must be recertified by an HCP and re-enroll in the program annually. (See diagram 1.) The 13 medical conditions for which patients may receive cannabis in Minnesota are: • Cancer associated with severe/chronic pain, nausea or severe vomiting, or cachexia or severe wasting • Glaucoma • HIV/AIDS • Tourette Syndrome • Amyotrophic Lateral Sclerosis (ALS) • Seizures, including those characteristic of Epilepsy • Severe and persistent muscle spasms, including those characteristic of Multiple Sclerosis • Inflammatory bowel disease, including Crohn’s disease • Terminal illness, with a probable life expectancy of less than one year • Intractable pain • Post-Traumatic Stress Disorder • Autism

•

Obstructive Sleep Apnea Starting in July 2019, patients with Alzheimer’s Disease may also qualify. These conditions were authorized in spite of minimal evidence of efficacy in the medical literature. Because marijuana is a Schedule 1 controlled substance and illegal in the United States, it has been difficult to gather research on its therapeutic uses. However, there is a growing body of studies beginning to support the use of marijuana in treating certain illnesses. Some of the best information we have are the data gathered by the Minnesota Department of Health (MDH) since implementation of the law in July 2015. For example, in a report published by the MDH at the end of the first year of the cannabis program, patients were asked to rate their response to medical cannabis on a 1 to 7 scale, where 1 signified no benefit and 7 signified great benefit. For all qualifying conditions, 64% of surveyed patients gave a 6 or 7 score as their response to treatment, while only 4% answered 1. The reported

MetroDoctors

The Journal of the Twin Cities Medical Society

benefit to patient-reported outcomes was present across all conditions, with the 6/7 score ranging from 51% for seizures to 79% for HIV/AIDS. All responding patients with Tourette Syndrome noted a benefit of at least 4 or 5. These findings must be tempered with the lack of placebo control in the study. Given recent concerns about the use of opioid medication, cannabis dispensed in the treatment of pain may have particular significance. Intractable pain was added as a qualifying condition in July 2016. By the end of that year, 2,290 patients struggling with pain were enrolled in the program. A survey reported by the MDH found that 61% noted a benefit of 6 or 7; 58% of them reported that they were able to reduce their use of other pain medications when they started taking cannabis. Opioid medications were reduced for 38% of the patients, with nearly 60% of them decreasing use of at least one opioid by more than 50%. In addition to intractable pain, there may be benefits for patients who experience pain as a side-effect to other treatments. For example, researchers at HealthPartners Institute are collaborating with the MDH to see what effect medical cannabis has on cancer patients’ opioid use, and whether the emerging therapy is effective at treating other cancer-related symptoms. Of course, any positive benefits of cannabis employed for medical purposes must be tempered by an assessment of the associated risks. More research has been done on this topic than on the therapeutic uses of this drug. Most studies have primarily looked at the unregulated smokeable form of cannabis, rather than the controlled amounts available in Minnesota’s cannabis program. It’s clear that marijuana can unmask a tendency toward psychosis. Patients with known schizophrenia or who have other risk factors for psychosis are probably not good candidates for this treatment. Large doses of marijuana used over long periods of time have been shown to cause significant and irreversible cognitive impairment among adolescents and young adults. The effect of cannabis on the developing fetus is unknown. This lack of data prompted investigators at HealthPartners Institute to explore the potential impacts of marijuana use among pregnant women and fetal development. Currently its use in pregnant women — as well as breastfeeding women — is contraindicated. As with alcohol, marijuana intoxication can MetroDoctors

affect safety when driving or using heavy equipment. A report looking at the experience of patients during the first year of the Minnesota cannabis program noted that 18% of patients reported negative physical or mental side effects. 90% of these were mild to moderate, with the most common being dry mouth, drowsiness, or fatigue. There were no side effects that were life threatening or required hospitalization. Marijuana can be addicting, and should be used in caution with patients known to have a substance use disorder. However, according to R.S. Gable,1 the risk of dependence is much less for cannabis than for substances such as opioids, nicotine and alcohol. It’s about as addicting as caffeine. It also has a much lower active/lethal dose ratio than any of these other drugs. The Drug Enforcement Administration has stated that there have been no reported overdose deaths from marijuana. Perhaps the greatest barrier to increased use of cannabis in Minnesota is the cost. It is considered an experimental drug, and insurance companies won’t pay for it. The cost to an individual patient can range from $200 up to $1,000 each month. This is in addition to the $200 annual fee to enroll in the program, or $50 for patients on government programs such as Medicaid. Should healthcare practitioners participate in this program and certify qualifying

The Journal of the Twin Cities Medical Society

patients for the use of medical cannabis? It’s estimated that fewer than 15% of physicians who practice in specialties that care for patients with one of the listed conditions have chosen to do so. Given the limited evidence available, the answer is more of a philosophic than a scientific one. If clinicians are committed to practicing only evidence-based medicine, they will likely wait for more definitive data before certifying patients. However, clinicians who are caring for patients that have found little or no benefit in other therapies may certify them for cannabis use knowing that the experimental drug is not associated with serious risk. Either way, the decision to participate in the Minnesota Cannabis Program is up to the individual clinician. For more information, visit www.health. state.mn.us/topics/cannabis/. Arthur Wineman, MD is Chair of the Family Medicine department and Regional Medical Director in Primary Care at HealthPartners. A graduate of the Johns Hopkins School of Medicine, he has practiced at HealthPartners for over 30 years. In 2015 he served on the Intractable Pain Advisory Council convened to advise the Minnesota Commissioner of Health about the use of cannabis for the treatment of pain. References 1) R.S. Gable: Acute toxicity of drugs versus regulatory status. In J. M. Fish (Ed.), Drugs and Society: U.S. Public Policy, pp.149-162, Lanham, MD: Rowman & Littlefield Publishers.

Overview of MN Medical Cannabis Program PATIENT HAS A QUALIFYING CONDITION

HEALTH CARE PRACTITIONER CERTIFIES CONDITION

DID YOU KNOW THAT MINNESOTA IS THE FIRST STATE PROGRAM IN THE COUNTRY TO OFFER ONLY SMOKE-FREE MEDICAL CANNABIS?

PATIENT* REGISTERS INFORMATION, PROOF OF I.D. & PAYMENT

APPROVED PATIENT IS ADDED TO REGISTRY

MEDICAL CANNABIS MAY NOW BE OBTAINED AT ANY OF THE CANNABIS PATIENT CENTERS ACROSS THE STATE

MANUFACTURERS AUTHORIZED REGULATED INSPECTED

*Care-giver may represent a patient by applying and meeting conditions including a background check.

May/June 2019

is for skin cancer care. University of Minnesota Health is bringing innovation to skin cancer treatment. As a leader in therapies and treatment options for your skin cancer patients, we are proud to offer care for patients right in their own communities. Through a multidisciplinary approach, we are able to individualize care plans for our patients, offering advanced screening techniques, a number of cutting-edge treatments, and clinical trials for advanced cancers. University of Minnesota Medical Center’s Cancer Care Program is ranked nationally by U.S. News & World Report. Refer your patients by calling 855-486-7226. Burnsville • Edina • Maple Grove • Minneapolis • Princeton • Wyoming

Visit MHealth.org/skincancer

The University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. © 2019 University of Minnesota Physicians and University of Minnesota Medical Center.

Cannabis

Colleague Interview: A Conversation with Tom Arneson, MD, MPH

om Arneson, MD, MPH is the Research Manager at the Office of Medical Cannabis within the Minnesota Department of Health. He provides a clinical and research perspective to implementation of the state’s medical cannabis program and oversees research on the program’s impact. His career has included positions focusing on population health research and medical quality improvement. Dr. Arneson received his Bachelor of Arts degree from Harvard, his Doctor of Medicine degree from Mayo, and his Masters of Public Health degree from the University of Minnesota. He is board certified in Public Health and General Preventive Medicine.

Note: Opinions expressed by Dr. Arneson are his own and do not necessarily reflect opinions of the Minnesota Department of Health.

Have physician attitudes toward medical cannabis changed since the program started? Week by week there are additional physicians registering themselves in the program so they can certify patients. My belief is that this is due, at least in part, to two things: 1) word getting out that some patients really do seem to have experienced substantial benefit with relatively few serious problems; and 2) increased knowledge about cannabis and the endocannabinoid system, products available through the Minnesota program, and details of how the program works.

What has surprised you most during your nearly five years at the Office of Medical Cannabis? As I have learned more and as time has passed, I have come to appreciate the depth of research going on worldwide regarding the endocannabinoid system (ECS) and the technologies and consequences of manipulating components of the system. The products available through the MN medical cannabis program manipulate the endocannabinoid system as does smoking marijuana and taking the prescription drugs Marinol or Epidiolex. But pharma companies are also expending enormous resources to MetroDoctors

The Journal of the Twin Cities Medical Society

develop synthetic molecules to act on the ECS. I believe 20 years from now there will be a whole class of ECS modulating drugs, consisting of both extraction products and synthetic molecules going way beyond synthetic versions of THC and CBD.

What worries you most about the coming legalization of recreational marijuana in MN? From our experience with medical cannabis, I have a number of concerns, including use by certain populations that we have warnings for in the medical cannabis program: 1) children and young adults (with particular concern for harm to the developing brain); 2) pregnant and breastfeeding women; and 3) persons with personal or family history of psychotic mental disorders such as schizophrenia. However, the issue I’ll discuss here is good laboratory testing. One of the benefits of buying products produced through Minnesota’s medical cannabis program is that each lot of the cannabis-extraction products goes through required laboratory testing by a third party laboratory approved by the Health Department. The products are tested to make sure they have the amounts of THC and CBD they say they do and that they are free of contamination from biologic agents, pesticides, heavy metals, etc. Effective policies for testing within a recreational market would help customers be confident they know what they are taking into their body. Unfortunately, I have heard accounts (Continued on page 12)

May/June 2019

Cannabis Colleague Interview (Continued from page 11)

of unscrupulous laboratories and inadequate policies and enforcement in other states, undermining such confidence.

How has approval for the recreational use of cannabis (legal in many states already) impacted its legal medical utilization? I’m not a deep expert in this, but my perception is all the states have retained their medical cannabis program after legalizing adult use. For the most part, these states’ medical cannabis programs involved mostly smoked plant material and edibles, so their experiences are not likely to be directly applicable to Minnesota’s medical cannabis program. Several of the states have made taxes on medical cannabis purchases lower than those in the general retail market, which creates an incentive to enroll in the medical program. Details of taxation, what products are allowed, and what is actually produced and offered for sale in the adult use market will have an influence on the medical cannabis program, I think.

How difficult is it/would it be to oversee the use of cannabis in a state where it is legal in light of its illegality in federal laws? What additional provisions should a law legalizing recreational marijuana use contain? Though states’ medical cannabis programs are more constrained than their adult use markets, lessons about federal interference with state medical programs might give some insight. So far, there has been little interference. During the Obama administration there were formal memoranda saying federal agents would not interfere with well-regulated state medical cannabis programs. Those memoranda were withdrawn during the Trump administration, but there has not been much change in federal interference as far as I can tell. When the memoranda came out, there was some discussion about what constitutes a well-regulated medical cannabis program and, perhaps as a consequence, some of the states generally thought to have some of the “loosest” regulations took action to tighten up their programs. I really don’t know what to predict in the future regarding federal involvement in state-level cannabis legislation.

What are the most important aspects of recreational marijuana use that practitioners should be aware of? I can only speak from my experience with the medical cannabis program. From that context cannabis use can have health impacts, including undesired drug-drug and symptom-amplifying interactions. So it is helpful if the doctor-patient relationship is such that the patient feels comfortable sharing information on their cannabis use. If there is a trust relationship and the clinician has accurate knowledge of potential risks and benefits of the major 12

May/June 2019

cannabinoids, then important cautions and suggestions about cannabis use can be communicated effectively. This has the potential to be very important, but it relies on clinicians building their knowledge base.

Comment on the direction of current public health cannabis research. What questions/issues are being studied? What notable changes/improvements are/ will be incorporated in community health care as a consequence? Articles on “lessons learned” from states that legalized adult use are starting to appear. One of those lessons is to prepare for adult use legalization by ensuring data collection systems are in place to assess consequences of the legalization. This can take more than a year, especially in order to get baseline data before the legalization takes effect. Among the issues that need to be assessed are use patterns in different population groups, injuries and harms in different domains (automobile collisions, workplace injuries, etc.), and patterns of criminal activity.

What future medical disease applications are on the horizon for cannabis? We don’t know what petitions there will be until they arrive in our in-box. Every year there is a two month window — June and July — when the public can petition to have medical conditions added as qualifying conditions for the program. The form asks the petitioner to describe scientific evidence supporting a role for cannabis products in treating the condition. Petitions for conditions considered previously will not be accepted unless the petition presents new scientific evidence. When a petition is accepted, my staff and I prepare a research brief describing the condition, how it is currently treated, evidence supporting a role for cannabis as therapy, and positions of national medical organizations (if any). The petition and the research brief are posted on the OMC website and comment in support or opposition is welcomed from the public.

What resources and/or recommendations for physician education are available to enhance clinician expertise for discussing cannabis in our practices going forward? A good starting point is a report released in 2017 by the National Academies of Sciences, Engineering, and Medicine: The Health Effects of Cannabis and Cannabinoids. Here is a link to the online version: https://www.nap.edu/read/24625/chapter/1. It focuses on current knowledge of benefits and harms from use of cannabis products. It doesn’t have much discussion of the science of cannabinoids and the endocannabinoid system, but there are several good review papers for that topic. In the “For Health Care Practitioners” section of our OMC website, I maintain an annotated list of review articles and reports, organized by clinical area. MetroDoctors

The Journal of the Twin Cities Medical Society

Cannabis

Neurodevelopmental Considerations in Cannabis Use The recent attention to cannabis has led to a barrage of questions to medical providers and youth-serving professionals regarding the effects of cannabis on the adolescent brain. The past two decades have brought a wealth of research on the neuroscience of the developing brain. This article will highlight the research on cannabis and the developing brain and offer â&#x20AC;&#x153;nuggets of knowledgeâ&#x20AC;? to help providers navigate the questions and concerns presented by our patients and clients. Nugget #1: Cannabis use during the prenatal period may affect brain development in lasting ways. Pregnant women have been using cannabis at an increasing rate. A recent study of over 220,000 pregnant woman reported that 11% of participants with nausea and vomiting disclosed cannabis use.1 Studies on prenatal cannabis use suggest adverse neurodevelopmental effects on attention, perception, cognition, memory, impulse control, IQ and reading comprehension in the fetus.2 One study found an association with increased symptoms of hyperactivity, inattention, and impulsivity, as well as increased delinquency and externalizing behaviors in children age 10.3 Another study found no change in global IQ, but negative impacts on executive function.4 Further, prenatal exposure to cannabis is associated with cannabis use in young adulthood, even after controlling for other factors.5 It is important to note that some findings on the effects of prenatal cannabis By Andria Botzet, MA, LAMFT, Jenna Triana, MD, Katharine Heins, PharmD, and Linda Skalski, PhD

May/June 2019

Andria Botzet, MA, LAMFT

Jenna Triana, MD

Katharine Heins, PharmD

use have been inconsistent and further research is needed. In the research currently available, more negative than positive or neutral findings appear, and many studies without statistically significant findings show a trend toward negative effects on neuropsychological development.2 Animal studies, which are better able to be randomized and controlled when studying maternal substance use, associate prenatal exposure to cannabis with hyperactivity and deficits in memory 6 and in a study of rats, it was linked to increased anxiety, inhibited social interaction, and increased emotional reactivity.7 Nugget #2: Adolescent brains function differently than adult brains. The developmental stage between approximately 11-25 years is critical. During this time the brain is, quite literally, remodeled in such a way that it develops the ability to engage in complex higher order thinking and emotion regulation. Brains enter adolescence with an overabundance of cortical synapses between neurons which impairs efficient communication between brain regions. Some of the most important neurodevelopmental tasks of adolescence are: 1) synaptic pruning in which unneeded synapses are

Linda Skalski, PhD

carefully trimmed away; 2) myelination of remaining synapses, increasing the efficiency of neural communication; and 3) changes in neurotransmitter concentrations, which can modify cognitive and behavioral functioning.8 Another important developmental milestone is maturation of the prefrontal cortex (PFC), which plays a central role in executive functioning and our ability to regulate affect and behaviors. These changes are believed to promote more efficient neural processing and to optimize neurocognitive performance in later adulthood. For these reasons, we can generally expect adolescent phenotypes to include greater peer motivation, sensation-seeking behavior, and reward responses as compared to adult phenotypes.9 Further, it has been shown that the maturing adolescent brain may be more vulnerable to drug effects and have increased risk for developing substance use disorders in both adolescence and adulthood.10, 11 Nugget #3: Cannabis use interacts with neurological development during adolescence. The naturally occurring endocannabinoid system in humans plays a key role in overseeing adolescent brain development (ABD). The endocannabinoid

MetroDoctors

The Journal of the Twin Cities Medical Society

system consists primarily of cannabinoid receptors (CB1 and CB2), endocannabinoid ligands (e.g., anandamide), and enzymes. The CB1 receptor is widely distributed throughout the brain and increases in concentration during ABD. These receptors play a role in regulating the balance between inhibitory and excitatory neurotransmitter release and are, thus, centrally involved in neurochemical communication.12 This regulatory role has potential for far-reaching effects during ABD, as the endocannabinoid system is implicated in multiple biological processes including stress regulation, anxiety, cognition, memory, motor movements, and pain perception.15 Cannabis contains multiple components, called cannabinoids, that interact with specific receptors within the central nervous system. The main psychoactive cannabinoid, delta-9-tetrahydrocannabinol (THC), is similar in structure to the neurotransmitter anandamide, and can therefore bind to natural cannabinoid receptors, activating neuronal activity and disrupting normal endocannabinoid system functioning. Recent research finds that cannabis exposure during ABD leads to permanent changes in brain structure and function, largely due to inaccurate synaptic pruning and disrupted PFC maturation.8 Additionally, chronic cannabis use decreases naturally occurring dopamine concentrations in the brain. Substance use stimulates excess dopamine production, to which the brain seeks to equilibrate by dramatically reducing natural production of dopamine. Dysregulation of the dopamine system during ABD can lead to reduced dopamine concentrations being incorporated into the brain architecture. That is, even after a period of abstinence from cannabis, dopamine levels remain lower than prior to cannabis use. Nugget #4: Many research studies suggest that cannabis use during adolescence increases the risk of multiple negative consequences. Though some research has supported medicinal use of cannabis, no formalized studies have examined such use in MetroDoctors

humans under the age of 18.22 Medicinal or not, earlier age of cannabis initiation is associated with increased risk of future substance use and dependence, even after controlling for relevant sociodemographic characteristics and other drug use.21 While it is possible that the correlation between cannabis and later illicit drug use is better explained by other factors, evidence from animal studies suggests the relationship is causal.21 Many scientific studies have found that early exposure to cannabis increases risk of cognitive impairment and psychiatric illness, though outcome severity is affected by age of first use, frequency and quantity of use, mode of administration, and other individual factors. Regarding cognition, it is well known that the acute effects of cannabis intoxication include impairments in memory, executive function, and motor skills. A longitudinal cohort study of more than 1,000 participants found that heavy cannabis use during adolescence led to a significant decline in IQ, which did not resolve after a period of abstinence.13 Another study found that cannabis use in adolescence was associated with negative impacts on work commitment, financial stability and social environment in adulthood, though this study was limited by a narrow demographic scope.1 Other studies have suggested that cannabis use during adolescence increases the risk of mental health disorders, including anxiety, mania, psychosis, and depression. Evidence links cannabis to anxiety disorders, although it is not yet clear which comes first.15 Meta-analyses have suggested that cannabis may be a causal factor in the development of mania symptoms.16, 17 Similarly, cannabis use during adolescence has been strongly linked to psychosis, especially in conjunction with genetic factors and stress.18 Research has also suggested increased frequency of suicidal ideation,19 though no consistent data has suggested causality. The evidence relating cannabis to depressive disorders is also unclear, with some studies finding a higher risk for depression when there is an earlier age of onset and higher frequency of use.20

The Journal of the Twin Cities Medical Society

Andria Botzet, MA, LAMFT, is a family therapist within the Department of Psychiatry at the University of Minnesota, assisting adolescents and families who struggle with substance abuse and other addiction issues, as well as anxiety, depression, and other stressful life circumstances. She also has over 20 years of experience working at the University of Minnesotaâ&#x20AC;&#x2122;s Center for Adolescent Substance Abuse Research, conducting research studies on a variety of topics related to adolescent substance use. Andria has also collaborated with multiple agencies as a subject matter expert in positive parenting and brief intervention techniques. Contact: botze003@ umn.edu. Jenna Triana, MD, is a Child and Adolescent Psychiatry Fellow at the University of Minnesota where she also completed medical school. Before fellowship, she completed her general psychiatry training at the University of Colorado in Denver. She developed a specific interest in the medical and legal issues around cannabis while training in a fully legalized cannabis state and having the opportunity to see many of the pros and cons first hand. Other interests include medical education and systems-based and family-centered approaches to patient care. Contact: jctriana@umn.edu. Katharine Heins, PharmD, is a clinical pharmacist at the University of Minnesota Psychiatry Clinic who practices Medication Therapy Management (MTM) to help ensure effective and appropriate medication use and provide comprehensive medication education to both patients and providers in clinic for optimal decision making and health outcomes. She meets with a variety of patients, but has gained particular interest in assisting adolescents and young adults through substance use recovery. Contact: kheins3@ fairview.org. Linda Skalski, PhD, is an Assistant Professor of Psychiatry and Behavioral Science at the University of Minnesota. Contact: lskalski@ umn.edu. References available upon request.

May/June 2019

Sponsored Content

Is Cannabis Good Medicine? Contributed by Joseph Sicora, MD

annabis as a medical treatment is not as radical as you may think. Many original medications came from nature, like aspirin, which originated in the bark of a willow tree. The vast majority of my customers who are certified for and actively use medicinal cannabis indicate their quality of life has improved — their pain is lessened, their appetite is improved, and their nausea is reduced. Even small improvements in their symptoms can make a big difference for them. More people could consider this treatment option if it fits their values and situation. Below are several important issues for physicians to consider as they contemplate how medicinal cannabis may fit into their practice. Balancing THC vs. CBD

The two most widely understood substances in the cannabis plant are delta-9 tetrahydrocannabinol (THC) which causes a “high;” and cannabidiol (CBD) which has no more than 0.3% THC, so customers feel very little, if any, change in consciousness. Both CBD and THC have medical benefits and are considered safe, with minimal side effects. The two Minnesota state-sanctioned medicinal cannabis manufacturers produce different formulations that range from a high-THC component to help with appetite and non-inflammatory pain issues; to low THC/high CBD, for treating conditions like seizures or inflammatory problems. Both THC and CBD have pain-relieving benefits and can help with insomnia, anxiety and spasticity. Providers can consider medicinal 20

May/June 2019

cannabis for customers who have one of the 13 approved medical conditions and are experiencing pain, nausea, weight loss, poor appetite, or are seeking end-of-life comfort care. Impact on Cognitive Functions

Most of the studies that evaluate cognitive impact have been conducted with people using recreational cannabis which is not regulated or dosing specific. With state-regulated cannabis, the proportions of THC and CBD within it are regulated. Similar to alcohol use or other sedating, psychoactive chemicals, it’s reasonable to expect that while people are under the influence, their cognitive functions are not going to work as well. There are a lot of smaller studies showing chronic users of cannabis have an impairment in attention, concentration and memory while they are under the influence. But they also show that it’s a time-limited effect that is limited to while they’re under the influence. There is reasonable evidence that cognitive functions return to normal once the effects of cannabis wear off and there are no persistent, long-term impacts. And, medicinal cannabis may potentially

have reduced impairment because of the low THC formulations used to treat many conditions. Looking at 15 different studies that required 72 hours or more of abstinence, results showed that cannabis did not have any effect on long-term, cognitive functions once people were no longer under the influence. Attention, concentration, memory and learning all returned to baseline. There are more than 80 active components in cannabis, including a multitude of cannabinoids that are not psychoactive and have no impact on cognitive functions. With so many different chemicals in the cannabis plant, it’s going to take some time to find their best use. While published scientific evidence with good, long-term, double-blind studies is lacking, a summary of medicinal cannabis clinical trials and observational studies in humans published in peer review journals can be found on the Minnesota Department of Health website. Anti-inflammatory Benefits

Several of the conditions approved for medicinal cannabis use in Minnesota are related to inflammation and there is good anecdotal evidence supporting its use. A growing number of studies are showing that both THC and CBD reduce the body’s inflammatory response through their interactions with the endocannabinoid system, which can help regulate the immune system. Consider medicinal cannabis if the standard remedies to fight inflammation aren’t helpful or if a customer does not want to follow the standard medical model based on their beliefs and/ or priorities.

MetroDoctors

The Journal of the Twin Cities Medical Society

Treating Alzheimer’s and Dementia

Beginning in August 2019 new qualifying conditions for medicinal cannabis in Minnesota will include Alzheimer’s and dementia. Given our lack of good medications or treatments for dementia, this option may generate interest by customers with an early diagnosis of dementia or their family members. Medicinal cannabis also has the potential to provide another alternative for customers with more advanced dementia to help control challenging behaviors. FDA Endorsements

In June 2018, the FDA approved Epidiolex as the first drug with an active ingredient derived from cannabis to treat rare, severe forms of epilepsy including Lennox-Gastaut syndrome and Dravet syndrome; it’s actually the first FDA-approved drug to treat Dravet syndrome. The FDA has also approved medications containing synthetic THC cannabinoids called dronabinol (Marinol) and nabilone (Cesamet) to reduce nausea and vomiting in people undergoing chemotherapy. The FDA found that most customers respond to a relatively low dose of dronabinol, 5 mg three or four times daily, for chemotherapy-induced nausea and vomiting. Dronabinol is also approved to treat loss of appetite and weight loss in people with AIDS. Reproduction Concerns

There are studies that indicate cannabis reduces sperm production in men who use it chronically. It also gets into breast milk and is not recommended for women while pregnant or breastfeeding.

it’s important to find the right balance and most effective dosing for each customer. For people in very difficult circumstances, there is often a tradeoff between how awake and alert they want to be and how well their pain is controlled. But that’s a small minority. The vast majority of people are able to be comfortable and live their best quality of life, given their health circumstances. At North Memorial Health, we strive to help our customers achieve their best health. In the hospice world, our goal is quality of life and comfort for however much time people have remaining. Often they are struggling with significant pain issues and there are not great alternatives for them. Medicinal cannabis can sometimes be the best treatment to reduce their suffering. Cost Concerns

Insurance companies do not cover medicinal cannabis because it’s still federally illegal. Thirty-three states and the District of Columbia have legalized cannabis in some form. In Minnesota, there’s a $200 annual registration fee and customers can spend $100 to more than $1,000 each month for medical cannabis, depending upon the type and amount purchased.

MetroDoctors

Joseph Sicora, MD, is a family medicine physician at North Memorial Health, certified in geriatrics, hospice and palliative medicine. Dr. Sicora has been certified to prescribe medicinal cannabis since it became legal in Minnesota in 2015. Typically, Dr. Sicora has 200 to 300 customers actively using medicinal cannabis. He also helps educate new physicians at the University of Minnesota Department of Family Practice and Community Health. References: 1. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research; National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda; Washington (DC): National Academies Press (US); 2017 Jan 12.

Comparing Cannabidiol and Tetrahydrocannabinol

Though both can treat many of the same symptoms safely with minimal side effects, there are some key differences. Cannabidiol (CBD)

Tetrahydrocannabinol (THC)

Psychoactive

Yes

Relieve pain

Yes

Sedation vs. Pain Control

The most common medicinal cannabis use in the United States is for pain control; 64% of customers in the Minnesota program are certified with intractable pain. There is substantial evidence that cannabis is an effective treatment for chronic pain in adults1 with many viewing cannabis as an alternative to opioids. As with any drug, if cannabis is used as prescribed and intended, addiction is not an issue. While cannabis can be sedating,

However, costs are coming down as more people participate and the economy of scale kicks in.

Reduce nausea & vomiting

Yes

Ease migraines

Yes

Reduce anxiety

Yes

Anti-inflammatory effects

Yes

Stimulate appetite

Yes

Decrease seizures

Yes

Shows on drug test

Yes

The Journal of the Twin Cities Medical Society

May/June 2019

Cannabis

CBD From Industrial Hemp — Is It Legal? Introduction

Over the past couple of years, there has been a rapid proliferation in the sale of products containing cannabidiol (CBD) derived from industrial hemp. Many of the products are being marketed for human or animal consumption for either: 1) use in preventing, treating or curing diseases; or 2) use in altering the structure or function of human and animal bodies. Healthcare professionals are being asked by their patients about the efficacy, safety and legality of these products. With the exception of Epidiolex, which was recently approved by the US Food and Drug Administration (FDA) for the treatment of certain pediatric seizures, no product containing CBD has been approved for use by that agency. In addition, the FDA has stated that CBD cannot be sold as a dietary supplement. None of the manufacturers of these products appear to be registered by the FDA or licensed by the Minnesota Board of Pharmacy (Board) as drug manufacturers. It is probable that many of the companies are not following current good manufacturing procedures for drug products. Consequently, the Board cannot offer even minimal assurances to the public that these products are both effective and safe. Contrary to the claims of some who are involved in the burgeoning industrial hemp industry, it is not legal to extract CBD from industrial hemp, place it into a product intended for human or animal consumption, and sell those products. The sale of such products is illegal under both federal and Minnesota law. At this time, the primary issue does not involve the By Cody Wiberg, PharmD, MS, RPh

May/June 2019

status of hemp or CBD as a controlled substance. Instead, such products are considered to be misbranded and adulterated drugs under both the federal Food, Drug & Cosmetic Act (FD&C Act) and under certain sections of Minnesota Statutes Chapter 151. Other provisions of the FD&C Act make it illegal to put extracted CBD into food products. Cannabis Sativa and CBD

Cannabis sativa is an herbaceous plant species that originated in central and south Asia but that is now grown around the world. It has been cultivated throughout human history and has been used as a source of fiber, food, seed oil, and medicinal substances. Due to the psychoactive effects of 9 tetrahydrocannabinol (THC), Cannabis has been widely used recreationally. Cannabis has also been used in religious ceremonies. Different varieties of Cannabis sativa can have differing concentrations of the cannabinoids discussed below. In particular, hemp is a strain of Cannabis that has lower concentrations of THC. Hemp has been used for several millennia as a source of fiber to make ropes, cloth, paper, and other products. Hemp seeds are used as a food substance and are a source of protein, fiber, and magnesium. Varieties of Cannabis sativa that are high in THC concentration and that are used for recreational purpose due to their ability to produce a “high” are commonly referred to as marijuana or marihuana. The difference in concentration of THC has important legal ramifications, as explained below. CBD is one of dozens of cannabinoid substances produced by Cannabis

sativa. Unlike THC, CBD does not produce the high associated with marijuana use. Since CBD does not cause a high, some individuals mistakenly claim that it is not psychoactive. However, a psychoactive substance acts on the central nervous system and alters brain function, resulting in temporary changes in perception, mood, consciousness and behavior. CBD most definitely acts on the central nervous system and it can alter perception and mood. In fact, proponents of its use often claim that CBD can have a calming effect, reduce anxiety, and even treat depression. CBD acts on a variety of signaling systems and receptors within the body, including serotonin receptors, but does not activate cannabinoid receptors. It is metabolized by the cytochrome P450 enzymes and can therefore potentially interact with many commonly prescribed medications. Legal Considerations for CBD

When the Minnesota Legislature enacted the Industrial Hemp Development Act (Minn. Stats Chapter 18K), it defined

MetroDoctors

(Continued on page 25)

The Journal of the Twin Cities Medical Society

1,000 TO 28,000 Square Feet

MEDICAL SPACE FOR LEASE 701 25th Ave S Minneapolis

2800/2828 Chicago Ave Minneapolis

S M C

2800/2828 M B

R M B

R M B

Edina, MN

Minneapolis, MN

• • • • • •

6545 France Ave Edina

Minneapolis, MN

303/305 Nicollet Blvd Burnsville

Burnsville, MN

1,000 to 28,000 square feet available Custom build your space Various locations to expand your practice Oncampus; oﬀcampus locations Competitive rental rates Generous Tenant Improvement allowance

New Location. Eﬃcient Space. Medical Neighborhood. Optimal Care. We focus exclusively on healthcare real estate and have a number of space options that may be right for you. We help your practice design space that works for you and your patients. Our healthcare team has proven results and will guide you through the process of getting the right space for your practice. Leased By: ®

MIKE FLEETHAM

(952) 767-2842 MFleetham@MedCraft.com

medcraft.com/leasing

Owned By:

Love documentation? We do.

Whether itâ&#x20AC;&#x2122;s improving note quality, seeing more patients, or just getting home earlier, having scribes in your clinic will change your life! Email us at admin@clinicalscribes.com or check out our website for details:

www.ClinicalScribes.com Improving the lives of healthcare providers

CBD From Industrial Hemp (Continued from page 22)

“industrial hemp” to mean (emphasis added): “the plant Cannabis sativa L. and any part of the plant, whether growing or not, with a delta-9 tetrahydrocannabinol concentration of not more than 0.3 percent on a dry weight basis. Industrial hemp is not marijuana as defined in section 152.01, subdivision 9.” The emphasized sentence is important because Minn. Stats. §152.02 does not specifically list CBD, by name, as a Schedule I controlled substance. Listed instead are marijuana, tetrahydrocannabinols, and a large number of synthetic cannabinoids. CBD is neither a tetrahydrocannabinol nor a synthetic cannabinoid. The definition of “marijuana” found in Minn. Stats. 152.01 includes the phrase “every compound, manufacture, salt, derivative, mixture, or preparation of such plant. . . .” Consequently, a compound, manufacture, preparation, or derivative of the marijuana plant is itself defined as marijuana. Since marijuana is a Schedule I controlled substance, its compounds and derivatives are also scheduled. But as noted above, industrial hemp is explicitly excluded from the definition of marijuana — so, when derived from a hemp plant, CBD is not directly a Schedule I controlled substance. Ironically, CBD derived from marijuana would appear to be a controlled substance. There is a possibility that CBD derived from hemp might indirectly be a Schedule I controlled substance if it was considered to be an analog of CBD derived from marijuana. Even though CBD derived from hemp may not be a controlled substance, the sale of products that contain CBD is illegal under both federal and state law. The federal Agricultural Act of 2014 legalized the growing and cultivating of industrial hemp for research purposes in states where such growth and cultivation is legal under state law. However, that Act allowed growth and cultivation by an institution of higher education or state department of agriculture, only for purposes of agricultural or other MetroDoctors

academic research or under the auspices of a state agricultural pilot program for the growth, cultivation, or marketing of industrial hemp. It did not authorize general commercial sales of products that contain CBD derived from hemp. The federal Agricultural Act of 2018 went further by explicitly stating that none of the provisions of the Food, Drug & Cosmetic Act (FDCA) are pre-empted by the hemp provisions. That effectively means that products containing CBD can’t be sold when drug claims are made — unless the product goes through the new drug approval process, the manufacturer is registered by the FDA, and current good manufacturing procedures are followed. Any products that don’t meet those requirements are considered to be misbranded and adulterated drugs. Finally, certain provisions in the FD&C Act also prohibited the sale of CBD as a dietary supplement. When the Minnesota Legislature enacted the Industrial Hemp Development Act in 2015, growing of industrial hemp was authorized only for research purposes. That Act does not pre-empt any provisions of Chapter 151. Consequently, CBD products derived from industrial hemp are drugs, as defined in Minn. Stats. §151.01, subd. 5. Under Minnesota law, drugs are misbranded and adulterated if: they are not approved for medical use by the FDA; their labeling has not been approved by the FDA; they are not manufactured at a facility registered by the FDA and licensed by the Board; or they are not manufactured using current good manufacturing procedures. From the labeling of some CBD products, it is clear that they are intended to affect the structure or function of the bodies of humans and animals. In some cases, the labeling claims that the products can be used to treat specific diseases. Any products, other than a food product, that makes such claims fall under the legal definition of the word “drug” that is found in Minnesota Statutes Chapter 151. And if they are drugs, their sale is illegal under Minn. Stats. §151.34, which begins as follows:

The Journal of the Twin Cities Medical Society

It shall be unlawful to: 1. manufacture, sell or deliver, hold or offer for sale any drug that is adulterated or misbranded; 2. adulterate or misbrand any drug; 3. receive in commerce any drug that is adulterated or misbranded, and to deliver or proffer delivery thereof for pay or otherwise. Note that the sections of Chapter 151 referenced do not apply to products made by the manufacturers regulated by the Minnesota Department of Health under the state’s Medical Cannabis program — because of this language in Minn. Stats. §152.29: “For purposes of sections 152.22 to 152.37, a medical cannabis manufacturer is not subject to the Board of Pharmacy licensure or regulatory requirements under chapter 151.” In summary, the sale of most products that contain CBD, extracted from any type of cannabis plant, remains illegal under both federal and state law. The exceptions would be FDA-approved drugs, such as the recently approved Epidiolex — and the products allowed to be sold under state law by the manufacturers that are regulated by the Minnesota Department of Health, Office of Medical Cannabis. Cody Wiberg, the Executive Director of the Minnesota Board of Pharmacy, received a Doctor of Pharmacy from the University of Minnesota in 1985. He has worked as a clinical pharmacist, community pharmacist and nursing home consultant. From 1999, until he joined the Board in September of 2005, he was the Pharmacy Program Manager for the Minnesota Department of Human Services. Dr. Wiberg is a Clinical Assistant Professor for the University of Minnesota College of Pharmacy and an Instructor and Course Director for the University of Florida Graduate School. (From which he received a Master of Science in Pharmacy Policy and Outcomes in 2009). He is also a course director for the University of Wyoming Graduate School. Dr. Wiberg was named to Minnesota Physician’s quadrennial list of the state’s 100 Most Influential Health Care Leaders in 2008, 2012 and 2016.

May/June 2019

Cannabis

Lessons Learned from Colorado on the Health Impact of Legalized Marijuana Introduction

Colorado has an extended history of marijuana legalization. Medical marijuana was first legalized in 2001, and in 2009 commercialization of marijuana began with the opening of medical marijuana stores. In November 2012 Colorado voters legalized recreational marijuana and on January 1, 2014 recreational marijuana stores opened for business. In the years since marijuana came to the Colorado market, public health experts and policy makers have seen various trends, expected and unexpected, and faced some challenges in implementing marijuana regulation and protecting public health. Lessons learned from this experience can be of value to stakeholders in other states considering or responding to marijuana legalization. Key public health topics include surveillance, policy, public education and marijuana testing. Marijuana Public Health Surveillance

Surveillance is essential to monitoring the impact of marijuana legalization. State-added questions to population-based surveys about marijuana use provide insight into health behaviors surrounding marijuana use and potential demographic differences. Colorado adds questions to regularly administered adult and adolescent surveys asking about marijuana use in the past 30-days, daily or near-daily use, method(s) of use, and driving after use. On surveys that target pregnant and breastfeeding women and parents with children, questions are asked about marijuana use before/during/after pregnancy, By A. Elyse Contreras, MPH, Katelyn E. Hall, MPH and Daniel I. Vigil, MD, MPH

May/June 2019

A. Elyse Contreras, MPH

Katelyn E. Hall, MPH

use during the time a child is breastfed, use in the home around children, method of use in the home, and safe storage of marijuana. The earlier efforts begin in collecting cross-sectional data, the more data points there are to compare over time. Having systems and questions in place prior to legalization is strongly suggested as baseline data allows meaningful comparison with post-legalization data. Survey data can provide insight into areas of potential concern. Results from the Behavioral Risk Factor Surveillance System (BRFSS) survey show past 30-day marijuana use among Colorado adults remained stable at 13.5% from 2014-2016.1 In 2017, prevalence rose significantly to 15.5%, with nearly half (7.6%) using marijuana daily or near-daily.1 Of adults who reported use in the past 30-days, 84.3% indicated they smoked marijuana,1 which is concerning from the public health perspective of potential long-term chronic health effects. Healthy Kids Colorado Survey (HKCS) results show marijuana use among high school students has remained stable since data collection began in 2005, with the most recent estimate of 19.4% reporting use in past 30-days.2 However, the increase in use of alternate marijuana products among adolescents,

Daniel I. Vigil, MD, MPH

such as edible marijuana and high-THC concentrated products, is concerning. In 2017, of high school students who used marijuana in the past 30-days, 7.6% indicated they used a highly concentrated THC product (up from 4.3% in 2015) and 9.8% indicated they consumed a marijuana edible product (up from 2.1% in 2015).2 Results from the 2016 Colorado Pregnancy Risk Assessment Monitoring System (PRAMS) shows the percentage of women using marijuana during pregnancy remains stable at 7.8%.3 However the percentage is highest among women who are younger, less educated, and/or have unintended pregnancies.3 This is concerning as prenatal marijuana exposure can lead to cognitive and attention problems later in childhood.4 The 2017 Colorado Child Health Survey (CHS) indicates 11.2% of Colorado homes with young children had marijuana in or around the home.5 Although the majority of adults store their marijuana safely in the home (77.6%), it is estimated 23,000 homes with children may have marijuana stored in an unsecured location, posing a potential exposure danger.5 Surveillance of adverse events is an additional way to gauge the impact of legalization on population health. Hospital

MetroDoctors

The Journal of the Twin Cities Medical Society

Figure 1: Rates of hospitalizations with substance-related billing codes in Colorado, 2000-2017

7,000

6,000

Rates per 100,000

6122 5,000

4,000 3439

3,000

2519

2,000

821 1,000

347 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Stimulants

Cocaine

Alcohol

Marijuana

Opioids

Produced by: Marijuana Health Monitoring Program, Colorado Department of Public Health & Environment 2018. Data Sources: Colorado Hospital Association (CHA). Marijuana-related ICD-9/10-CM billing codes included at least one of the following cannabis codes in the up to 30 discharge diagnosis/billing codes: accidental poisoning by psychodysleptics (E854.1), poisoning by psychodysleptics (969.6), poisoning, adverse effects and underdosing by cannabis (T40.7), cannabis abuse (305.2 & F12.1), cannabis dependence (304.3 & F12.2), and cannabis use (F12.9).

MetroDoctors

Marijuana Policy, Education and Prevention

Marijuana policy in Colorado was initially approached as an adaptation of tobacco and alcohol regulations surrounding age and consumption restrictions but was soon refined in response to concerning events

(Continued on page 28)

Figure 2: Unintentional Marijuana Only Exposures Reported to the Rocky Mountain Poison and Drug Center (1/1/00-12/31/17) in Colorado by age: 0-8, 9-17, 18-24, and 25+ years.

60 50

Number of Marijuana Exposures

data and poison center call data are closely monitored for potential marijuana adverse health events. Hospitalizations and visits to the emergency department (ED) are monitored via data containing diagnosis codes related to marijuana use. The rate of hospitalizations with marijuana diagnosis codes increased in the years post legalization in Colorado (Figure 1).6 Of particular concern are hospitalizations and ED visits of children under nine years of age. Symptoms of THC intoxication present more severely in this age group than in adults, often requiring more immediate and intensive medical intervention.7-10 Rates of both hospitalizations and ED visits among children under age nine have increased over the years as marijuana has become more available in Colorado.6 Similarly, calls to the poison center regarding marijuana exposure have increased since legalization, with an increasing trend in calls pertaining to children under age nine (Figure 2).11 Consumption of edible marijuana products consistently accounts for the majority of calls in this age group, presumably due to unintentional exposure.11

and trends in data. A hallmark example was observed in Colorado marijuana edibles products. In 2014, rules regarding marijuana edibles were nonspecific in regard to dose and serving size, leaving some consumers heavily and adversely intoxicated after ingesting doses of up to 100mg THC in a single edible product (ex. one cookie). Edible regulations were quickly enacted, standardizing the dose to 10mg THC per serving.12 Other regulations ensued, requiring child-proof packaging, marking edible products with a THC warning, banning certain words on packaging (i.e. “candy”), prohibiting the adulteration of pre-manufactured foods and edible items in the shapes of fruit, animals and humans.12 Marijuana education and prevention is priority in Colorado. Early on, when the state was allocating revenue generated by marijuana tax dollars, ongoing funding was dedicated to educating adults about safe, legal and responsible use, and youth on potential dangers and consequences of marijuana use — an effort to prevent use initiation. Documented knowledge of marijuana health effects from the peer-reviewed literature and inferences made from the surveillance data on marijuana use and adverse events form the foundation

40 30 20 10 0

5 1

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 25 + years old 18-24 years old 9-17 years old

0-8 years old

Produced by: Marijuana Health Monitoring Program, Colorado Department of Public Health & Environment 2018. Data Sources: National Poison Data System (NPDS).

The Journal of the Twin Cities Medical Society

May/June 2019

Cannabis Lessons Learned from Colorado (Continued from page 27)

of these efforts. Using validated methods of research, these evidence-based campaigns are designed to target particular groups within the population, with customized messaging likely to resonate with that group. The current campaign, Responsibility Grows Here (www.responsiblitygrowshere.com), houses the education and prevention resources for parents, educators, consumers, tourists and clinicians. Continuing Challenges

Marijuana laboratory science is slowly progressing. All marijuana products in Colorado are required to be tested for THC content, total yeast and mold, mycotoxins, Shiga toxin-producing Escherichia coli, Salmonella, pesticides, metals and residual solvents.13 However, there is no industry standardized protocol for conducting these tests on marijuana products. Therefore, labs must independently develop their own standard operating procedures and testing methods. Validating these procedures and methods takes time. In addition, as new marijuana products are developed, new methods must be designed specifically for those products. With the wide variety of marijuana products produced and influx of new products coming to market, labs struggle to keep pace. With marijuana products evolving rapidly and containing high concentrations of THC, research has fallen behind. Marijuana products sold in Colorado contain vastly higher concentrations of THC compared to products of past years. In 2017, the average THC content of marijuana flower in Colorado was 19.6% and concentrated marijuana products averaged 68.6%.14 Studies featured in published literature rarely use marijuana with such high THC content, leaving a gap in knowledge of acute and long-term health effects of high-potency products. Colorado addressed this lack in knowledge at the legislative level and procured marijuana tax dollars to fund seven observational marijuana research studies on various topics of high public health concern. Researchers were encouraged to design their studies 28

May/June 2019

so that participants could use their own marijuana products from the Colorado market in their research. Conclusion

In the years since marijuana came to the market in Colorado, public health initiatives have been successful in collecting data on marijuana use estimates and adverse health events from multiple surveillance sources. Surveillance data coupled with documented evidence from the peer-reviewed literature on the health impacts of marijuana use also led to successful public health messaging to targeted audiences. Adult education of safe and responsible use and youth prevention efforts have also been successful. These approaches are recommended to other states and jurisdictions looking to legalize with the advice to start them prior to legalization. Valuable lessons can also be learned from Colorado’s experience with marijuana policy with marijuana edibles. Issues with laboratory testing should be anticipated on a product lacking industry standards for laboratory methods. Finally, contribution to the knowledge base is vital as there is much needed research on the impact of marijuana legalization and the health consequences of current day marijuana products. A. Elyse Contreras, MPH is an epidemiologist and manager of the Marijuana Health Monitoring and Research Program at the Colorado Department of Public Health and Environment. Since the programs’ inception in 2014, she has participated in the processes that helped shape the current public health framework of legalized marijuana. Elyse has a Master’s in Public Health degree from the University of Colorado Denver. Katelyn Hall, MPH is an epidemiologist and statistical analyst in the Marijuana Health Monitoring and Research Program at the Colorado Department of Public Health and Environment. She works on the cutting edge of developing population surveillance on the health impacts of marijuana legalization. She has a Master’s in Public Health degree and is a PhD candidate in the epidemiology department at the University of Colorado Denver.

Daniel Vigil, MD, MPH is a preventive medicine physician who has focused on marijuana research and data with the Colorado Department of Public Health and Environment since 2014. He has served on multiple state and national marijuana epidemiology and policy workgroups, including a CDC Foundation-led multi-state collaborative. He has presented for numerous conferences and stakeholder groups, to share in-depth data and research findings concerning marijuana. References 1. Colorado Department of Public Health and Environment. Behavioral Risk Factor Surveillance System (BRFSS) Data. 2019; www.colorado.gov/ marijuanahealthinfo/brfss-data. 2. Colorado Department of Public Health and Environment. Healthy Kids Colorado Survey (HKCS) Data. 2019; www.colorado.gov/marijuanahealthinfo/HKCS-data. 3. Colorado Department of Public Health and Environment. Marijuana Use During Pregnancy and Breastfeeding in Colorado. 2019; www.colorado.gov/marijuanahealthinfo/PRAMS-data. 4. Colorado Department of Public Health and Environment. Monitoring Health Concerns Related to Marijuana in Colorado: 2018 Summary. Colorado Department of Public Health and Environment;2019. 5. Colorado Department of Public Health and Environment. Child Health Survey (CHS) Data. 2019; www.colorado.gov/marijuanahealthinfo/CHS-data. 6. Colorado Department of Public Health and Environment. Colorado Hospital Association (CHA) Data. 2019; www.colorado.gov/marijuanahealthinfo/CHA-data. 7. Wang GS, Roosevelt G, Le Lait MC, et al. Association of unintentional pediatric exposures with decriminalization of marijuana in the United States. Ann Emerg Med. 2014;63(6):684-689. 8. Onders B, Casavant MJ, Spiller HA, Chounthirath T, Smith GA. Marijuana Exposure Among Children Younger Than Six Years in the United States. Clin Pediatr (Phila). 2015;10.1177/0009922815589912. 9. Wang GS, Roosevelt G, Heard K. Pediatric marijuana exposures in a medical marijuana state. JAMA Pediatr. 2013;167(7):630-633. 10. Wang GS, Le Lait MC, Deakyne SJ, Bronstein AC, Bajaj L, Roosevelt G. Unintentional Pediatric Exposures to Marijuana in Colorado, 20092015. JAMA Pediatr. 2016;170(9):e160971. 11. Colorado Department of Public Health and Environment. Poison Center Data. 2019; www.colorado.gov/marijuanahealthinfo/ poison-center-data. 12. Marijuana Enforcement Division. Code of Colorado Regulations Retail Marijuana Rules R 402Retail Marijuana Sales: General Limitations or Prohibited Acts. In: Colorado Department of Revenue, ed, 2019. 13. Marijuana Enforcement Division. Code of Colorado Regulations Retail Marijuana Rules R 712-Retail Marijuana Testing Facilities: Sampling and Testing Program. In: Revenue CDo, ed, 2019. 14. Colorado Department of Revenue. Market Size and Demand for Marijuana in Colorado 2017 Market Update. 2018.

MetroDoctors

The Journal of the Twin Cities Medical Society

Environmental Health — Clean Energy: RX for Health Minnesota’s climate is changing; dangerous weather extremes are more frequent; fossil fuel pollution is contaminating our air and water. And this is making our patients sick. We also know that these health threats disproportionately impact low-income people and communities of color. As a medical student 40 years ago, I saw Lyme’s disease being reported in a handful of Minnesota counties and now it is reported in all MN counties.1 A recent study showed that our increasing number of heat stress days is resulting in a higher incidence of fetal congenital heart defects, especially in the Midwestern states.2 Data from a 2015 MPCA report indicate that air pollution in Minnesota resulted in over 3,800 premature deaths in patients with pre-existing heart and lung disease.3 By Mike Menzel, MD

A major step to mitigate the health effects of climate change is to move toward clean energy. The 100% Renewable Energy by 2050 bill in the Minnesota House (HF 700) and Senate (SF 850) will move Minnesota forward. Both bills would incrementally increase Minnesota’s renewable energy standard for electric utilities to 100% carbon free in 2050. All Minnesota electric utilities are on track to meet or exceed the cumulative increases between 2020 and 2050. Minnesota is already a leader in clean energy production and its economy is growing twice as fast as the state’s economy as a whole. Recently, a McKnight Foundation study indicated that Minnesota could obtain 91% of its electricity from renewable sources in a cost-effective manner using current technology and, at the same time, create 50,000 new jobs in the field.4 Minnesotans

can continue to send $13 billion out of the state each year to buy fossil fuel energy or we can work to redouble our investment in wind, solar and storage. Many health professionals are speaking publicly and medical organizations such as the AMA and MMA have policy statements on health and climate change. The prescription is not complicated; to have good health you must live in a healthy environment. Mike Menzel, MD, is a member of the TCMS Environmental Health Task Force. References: 1. Lyme Disease Statistics, MDH 2018. 2. JAHA, 30 Jan 2019. 3. MPCA, Air Quality in Minnesota • 2015 Report, p13. 4. Minnesota’s Smarter Grid, McKnight Foundation, 2018.

Nominations are now open for the 2019 Charles Bolles Bolles-Rogers Award Background

The late Mr. Charles Bolles Bolles-Rogers established this award, originally called the St. Barnabas Bowl, in 1951. Mr. Bolles-Rogers served on the St. Barnabas Hospital Board of Trustees and was President of that Board for many years. Mr. Bolles-Rogers died in 1975 at the age of 91 but prior to his death, he made provision for this award to be funded in perpetuity. This award is awarded through the Twin Cities Medical Society Foundation. Criteria

Candidates for this “Physician of Excellence” award are nominated by their colleagues at Twin City area hospitals and/or clinics for achievement or leadership in medicine, contributions to clinical care, teaching and/or research. This candidate is considered to be an outstanding physician by his or her peers. The award is presented to the recipient by the Officers of the Twin Cities Medical Society Foundation and the Twin Cities Medical Society at a medical staff meeting at the recipient’s hospital, clinic or other appropriate forum. How to Nominate a Physician

The Chiefs of Staff of the Twin Cities area hospitals and Clinic Administrators/Leadership submit nominations for the Charles Bolles Bolles-Rogers Award annually. The Twin Cities Medical Society Foundation Board of Directors has the honor of selecting the recipient. Download a nomination form at https://www.metrodoctors.com/awards. Contact Nancy Bauer for more information: nbauer@metrodoctors.com; (612) 623-2893. Nominations are due by July 31, 2019.

MetroDoctors

The Journal of the Twin Cities Medical Society

May/June 2019

Spotlight on Books MetroDoctors is pleased to promote books recently published by past and present TCMS members. To include your recent publication, contact Nancy Bauer at nbauer@metrodoctors.com. Disclaimer: Publication of book titles does not constitute endorsement by TCMS or the MetroDoctors editorial board. A Migraine in Room 3, A Stroke in Room 4; A Physician Examines His Profession Paul Schanfield, MD, a St. Paul Neurologist, wrote A Migraine in Room 3, A Stroke in Room 4; A Physician Examines His Profession, emphasizing patient-centered care. As William Osler said: “The good physician treats the disease; the great physician treats the patient who has the disease.” Besides detailing his medical education philosophy, Schanfield critiques American health care and lovingly records hundreds of memorable patient quotes. The website includes a link to the publisher: amigraineinroom3.com.

THE

SAVE

DATE

Senior Physicians Association Spring Gathering with Rev. Nancy Nord Bence, Executive Director of Protect Minnesota “Cure Gun Violence: Public Health Solutions to a Public Health Problem” Gun violence is a pervasive negative influence in America today, stealing lives, devastating families, oppressing communities, and costing our state over $2 billion every year. One American is shot every five minutes and three Minnesotans are shot every day. Healthcare professionals regularly deal with the adverse effects of gun violence and can serve as catalysts to solutions. This presentation will provide an overview of gun violence from a public health perspective and outline effective solutions.

Join your colleagues for this interesting presentation: Tuesday, May 21, 2019 Broadway Ridge NE 3001 Broadway Street NE, Conference Room D Minneapolis, MN 55413 11:30 am – Social/Gathering 12:00 Noon – Call to Order and Lunch 12:20 pm – Guest Speaker Registration will open on May 1 The mission of Protect Minnesota is to promote a culture of health and safety for all Minnesotans by preventing gun violence through research, legislation, education, and community investment. Founded in 1991, they are the only independent, statebased gun violence prevention organization in Minnesota.

2019 Sharing the Experience Advance Care Planning State Conference

Join colleagues for a day focusing on the importance of conversations that matter.

Thursday October 3, 2019 8:00AM—4:30PM Earle Brown Heritage Center, Brooklyn Park, MN

May/June 2019

MetroDoctors

The Journal of the Twin Cities Medical Society

In Memoriam EUNICE DAVIS, MD, PHD, passed away on January 28, 2019. Dr. Davis was a pediatrician and an advocate for people with developmental disabilities, serving on the Minnesota Governor’s Planning Council on Developmental Disabilities. She joined the medical society in 2002. ROLAND DUMONCEAUX, MD, passed away on February 10, 2019. He had been a member of the medical society since 1968. YALE KANTER, MD, passed away on February 8, 2019. An ophthalmologist, Dr. Kanter joined the medical society in 1968. JOHN SONG, MD, passed away on February 27, 2019. Dr. Song was an internist practicing at the University of Minnesota, and was a founder of the Phillips Neighborhood Clinic, staffed by UMN Academic Health Center students providing free health care to the local community. Dr. Song joined the medical society in 2007.

Search for Twin Cities Medical Society on Facebook and follow us on Twitter @TCMSMN

RICHARD STREU, MD, passed away in March 2019. Dr. Streu practiced Family Medicine at Camden Physician Associates for nearly 40 years. Dr. Streu’s leadership included serving on the TCMS Board of Directors, Chief of Staff at North Memorial Hospital, and President of MN Academy of Family Physicians. He joined the medical society in 1962.

Career oPPortunItIes

Please also visit www.metrodoctors.com

Recruit With

MetroDoctors!

Rates starting as low as $175—call today! Options for website listings available as well. www.metrodoctors.com

Betsy Pierre, ad sales (763) 295-5420 betsy@pierreproductions.com

Join our physician family Practice with us and build lasting relationships with our patients and communities. With 12 hospitals, 56 primary care clinics, 55 specialty clinics, and 40 pharmacies, we are one of the most accessible systems in Minnesota. Why practice at Fairview? • Patient-centered organization, striving to own the complexity of care • Competitive beneﬁt and compensation plans • Career development in leadership, committees, Lean and quality initiatives

Visit fairview.org/careers Email recruit1@fairview.org Call 1-800-842-6469

TTY 612-672-7300 | EEO/AA Employer

MetroDoctors

The Journal of the Twin Cities Medical Society

May/June 2019

LUMINARY of Twin Cities Medicine By Marvin S. Segal, MD

NEAL L. GAULT JR., MD The knowledge, proficiency and capability of Minnesota medicine were shared worldwide through the interest and dedication of our Luminary. That influence, which had its beginnings in the mid20th century, continues to this day. Dr. Neal Gault’s very early years were spent in Texas, his birthplace. After working his way through and receiving his BA from the University of Texas, his dedicated presence in Minnesota was firmly established until his 2008 death at age 88. Beginning with his MD graduation from our U of M in 1950, his internship, internal medicine residency and fellowship were respectively served at Minneapolis General, the Minneapolis V.A., Ancker and University Hospitals. His WWII era Air Force service assignment in medical administration served him well as he complemented that continuing interest with his burgeoning clinical career. Dr. Gault rose through the academic ranks at the U of M, initially becoming an Assistant Dean while moving toward full Professorship in Dr. Cecil Watson’s Department of Medicine. Soon after, Neal answered the call of former Minnesota Governor, Harold Stassen, to aid in the “gigantic task” of rebuilding the medical college of Seoul National University in the wake of the post Korean War period. The Gault family actually moved there for a two-year period as he gently blended his Minnesota obtained medical and administrative expertise into the culturally different Korean medical educational system. The success of that assignment had far-reaching implications for both Dr. Gault and Minnesota’s involvement in international medical education. His stint as Minnesota’s Assistant Medical School Dean (serving with, among others, Drs. Al Sullivan and Mead Cavert) was interrupted for four years by positions as Associate Dean and Chief of Medicine at the University of Hawaii Medical School. Upon the retirement of Dean Robert Howard in 1970, Dr. Gault “came home” to assume the deanship of his alma mater for a dozen years. Along with the considerable responsibilities inherent in that role, he became an acknowledged and internationally renowned medical education specialist. His considerable travels and influence took him, in addition to Korea, throughout the Pacific Rim and Latin America. It was no easy task to artfully and technically help to replace centuries of “eastern medicine,” but Gault did so via Minnesota exchanges with foreign students and faculty — thereby sowing the 32

May/June 2019

seeds of modern cutting-edge medicine throughout Asia and other areas of the world. Well after Neal’s official retirement, his inspiration contributed to the development of the Global Medical Education and Research program headed by former Luminaries, Drs. Paul Quie and Phillip Peterson — a project that continues to reap Photo courtesy of current academic benefits. Tim Rummelhoff Photography Dr. Gault’s objective brilliance, leadership capabilities and dedication led to many honors and recognitions — literally, too many to mention. They began with earning AOA membership in his student days and included appointment as Honorary Consul General of Japan (Order of the Rising Sun), Presidency of the Minnesota Academy of Medicine, an Air Force Surgeons’ Commendation Medal, and the U of M’s prestigious Outstanding Achievement Award (for remarkable meritorious fundraising and other activities). However . . . what about the more subjective aspects of the good doctor? Neal was very involved in his physician wife’s and three accomplished children’s activities and lives. His pleasant easy-going manner was evident to all who were fortunate enough to have worked with him professionally — in both his savvy clinical endeavors and his administrative successes. Dr. Helene Horwitz, one of Neal’s valued Assistant Deans, stated, “He was always there to be of help,” and Dr. Peterson described him as “A visionary of the highest order.” The numerous accomplishments of this personable and gifted leader have had innumerable profound and far-reaching positive effects upon our local and international medical communities. We are proud to add this Luminary honor to his still-growing list of accolades. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

A culture centered in humility, compassion, respect and shared leadership At HealthPartners and Park Nicollet, we believe outstanding health care is delivered when we merge the science of medicine with the compassion, spirit and humanity in our hearts. Our clinician culture fosters trusted, powerful, healing relationships with our patients and with each other. It inspires our constant improvement. And it leads to satisfying careers.

APPLY TODAY Learn about open positions and apply at healthpartners.com/metrodoctors.

I get to see families and kids grow. And I grow with them.

JASON MAXWELL, MD PEDIATRICS