Vol. 205 January 1, 2019 Hemp, MJ, THC, and CBD . . . Wha.a.a.a?

December 31, 2018

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Hemp and marijuana are both cannabis plants. 

But they are not the same.

There are 80 different cannabinoid compounds in cannabis plants. THC and CBD are the largest in volume. Both hemp and MJ have THC (the chemical that gives you the high) and CBD (the chemical that does not); but in vastly different amounts.  Hemp products have only 0.3% THC.  Marijuana contains from 5% to 30% THC. The CBD in MJ actually regulates (moderates) the effect of THC, produces no euphoria, and is non-addictive.

The Kentucky Supreme Court decided years ago that marijuana and hemp were the same. Woody Harrelson in 1996 was charged with “illegal possession of marijuana” in Kentucky when he announced that he had “planted 4 hemp seeds.” Four years later a Lee County jury acquitted him of that charge. The jury knew that marijuana and hemp were not the same. Hemp has about 25,000 different manufacturing uses and was one of Kentucky’s leading crops until the Marijuana Tax Act of 1937 shut down production. 

Both MJ and hemp are touted to help treat medical illnesses. Some studies show that CBD may be effective in selected medical illness. Our medical knowledge about CBD’s ability to “enhance wellness” is about at the same stage as our scientific understanding of probiotics. Neither seems to do any harm, but there are few studies that indicate they provide any real benefit.

The few studies of medical marijuana have used THC in pill form. Most promoters of medical marijuana believe that the whole marijuana product has to be smoked or ingested to get any benefit. Nobody smokes marijuana for its CBD. Interestingly, marijuana does NOT treat glaucoma. It turns out that the early studies suggesting that were too small and not controlled enough to support that conclusion.

Medical marijuana is now legal in 33 states and D.C.. Hemp products have been legal in all 50 states for some years.

It is the “hemp-derived” CBD oil that is legal and available on Amazon, at Target, or at your local gift and wellness store as one of 150 “wellness” CBD products derived from hemp. Any “marijuana-derived” CBD product carries all the baggage of current marijuana laws. Hence, a good deal of confusion.

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“Hemp-derived” CBD was a $591 million(M) dollar business in the U.S. this year. With the 2018 Federal Farm Act (spear headed by Mitch McConnell, R- Ky) that lifts decades-long U.S. prohibition of hemp cultivation on January 1, 2019 (today), the U.S. hemp industry is predicted to grow to $22 billion(B) by 2022.

The largest marijuana-producing company in Canada is salivating (Hey, remember that the U.S. Supreme Court has ruled that corporations are persons, so why can’t they salivate?) about going into the distribution of hemp-derived CBD-infused “sports” beverages in the U.S.  Vogue magazine calls CBD wellness products one of the top 10 trends in 2018.

Because of severe federal restrictions on research on marijuana there is little reliable scientific data about its medical benefits.  What few studies there are or not always clear about what is actually being tested; THC, CBD, or the other 80 cannabinoids. So there is ample room for scientific and public discussion about the relative medical benefits of THC, CBD, hemp seeds, hemp oil, or other compounds in marijuana and hemp. The lack of real data about relative benefits and risks will continue to allow proponents of one product to shill louder than the others for the consumer’s dollar.

It is helpful to remember that this lack of knowledge about marijuana is such that a physician can NOT write an actual  prescription for it. A physician’s prescription for any medication has to designate the medication’s name, dose, form, and instructions for frequency and duration of use. There is no data to allow the physician to know how to do that for marijuana. Selective physicians can only certify a person as eligible for medical marijuana use. The “patient”  then takes the certificate (not a prescription) to the marijuana store and buys the type, the form, and the dose of the substance he or she chooses.  How does the user know what to buy? By word of mouth, advice from the store keeper, and good old trial and error. Hardly deserves the term “medical use”, does it?


Vol. 108 August 15, 2014 “Big” Marijuana?

August 15, 2014

hubWhat will be the future impact of marijuana use?

A recent article in the New England Journal of Medicine suggests very plausibly
that the history of tobacco use tells us how the marijuana industry might develop.

 


“The tobacco industry has provided a detailed road map for marijuana:

  • deny addiction potential,
  • downplay known adverse health effects,
  • create as large a market as possible as quickly as possible,
  • and protect the market through lobbying, campaign contributions, and other advocacy efforts.”

Marijuana (MJ) IS LESS addictive than tobacco. Presently about 9% of MJ users meet the criteria for dependence as compared to 32% for tobacco users. But, recent studies show that heavy MJ use by an adolescent can lead to structural brain changes and subsequent dependency as an adult. All researchers agree that MJ use in those under 21 years can be harmful and should not be permitted. Most agree that MJ is NO more a gateway drug than alcohol and tobacco are.

MJ’s effect on cognitive functioning IS LESS than alcohol, but it can slow reaction time. Effects of MJ are independent of blood or urine levels. There is no breathalyzer test for MJ. DUI standards for MJ do not exist. (see Buzzfeed video, “Drunk vs. Stoned”)

We now accept that smoking tobacco is a major cause of death. To our knowledge no one has ever died of marijuana. Since it is inhaled it can cause lung damage, but it doesn’t cause cancer. Sensitive to the concern about damage caused by inhaled MJ, sellers are already pushing vaporizers and edible products. A rumored joint venture between a medical MJ vendor and an e-cigarette manufacturer apparently sent stock prices soaring.

MJ is cited often for its useful effects for cancer and AIDS patients, and those benefits are real. There is very little evidence that MJ “reduces anxiety”. Such claims imply that “a little reduction of anxiety” will, of course, make your work and life easier and users will be more successful. Can’t you just envision the ad campaigns for “cool”, “mellow”, and “helpful MJ”?

Cigarettes started out as a “roll your own” process used by a small portion of the population in the 1880’s. By 1950 half of our population used tobacco, mostly cigarette smoking. As the process of making cigarettes was industrialized, 120,000 cigarettes a day were rolled and packaged by machines. Advertising and marketing soon expanded the use of cigarettes to the general population with special targets of women and the young. Cigarettes were made “more mellow” and had additives to speed absorption and “enhance taste”. Increasing the potency of MJ is already well under way and literally has free rein, since there is no standardization of MJ products. Competitive sellers boast of their product’s enhanced potency and use it as a marketing tool.

As the tobacco industry grew, so did the smoking lobbies and corporations that resisted regulation of tobacco products or distribution of the scientific studies of tobacco effects. The National Cannabis Industry Association with 450 business members and offices in Washington, D.C. and Denver already exists.  The strength and power of the tobacco lobby prevented us for 50 years from accepting cigarette smoking as a public health problem. Unlike cigarettes, MJ also has the internet that provides direct, and directed, advertising to the public; a fantastically effective and profitable way to sell a product as proven by our pharmaceutical companies.

Anyone that does not believe that MJ will become a major business need only look at the competitive scramble for permits in states newly allowing medical marijuana dispensing ; a fierce competition despite ambiguity of Federal vs. state law compatibility, as well as hefty application and annual permit fees.

“The free-market approach to tobacco clearly failed to protect the public’s welfare and the common good: in spite of recent federal regulation, tobacco use remains the leading cause of death in the U.S.” The author calls for “collaboration among the FDA, NIH, SAMHSA (Substance Abuse and Mental Health Services Administration) , the National Highway Traffic Safety Administration, and other agencies” to “understand the harms and forecast the effects of industrialization” of MJ. In light of the ineffectiveness of multiple governmental agencies in “collaborating” to ensure proper, transparent food labeling and enhance the public health, one can’t be too optimistic about government’s effectiveness in influencing the manufacture, selling, and use of MJ in the future.

References:
1. NEJM 371:5 July 31, 2014 “Big Marijuana – Lessons From Big Tobacco”, Richter and Levy
2. Institute of Medicine, Marijuana and Health, 1982
3. Institute of Medicine, Marijuana and Medicine – Assessing the Science 1997


Vol. 92 June 15, 2013 Medical Minds Muddled on Medical Marijuana / Privacy Was Gone Before NSA’s PRISM

June 17, 2013

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 M x 5

The New England Journal of Medicine presented online a case of a 68-year-old woman with metastatic breast cancer and asked physicians to vote whether she should be prescribed marijuana to alleviate her symptoms. 76% of 1446 physicians from 76 countries voted “yea”.  About 2/3 of all votes came from North America (that includes Canada and Mexico you know) and 76% of North American physicians voted “yea”, BUT the range of response was huge. Only 1% of 76 Utah physician voters said “yea”, but  96% of 107 Pennsylvania physicians said  “yea”. Hardly any physicians chimed in from Asia or Africa causing the NEJM to comment, as only it can, “perhaps this topic does not resonate as much as other issue there”.

One of the physicians conducting this poll was James Colbert. We have been unable to ascertain if he is a relative of Steven Colbert. (When IS  the technology of PRISM going to be available to us bloggers, anyway?)

Common threads in the  118 comments posted were:
1. Does marijuana even belong in the purview of physicians, or just legalize it and let patients decide whether to use it or not?
2. Most physicians who supported its use would do so “in certain circumstances”; implying strongly, to me,  that physician control over use was assumed by supporters.
3. All camps called for more research to move toward a stronger basis of evidence

ALL YOU NEED IS A TELEPHONE

Remember December 2, 2012?
That was the day two Australian DJ’s called a London hospital and got all sorts of confidential medical information from a nurse caring for the Duchess of Cambridge. It was a prank, easy to do, but had disastrous consequences – and NOT for the patient, as you may recall. HIPPA established federal laws to protect privacy of medical information in 1996. The HITECH Act set up legal mechanisms to “ensure” privacy and security of electronic medical identity and health information. The Office of the National Coordinator for Health Information Technology recommended no less than eleven things individuals should do to protect their information on mobile devices.

And … CMS (Centers for Medicare and Medicaid) currently track at least 300,000 compromised Medicare-beneficiary numbers. A “Medicare-beneficiary number” is the number your health care provider uses to bill Medicare. It is like someone using your, or your physician’s, ATM card!  The Office of Civil Rights has investigated 27,000 of 77,000 complaints regarding breaches of health information privacy. About 18,000 of those resulted in a required “corrective action”. That ain’t hay.

The human in the protective chain of health information confidentiality may be the most common weak link, but a lap top in the car of an Office of  Inspector General auditor in the hospital parking lot in 2011 could pick up private health information from unsecured hospital wireless networks.

I must admit it is hard for me to get too excited about NSA knowing “who calls who and when”, since I accept that it could enhance our national security, but I am waiting for the other shoe to drop, as I think it eventually will, on medical information about the Boston Marathon bombers.


Vol. 90 May 15, 2013 Medical Marijuana and Other Designer Drugs

May 15, 2013

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The implied expectation of the term “medical marijuana” is that a physician can write a prescription like any other prescription; one with a drug name, a precise dosage, a frequency, a mode of administration, and a quantity for a stated duration. For example, “Penicillin, 250 mg. tablets, take three times a day for 10 days”. Fat chance when it comes to a prescription for marijuana. There are over a hundred different types and strengths of marijuana (cannabis) and each marijuana product itself contains at least 460 active chemicals. The breeding efforts and expertise that has gone into producing “a better marijuana” is impressive. Anyone that protests “genetically engineered” tomatoes or oranges should not be smoking marijuana. Prescribing cannabinoids, a single active chemical often referred to as “synthetic marijuana”, in tablet or capsule form has been used as medical marijuana by oncology  and pain management centers for years.  “It just ain’t the same” according to marijuana advocates, and some research suggests that with 460 active chemicals in marijuana they may be right.
medicalmarijuana

The Massachusetts Department of Health has just issued 52 pages of regulations for dispensing medical marijuana. They will require a prescription to have a maximum amount that is expected to be sufficient for 60 days, defined as 10 oz. Ten ounces is about 284 grams and a “blunt” is about 1 gram, so that would be about 4 “blunts” a day for 60 days. Prescriptions can be written for patients over 18 yrs. with a “debilitating medical condition” (7 are specifically named plus “others”) or a “life-limiting illnesses” (expected death in 2 years). Patients under 18 yr. may get a prescription for the same reasons as agreed to by two physicians, one of whom is a pediatrician. Independent labs will be responsible for testing the product for contamination, usually a variety of heavy metals. The strength of the dispensed product and the degree of its effects will be variable.

So, what is so bad about marijuana? Use of marijuana (MJ) can acutely slow reflex time, impair motor coordination, and alter perceptions, similar to alcohol. Of course, these functions are all important for safe driving. There are more permanent and potentially more significant effects of heavy use of marijuana in adolescents.

According to recent research MJ is really not so bad for you if you are over 20 years old. Using the new techniques of functional MRI (fMRI) by which brain function as well as structure can be measured, it has been shown that contrary to previous thought, the frontal lobe is still undergoing maturation up to the age of 20.  Maturation of the brain as measured by the increase of white matter, the “tissue of connections” between all the components of the brain, is retarded by heavy (daily) use of MJ, especially in “early users” (start at age 13). The old TV spot of “This is your brain, and this is your brain on drugs” using the frying egg image may be correct for MJ use by those under 20. Adolescents in general tend to be impulsive and have some difficulty in judging the long-term consequences of present actions, and these are functions of the frontal lobe.

Unlike tobacco use that can be measured easily  in terms of number of cigarettes smoked per day and alcohol use that can be measured in ounces drunk per day or per hour, the variety of MJ product’s strength is so diverse that “daily use” is the only reliable marker for heavy users of MJ. Unlike tobacco and alcohol, heavy use of marijuana can NOT kill you. Lester Grinspoon, MD years ago called marijuana “the safest drug in the world”  since it is impossible to commit suicide with it. It is rare to hear about an accidental “marijuana overdose”.

MJ-morphine cartoon

The three drugs of adolescent choice today, tobacco, alcohol, and marijuana, do share a common denominator in that those who use one of the three drugs by age 13, will use one or more of the others before 18 yr. There is no evidence that one is the “gateway” to another. In fact, one research remarked that the concept of a gateway is more of a myth than a reality. He called development of addiction to one or the other substance as a “shared vulnerability”.

By their senior year in high school 36% in one survey had tried MJ. There is no way of predicting which of those could eventually become heavy (daily) users in danger of suppressing their higher neuro-cognitive functions. It is not a question of access to MJ. Student users in a treatment program and researchers presenting at a recent conference made it clear that access to MJ in middle and high school was currently wide open.  In fact, remember that Dr. Grinspoon’s wife got marijuana for their son undergoing chemotherapy for cancer in his schoolyard in 1967! Medical marijuana dispensaries are NOT going to increase access to MJ for adolescents.

Spice is a vegetable product sprayed with synthetic marijuana, cannabinoids, that can be smoked or brewed as a tea. It is sold in convenience and incense stores with the label “not for human consumption” to avoid FDA regulations. The cannabinoids can have 50 to 100 more of an affinity for binding to marijuana sites in the brain than MJ itself. Its effects are similar to but can be much stronger than “smoking a joint”, and about 11% of high school seniors have tried “Spice”. Cannabinoids are easily manipulated synthetic chemicals so that simple chemical changes are made in manufacturing to skirt FDA regulations.

Bath Salts are completely useless for baths. It is a white crystal of chemicals (cathinones) that produce amphetamine effects when ingested, smoked, or snorted. Like Spice it carries the label “not for human consumption”. It was sold as an over the counter health supplement free of FDA regulations.  Both Spice and Bath Salts were first introduced in the U.K. and  Europe, and after much commercial success there they have come to the U.S. and Canada. Bath Salts were Federally banned in the U.S. in July 2012.

“Take home messages”:
1. Marijuana use before the age of 20 does have structural and functional effects on brain development, primarily but not limited to the frontal lobe. (“The frontal lobe, responsible for impulse control, is the last to develop and the first to go.”)

2. After the age of 20 there is little current evidence that MJ causes any permanent effect on brain function or structure.

3. There are  currently no predictors that will identify an occasional user of MJ as one who will become dependent or addicted to MJ (daily use), but the earlier one starts using marijuana (13 yo.) the more likely brain function will be effected.

4. Despite the “trustworthy karma” of medical marijuana, marijuana prescriptions will result in the dispensing of varied, complex, and inconsistent products.

5. Access to marijuana by middle and high school students in 2013 is now so easy according to both students and researchers  that medical marijuana dispensaries will provide little increased access to adolescents.

Resources:
1. The National Center on Addiction and Substance Abuse at Columbia University
2.ASAP, Adolescent Substance Abuse Program, Boston Children’s Hospital, Sharon Levy, MD MPH, Director


Vol. 76 October 15, 2012 The High Life and A Good Death

October 15, 2012

“Hey, D-u-u-de!”
-The Big Lebowski, 1998
.

“She had a good death.”
-traditional Irish Catholic saying

On Nov. 6 Massachusetts will vote on two medically related referendum questions: Medical Marijuana and Physician-Assisted Suicide.  In the spirit of transparency and to offer a break from mind-numbing candidate debates, I offer this short commentary on the two…and a proposal to combine them.

Ballot Question 3: “Do you approve of  a law that would eliminate state and criminal and civil penalties related to the medical use of marijuana allowing certain patients to obtain by a physician’s prescription marijuana  produced and distributed by new state-regulated centers,or, in specific hardship cases, to grow marijuana for their own use?”

Short name: Medical Use of Marijuana
A better name: “Marijuana by request of certain consenting adults”
Street spin: Very positive

Who’s against it:  AMA and Mass Medical Society – Concerns: “The slippery slope” What’s next? Legalization of marijuana?
Local police very concerned about increased cost of investigating and enforcing multiple backyard plots.
Anti-Smoking organizations.
When Congress passed the Marijuana Tax Act in 1937 making it illegal for anyone, including doctors, “to move cannabis without proper documentation”, the AMA opposed the bill!  (1)

Who’s for it: Lester Grinspoon, MD (2), most people under 50, and anybody who answers to the name, “Dude.”

What does the data show: Illegal marijuana is currently a bigger cash crop in Kentucky than tobacco. There are more medical marijuana shops in Denver than Starbucks. It IS (is NOT) a “gateway” drug…take your pick of positions…data supports both. 17 states have legalized medical marijuana.

Worst case scenario: Prescriptions for marijuana surpass number of prescriptions for SSRIs, Ritalin, and Oxycodone… or maybe that would be an improvement?

Economic implications: Could be a significant economic stimulus… in Kentucky, at least. The price of medical marijuana in California and Colorado is half the price that illegal marijuana was.

Possible future headline: “Legal Marijuana Aids Economic Recovery, Second Only to Casino Development.”

Ballot Question 2: “Do you approve of a law that would allow a physician licensed in Massachusetts to prescribe medication, at the request of a terminally ill patient meeting certain conditions, to end that person’s life?”

Short name: Physician Assisted Suicide
A better name: “Death with Dignity by request of certain consenting adults.”
Street spin: How can anything be positive about the term “suicide”? “Physician-assisted dying” is closer to the reality.

Who’s against it: AMA and Mass Medical Society; incompatible with the “curative and healer” roles of physicians – Concerns: “The slippery slope” What’s next? Lethal injections for psoriasis?
We can’t always be certain of which months are “the last 6 of my life”, but about 83% of hospice patients were right in one study.
Who’s for it: Many members of Ethics Committees in acute care hospitals who have helped patients and families endure prolonged, high-tech deaths.

What does the data show: Since its passage in 1997 less than 100 Oregon patients per year have requested end-of-life medications. In 2011 only about one-half of the people getting such prescriptions in Oregon actually took the pills. (Maybe it IS a question of patients’ desire for lost autonomy and control) In Oregon 90% of requesting patients were enrolled in a hospice program and nearly 90% had cancer.

Worst case scenario: Patients may desire more power over their medical life as well as their medical death.

Economic implications: May have positive impact on medical care costs if people choose not to go into hospitals and be admitted to ICUs in the last 6 months of their life.

Possible future headline: “AMA Admits Physicians Can’t Cure Everyone, Calls For More Dignity In Dying”

Proposed Ballot Question 4: “Do you approve of a law that would allow physicians to prescribe marijuana to end the life of a terminally ill patient?”

Short name: “Physician Assisted Dying by Marijuana”.
Street spin: It will never happen. Marijuana is the ONE drug that can NOT cause a lethal overdose (unlike alcohol, aspirin, and the others). Dr. Grinspoon described it as “remarkably non-toxic”. He initiated his intensive research into the effects of marijuana when he observed its benefits in his son undergoing chemotherapy. (His wife got the marijuana for Danny in the parking lot of a local high school because Dr. Grinspoon was initially so skeptical of its effects).(1)

References:
1. “Where’s the Pipe?”, Casey Lyons, Boston Magazine, October 2012
2. Marijuana Reconsidered, Lester Grinspoon,MD; 1971 and Marijuana:The Forbidden Medicine; 1997


Vol. 42 April 1, 2011 Updates on Health Care Reform

March 31, 2011

“You can always count on Americans to do the right thing – after they’ve tried everything else.”
-Winston Churchill

Mitt Romney announces his candidacy for Governor of Massachusetts

Persistently harassed by Tea Party leaders and other conservative Republicans for the inclusion of the “individual mandate requirement” in his Massachusetts Health Care Reform Act and tired of defending it as “good for Massachusetts but not necessarily for [insert name of any state in which Romney is that day]”, Mitt Romney has announced that he will abandon his exploratory campaign for the Presidency. He will return to Massachusetts to run for Governor against Duval Patrick. “Since this annoying issue of the individual mandate just won’t go away, I am going back to Massachusetts to undo it,” said Romney.

Donald Berwick, MD apologizes to Congress for his extreme behavior during his hearing

Though most reviewers remarked on Dr. Berwick’s evenhanded responses to the sometimes hostile questioning at the Senate Finance Committee hearing on his nomination as CMS Administrator, this blogger has a different view. I was present in the hearing room just after the TV cameras and microphones were turned off. Dr. Berwick, having kept his cool for so long, literally exploded, cussing the senators for their “mean-spirited, narrow-minded, myopic views of the federal government’s role in health care”. “Arguing with you is like talking to a dinner table.” When this outburst hit You Tube via someone’s cell phone the next day, Dr. Berwick quickly apologized. “As a pediatrician I thought I knew how to control temper tantrums, but somehow that hearing just conjured up all the adolescent turmoil that I thought I had outgrown, and I flew off the handle. I am extremely sorry, but am very thankful that my staff took away my iPhone before I was able to tweet.”

President Obama was so shaken by Dr. Berwick’s outburst that he has begun seeking a replacement; one who has experience in public policy, is a strong individual, is acceptable to most Republicans, and who is currently unemployed.  Arnold Schwarzenegger springs to my mind, though he is rumored to have returned to acting, “I lift things up and then put them down.”

Sarah Palin withdraws her opposition to “Death Panels”

According to David Williams writing for the Health Care Blog: “Chief among Sarah Palin’s assaults on truth and reason is her contention that providing reimbursement for end-of-life planning sessions with a health care provider is tantamount to a “death panel” where a “bureaucrat can decide based on a subjective judgment of [a person’s] ‘level of productivity in society,’ whether they are worthy of health care.” One ingredient of end-of-life planning is patients’ opting for palliative care. He summarized a recent study in New York state where patients who received palliative care cost Medicaid almost $7000 less in hospital costs per admission than a matched control group that didn’t receive palliative care. Patients receiving palliative care spent less time in the intensive care unit and were less likely to die there. They were also more likely to receive hospice care after discharge and to be discharged to appropriate settings.

Impressed by this report and other studies, Sarah Palin has withdrawn her opposition to the reimbursement of  “Death Panels” to help patients and families plan for end-of-life care. However, her newly found acceptance of rational end-of-life care is tempered by the unintended consequence of the increased satisfaction of families receiving palliative care.  “Most people on Medicaid are unemployed, deadbeats, or probably illegal immigrants, so why should we be spending time and money increasing their satisfaction with our health care system?”

Starbucks will add Urgi-Care Centers to their stores

Howard Schulz, CEO of Starbucks, announced that as of April 1 they would be establishing urgent care counters in selected urban stores. He is impressed with the successful implementation and rapid growth of convenient medical service centers in CVS pharmacies and wants to remain competitive in the crowded field of one-stop-service retail stores. According to Schultz, “Starbucks is the quintessential experience brand and the experience comes to life by our people.  The only competitive advantage we have is the relationship we have with our people and the relationship they have built with our customers.”

Analysts remark that this move is consistent with Starbuck’s image as a “home away from home and work” where one can go to relax, listen to music, buy a CD, work on a computer, read a newspaper, eat a snack, trip over a stroller, smile at the dogs tied up outside the door, and …get a cup of coffee.

Schulz also announced that a new flavor shot, “Potassium Iodide”, will be introduced in selected West coast stores in response to recent consumer inquiries there. Despite the phenomenal growth of medical marijuana stores in California and Colorado, Starbucks has no current plans to add this to their offerings. “A double espresso mocha caramel Vente is as high as you can go at Starbucks for the moment.”

Congress to hold hearings on what to call the new medical care payment system

The Accountable Care Organizations (ACO) proposed by the Affordable Care Act (ACA) will require the replacement of fee-for-service provider payments with a collecting together of all kinds of medical care bills which will then be paid out of a single account. Congress has known for a long time that no one knows what “ACO” means, and now, no one seems to agrees on what to call this new billing and payment method. The CMS, GAO, AMA, AHA, and AAMC just issued issued a report of their study of possible labels and asked for congressional hearings on their conclusion. Here are selected samples of the rejected names and their recommended conclusion:

“fee-splitting”– Though functionally similar to ACO methods the AMA objected to this because of their successful, long time efforts of labeling it as unethical.

“capitation” (also called “capitation-light” or “neo-capitation”) – Again, though functionally very similar to the ACO method, it was felt that this word had too many negative political, economic, and patient-control associations.

“global payments” – This one was very popular and is still in use by some people, but the negative associations with the weird weather we are having and with Al Gore nixed it. The fact that “global” corporations seem to be very successful in  avoiding anti-trust litigation was a definite plus for this label.

“rational budget allocation” – Sounded too much like the U.K. National Health Service,  definitely requires the advance planning dreaded by most physicians, and the  second word was the only one with a meaning accepted by all.

“single payment to all medical providers for a patient’s illness for life” (SPAM PILL)- An accurate statement, but much too long for an acronym or sound bite, and though the acronym implies a use of electronic networking (good), it has an  annoying connotation (bad).

After many meetings, exhaustive staff work, and numerous drafts of over 100 pages each the report finished with this final conclusion:

‘The one word that captures the collective nature of the new payment system with both warm, fuzzy connotations and a positive image is ‘bundling’, as in the soft, warm bundling of a baby in a blanket. Who could be threatened by that?”

HAPPY APRIL FOOLS DAY


Vol. 20 May 1, 2010 Medical Marijuana

April 30, 2010

“I now have absolute proof that smoking even one marijuana cigarette is equal in brain damage to being on Bikini Island during an H-bomb blast.”    Ronald Reagan

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“Researchers have discovered that chocolate produces some of the same reactions in the brain as marijuana. The researchers also discovered other similarities between the two but can’t remember what they are.”       Matt Lauer


Number of states that have legalized medical use of marijuana: 14 (1)

Date that the federal Justice Department instructed the U.S. Attorneys not to prosecute persons using marijuana for medical purposes in compliances with those state laws: October 2009

Date that that “instructional memo” could be rescinded:  at any time, presumably by a “new administration”

Number of states that have a registration and ID system for medical users which can be used as a first defense in case of an arrest for possession: 12 of 14

Amount of marijuana permitted to be possessed by a person for medical use: ranges from 6 plants and 1 oz. in Alaska to 15 plants and 24 oz. in Washington

  • Does Sara know?
  • “Gee, officer, I can’t believe it. The last time I checked there were only 5 plants here. I have no idea where the other 100 came from.”

Number of states that have medical marijuana dispensaries established by state law:  1 – California, of course.

Estimated number of marijuana dispensaries in Los Angeles:  600,”more than Starbucks stores” (2)

  • “One man’s latte is another man’s joint”
  • ” Do you want a tall, a grande, or a REAL venti?”

Number of specific diseases qualifying for medical marijuana use: 22

Number of additional  “debilitating conditions” qualifying:  3 –  hospice care, “other chronic medical condition”, and “any other medical condition approved by state agency”.

Earliest date that marijuana was suggested for medical uses:   2737 BC

First country to legalize marijuana for medical use:   Canada in 2001

Numer of celebrities that have died from prescription drug overdoses since 1962: 18

Number of those deaths involving marijuana: 0

Cost of 1 oz. of marijuana (about enough on average for 6 weeks of medicinal use) in Colorado: $350

Name of the trade organization for medical marijuana founded in Colorado in October 2009:  Colorado Wellness Association (2)

Number of medical literature articles between 1840 and 1900 describing the medical use of marijuana: 100 (3)

Major reason for decline of marijuana use and medical articles about it:  invention of hypodermic syringe and availability of opiates in 1850’s

Year that a tax ($1 an Oz.) on marijuana was imposed by the Federal Bureau of Narcotics to control recreational use but which also increased greatly the regulatory burden on medical use and experimentation: 1937

Year that Cannabis was removed from the U.S. Pharmacopeia and National Formulary:  1941

Year that the Institute of Medicine recognized the positive medical benefits of marijuana use:  1999

Number arrested in U.S. annually for use of marijuana for any reason:  750,000

References:
1.NEJM 362:16, april 26, 2010, 1453-56 , Hoffman and Weber
2. USA Today, april 20, 2010
3. History of Cannabis, Lester Grinspoon, MD, DEA statement, August 15, 2005


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