Medical Marijuana

In today's Miami Herald Paula Dockery argues in favor of legalizing marijuana for medical purposes stating that " legislative leaders refuse to consider the use of medical marijuana despite the growing body of medical evidence as to its beneficial use." She further emphasizes that medical marijuana has many uses and clinical indications and that legalization would provide access to treatment for those suffering from debilitating diseases. But her arguments are based on inflated claims and not facts. Yes, one can find clinical trials using cannabinoid extracts to treat pain and spasticity in multiple sclerosis and to improve nausea in patients undergoing radiation treatment BUT these trials are limited and rely on standardized dosages of cannabinoid extracts which the inhaled delivery of marijuana often cannot provide! There is no growing body of medical evidence as to medical marijuana beneficial effects and I favor clinical research initiatives to further investigate these claims. Meanwhile, the supporters of medical marijuana are deluding the public with premature and even false medical claims. I can only speculate that the prospects of huge profits from the sale of medical marijuana drive these initiatives. But in the end who will pay for the treatment of those who need help to treat their marijuana addiction? Are we again privatizing profits and leaving the cleanup of the mess for the taxpayer to pay for?

Cheaper or Better Care?

I hope that you are all doing well and have " survived " Thanksgiving. Well, I have another turkey for your to digest. According to the attached article published in HEALTH AFFAIRS (November 2013 vol. 32 no. 11 1977-1984) titled "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics" in which the authors claim that the elimination of restrictions on NPs’ scope of practice could have a large impact on the cost savings that can be achieved by retail clinics. Using multistate insurance claims data from 2004–07, a period in which many retail clinics opened, the authors analyzed whether the cost per episode associated with the use of retail clinics was lower in states where NPs are allowed to practice independently and to prescribe independently. They also examined whether retail clinic use and scope of practice were associated with emergency department visits and hospitalizations. The authors found that visits to retail clinics were associated with lower costs per episode, compared to episodes of care that did not begin with a retail clinic visit, and the costs were even lower when NPs practiced independently. We have to be prepared to counter these arguments by pinpointing the interface of quality and costs of care and that family physicians have the experience to achieve BOTH. Focusing on costs alone may have a detrimental effect on the quality of care rendered. Yours Bernd Happy Chanukkah to those who celebrate the Jewish holiday.

Suboxone in the News

By now most of you may have read the New York Times article titled "Addiction Treatment With a Dark Side" highlighting opioid dependence treatment and the use of Suboxone. Several issues I have in regards to the article: Opioid Dependence is a complex chronic disease requiring the skilled utilization of multiple treatment modalities INCLUDING Suboxone. Therefore, physicians should be first educated about the management of this disease BEFORE they start prescribing. An eight hour course is good but simply not enough. Suboxone was NEVER marketed as THE solution for the treatment of opioid dependence. Yes, if used inappropriately or abused , Suboxone can exert adverse side affects INCLUDING accidental overdose. By the way, so do many other medications and OTC products, including Tylenol. Data obtained from the U.S. Centers for Disease Control and Prevention show that more than 300 people die annually as a result of acetaminophen poisoning. Beginning in 2006, according to the CDC, the number of people who died after accidentally taking too much acetaminophen surpassed the number who died from intentionally overdosing to commit suicide. The American Association of Poison Control Centers (AAPCC), a nonprofit that receives federal funds, shows about 113 people dying each year as a result of overdosing on medicines with acetaminophen. Since 2006, acetaminophen has accounted for more fatalities than all other over-the-counter pain relievers combined, according to AAPCC data. Since its introduction in the US market I have repeatedly stressed the point that physicians should be trained and educated about the complex management of opioid dependence and warned about " Suboxone mills" run by unscrupulous physicians in search for a new revenue resources. RB has responded to these warnings and their representatives visited these offices trying to influence the adverse prescription habits of those "physicians". In the article the author questions the addition of Naloxone to Buprenorphine and appears to minimize the abuse potential of generic Buprenorphine. In my daily practice I witness every day attempts by new patients to obtain generic Buprenorphine DESPITE the fact that their insurance will cover Suboxone. Reason: abuse potential, diversion opportunities. In my opinion we need to continue educating physicians about the management and treatment of opioid dependence as a chronic disease and to convince our patients to seek qualified providers of those services. Yes, there are and will be abuses of this medication which has saved the lives of thousands of patients but those pale in comparison with the quality of live gained for so many of my patients. Yours Bernd

Medical Marijuana

I just returned from a speaking engagement in Los Angeles where I also visited Venice Beach. There, I found several "clinics" offering medical evaluation services to obtain a medical marijuana ID Card in order to legally purchase marijuana for medical purposes. At this "Doc in a Box" clinic a licensed California physicians is available for consultation as a medical cannabis specialists. "Patients" should have a documented medical record of diagnosis and treatment or a physician referral. During the exam the physician should document in the patient’s medical record that the patient has a serious medical condition and that the medical use of marijuana is appropriate. Needless to say that the definition of a "serious medical condition" seems to be very flexible and most people lining up at those "clinic" were mostly young, healthy looking and able-bodied applicants. None of those I observed were confined to a wheelchair, using canes or crutches. These clinics will mushroom in each of those states offering medical marijuana treatment solution and will offer legal access to a drug for a vulnerable young population. Are we really that naive to believe that medical marijuana will be confined to those who have serious medical conditions? Yours Bernd

Prescription Drug Monitoring Program Under Attack

The Florida Prescription Drug Monitoring Program is under attack. Launched in 2011 to track controlled substance prescribing, the database was designed to shut down pill mills and stop doctor shopping. According to Attorney General Pam Bondi the database is an important tool against drug abuse and that prescription drug-related deaths have declined for the first time in nearly a decade. But according to a law suit filed in Volusia county the Florida's prescription drug monitoring database program violates the state's constitution, invades the privacy of residents and subjects them to unreasonable searches. The constitutional challenge is part of a growing legal battle over how the State Attorney's Office for the 7th Judicial Circuit wound up with the prescription records for an estimated 3,300 residents and why that information was provided to five of six defense attorneys representing defendants related to a prescription fraud investigation. The American Civil Liberties Union said this week it could file federal complaints with the Department of Justice and the Department of Health and Human Services related to the disclosure of the prescription information. As a physician, supporter and PDMP user I submitted a letter to the editor to the Miami Herald which was published on 07/15/2013 pointing out that it was the illegal use of data obtained by an attorney which triggered this debate and that the PDMP does NOT violate patient privacy. I wholeheartedly agree with State Attorney Pam Bondi that "there are strong safeguards in place to protect people's prescription drug information within the Prescription Drug Monitoring Program by limiting access to that information, and those safeguards have not been compromised." These facts should be taken into consideration before attempting to dismantling the PDMP which is an essential tool to safe lives and protect the public from prescription opioid abuse and diversion. Yours Bernd

PDMP on Life Support

Attached a link to an article published in today’s Miami Herald titled “Statewide pain-clinic database may be abolished” focusing on efforts to shut down the Prescription Drug Monitoring Program (PDMP)in Florida. On Monday, the Florida Department of Health will hold a workshop in Tallahassee to discuss further limiting access to records of who writes and fills prescriptions for the most addictive drugs. The meeting comes in response to allegations last month that medical data for 3,300 Floridians had been “leaked.” The American Civil Liberties Union of Florida demanded a federal investigation, and critics pointed to the incident as evidence that the system was fundamentally flawed and had allowed an inevitable breach of privacy. It also proved a rare point of agreement between the ACLU and conservative lawmakers who have opposed the database for years, even as Florida gained a reputation as ground zero of a deadly prescription drug abuse epidemic. “I think this leak by the PDMP proves it is a risk for patients,” said state Rep. Rob Schenck, R-Spring Hill. “We should do away with the whole database.” But the leak is not due to a design flaw of the PDMP but the inappropriate use and misuse of data downloaded from the database. In this case a DEA agent queried the program for names of the doctors’ patients and got about 3,300 in return. That request led to six arrests, seven people whose identities had been stolen and 63 fake names used to get fraudulent prescriptions. The names of all those patients, including those not under investigation, were provided on computer discs to prosecutors and to the defense attorneys of those charged. They included clear warnings that the records were confidential. But one of those defense attorneys recognized a name on the disc — fellow lawyer Michael Lambert — and gave him a copy of all the names, despite the confidentiality warning. Lambert filed a lawsuit, alleging that law enforcement should never have received information about innocent patients. He demanded an injunction and asked the court to determine if the program is “an unconstitutional infringement upon the fundamental rights of the plaintiff and other Florida citizens.” In a subsequent complaint to the U.S. Department of Health and Human Services, the ACLU of Florida echoed Lambert’s objections. But no one asked an obvious question: was the “leak” made by the agent who included the names on the disc, or by the attorney who gave the disc to Lambert? As a result of this data leak Florida legislators and the ACLU are calling for the dismantling of the PDMP. Would Florida lawmakers also call for the dismantling of the electronic banking system because bank employees have access to financial data and some may even abuse this privilege? Lets not forget that the program is already on life support receiving a measly $500,000 annual funding out of a $74 billion budget, which was only granted in the final night of the 2013 session. In my professional experience the PDMP provides for accountability and transparency in the prescribing process for controlled substances. In my medical practice I identified at least a dozen patients who received controlled substances from several physicians and NONE of those colleagues were aware of it. Several of those prescriptions, if not identified, could have triggered accidental overdose and death. Instead of dismantling the system we should expand the program, fund an awareness campaign to educate physicians on how to use the program and to increase security measures to ascertain patient privacy. Now is not the time for rash decisions but rational thought and measured decision making. Lets not throw out the baby with the bath water. The PDMP save lives! Yours Bernd

Florida Gun Laws and Common Sense

Gov. Rick Scott signed a gun control bill Friday to close a loophole in firearm sales to some mentally ill people. According to the press release "Mental health and second amendment advocates worked together to produce this bill that does not affect persons voluntarily seeking mental health exams or treatments but rather closes a loophole in current law that could potentially put firearms in the hands of dangerous, mentally ill individuals who are a threat to themselves or others as determined by a court." The bill addresses a gap in Florida law that has allowed people who voluntarily commit themselves to a mental institution to buy a gun once they are released. The new law requires that before agreeing to voluntary treatment under the state’s Baker Act, individuals receive written notice that if treated, they may be prohibited from buying a gun or “applying for or retaining a concealed weapons or firearms license” while they’re deemed a danger to themselves or others. Their names are then added to a national data base that informs retailers of people prohibited from buying a gun. People who are involuntarily committed are already added to that list. A judge and a physician have to concur that an individual is no longer a danger to themselves or others to have their name taken off the national database. Scott said that since 2002, "just under 100,000 individuals have been disqualified from purchasing a firearm based on court adjudications of mentally defective or mental commitments." I applaud the Governor to his sudden realization and insight that " common sense parameters balance the rights of individuals to purchase firearms with society's reasonable expectation of public safety." I hope that he will apply the same parameters to allow physicians asking their patients if they store their guns safely to avoid an accidental shooting death within the confines of their home and family. Meanwhile, he continues to litigate in federal court seeking to prevent physicians asking their patients these common sense question. Yours Bernd

Healthcare in Florida

In healthcare there seem to exist two parallel universes:the one for normal earthlings crushed by 30% health insurance premium increases and the one for our politicians who pay peanuts for their own insurance. For example, Florida House members will pay just $8.34 a month for state-subsidized health care next year, or $30 a month to cover their entire family. That’s one-sixth of what state senators and most state employees will pay, and one-tenth of the cost to the average private-sector worker, according to the Kaiser Family Foundation. It’s also less than the $25 a month House Republicans wanted to charge poor Floridians for basic coverage such as a limited number of doctor visits or preventive care. Unless we enjoy living in a parallel universe we should NOT let them get away with it!!! Yours Bernd

Insurance Rate Increases

Blue Cross and Blue Shield of Florida (aka Florida Blue) has obtained the approval for a rate increase for several of their individual health insurance policies including BlueOptions-PPO-Individual-16842FL007, MyBasic NetworkBlue-PPO-Individual-16842FL008, BlueChoice-PPO-Individual-16842FL009, BlueSelect-EPO-Individual-16842FL012 and MyBasic BlueSelect-EPO-Individual-16842FL013. According to their web site the average increase will be 15.32% effective July 1st, 2013 and will affect 264,850 people. As a Florida Blue customer my rate increased almost 30% ! The reasons driving the dramatic premium increase include a 189.37% increase in costs for inpatient care compared to a 111.07% increase in outpatient care. It's of interest to note that the current Medical Cost Adjustment - the difference between what the insurer thought it was going to pay for medical services and what it actually paid during the current year - DECREASED by 466.64%! For the final rate determination the Florida Insurance Code requires that all individual and small group carriers obtain approval of their premium rates from the Office of Insurance Regulation (OIR). In addition, the Patient Protection and Affordable Care Act, otherwise known as Health Care Reform, requires that all weighted average rate increases in the individual and small group markets that exceed a stipulated threshold (currently 10%), must be assessed to determine if they are "reasonable". For individual and small group carriers issuing coverage in the state of Florida, the federal enforcement agency for the Patient Protection and Affordable Care Act, Health and Human Services (HHS), has delegated the authority to determine if rate increases are reasonable to the OIR. According to the OIR all Florida Blue's rate increases for individual and small group products either do not exceed the threshold, or have been determined to be "reasonable." Anyone who has received his/her new premium notice might have to get used to the new definition for "reasonable" rate increase. Its probably listed in the alternative Wikipedia published by the healthcare industrial complex which pays our politicians and corrupts our public life. Yours Bernd

Heroin Use On The Rise

Attached a link to an interesting article titled "As pill mills fade away, heroin fills the void" highlighting the emerging trend of heroin use among former Oxycontin abusers. I have noticed a similar uptick of heroin use among my patients seeking outpatient treatment. This is especially worrisome because heroin is cheaper and more potent than ever and it now spreads across all demographic and ethnic boundaries. We need to respond to this trend by developing and aggressive public education campaign about the dangers of heroin, introduction of needle exchange programs and promotion of outpatient treatment programs. Yours Bernd

The Gun Lobby Target Doctors

The gun lobby paranoia seems to have infected all branches of our government, but even I am surprised how far politicians are willing to go to please their NRA sponsors. In today's Miami Herald an article titled " Medical liability bill gets snagged by gun concerns" highlights such an example. According to the article a Senate priority bill to limit the liability of Florida doctors ran into trouble in the House on Monday when opponents suggested that it could be used by insurance companies who represent the doctors to create a private registry of gun owners. The bill, HB 827, would deal with what are known as “ex parte communications” in malpractice cases and would allow lawyers for doctors hit with a malpractice claim to interview any other doctor about a patient’s health record in private. Rep. James Grant, R-Tampa, believes that the provision could open the door to lawyers asking doctors about the gun-toting habits of their patients and, over time, use that information to build a database of gun owners who could be charged higher insurance rates. Grant filed an amendment to the bill Monday that would prohibit doctors from revealing any information about a patient’s gun ownership, as well as any history of child abuse, sexual abuse, substance abuse, mental health and reproductive history unless the patient’s lawyer is present. Just to make sure that we understand this mind-boggling political acrobatic: Rep Grant BELIEVES that insurance companies will mine these records to essentially eliminate potential risky clients, especially gun owners, who then would be charged higher insurance rates. Therefore, according to his amendment, doctors would be prohibited from collecting and revealing such information, unless the patient's lawyer is present. Sounds reasonable? Well, probably in the mind of those who believe that the government is trying to disarm Americans by buying ammunition in large amounts, or those who believe in black helicopters following their every move etc. What is more troubling that those "freedom fighters" are willing to gag doctors and force them to sanitize their medical records in order to please their NRA masters. Why do we vote for these NRA stooges? What happened to our individual freedom from interference in our lives and professions? Its time to expose these so-called politicians as willing executioners of the NRA. Yours Bernd

Needle Exchange Program

Attached a link to an interesting article published in today's Miami Herald titled "Needle exchange bill inching forward in the Florida Legislature" highlighting HB Bill 735 calling for a a five-year pilot program in Miami-Dade County to legalize syringe and needle exchange programs. Such exchanges operate in at least 35 states, but remain illegal in Florida. A similar bill in the Senate, sponsored by Miami Democratic Sen. Gwen Margolis, has stalled.The bill is based on research conducted by University of Miami students. The bill calls for the exchange program to provide free, clean and unused needles and hypodermic syringes in exchange for used needles and syringes as a way to curb the transmission of diseases among injection drug users, as well as to protect emergency workers and members of the public who might inadvertently come into contact with contaminated injection supplies. Participants would also receive educational materials, HIV counseling and testing and referrals to drug treatment. The program would operate for five years and be funded through grants and donations. I fully support needle exchange programs and the efforts to push this bill through the Florida legislature. The legislation is also being supported by the Florida Osteopathic Medical Association, the Florida Nurse Practitioner Network and the Florida Academy of Family Physicians. I am confident that FSAM will join the efforts, too. I look forward to your comments and responses. Yours Bernd

Stimulant Abuse: The New Prescription Drug Abuse Epidemic

Attached you find a link to an important article published in today's New York Times titled "A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise" highlighting the staggering increase in ADHD diagnosis and related stimulant prescription use. Nearly one in five high school age boys in the United States and 11 percent of school-age children over all have received a medical diagnosis of attention deficit hyperactivity disorder, according to new data from the federal Centers for Disease Control and Prevention. The figures showed that an estimated 6.4 million children ages 4 through 17 had received an A.D.H.D. diagnosis at some point in their lives, a 16 percent increase since 2007 and a 53 percent rise in the past decade. About two-thirds of those with a current diagnosis receive prescriptions for stimulants like Ritalin or Adderall, which can drastically improve the lives of those with A.D.H.D. but can also lead to addiction, anxiety and occasionally psychosis. About one in 10 high-school boys currently takes A.D.H.D. medication, the data showed. Sales of stimulants to treat A.D.H.D. have more than doubled to $9 billion in 2012 from $4 billion in 2007, according to the health care information company IMS Health.Even more teenagers are likely to be prescribed medication in the near future because the American Psychiatric Association plans to change the definition of A.D.H.D. to allow more people to receive the diagnosis and treatment. The question remains: are millions of children receiving medication merely to calm behavior or to do better in school? We also should be aware that those medications are often NOT taken as prescribed, shared with or sold to classmates, contributing to diversion long tolerated in college settings and also gaining traction in high-achieving high schools. The C.D.C. director, Dr. Thomas R. Frieden, likened the rising rates of stimulant prescriptions among children to the overuse of pain medications and antibiotics in adults.“We need to ensure balance,” Dr. Frieden said. “The right medications for A.D.H.D., given to the right people, can make a huge difference. Unfortunately, misuse appears to be growing at an alarming rate.” “There’s no way that one in five high-school boys has A.D.H.D.,” said James Swanson, a professor of psychiatry at Florida International University and one of the primary A.D.H.D. researchers in the last 20 years. “If we start treating children who do not have the disorder with stimulants, a certain percentage are going to have problems that are predictable — some of them are going to end up with abuse and dependence. And with all those pills around, how much of that actually goes to friends? Some studies have said it’s about 30 percent.” As physcians we should stop giving in to parents and patients pressures to prescribe these stimulants indiscriminately. We must refocus our efforts on proper and evidence based ADHD diagnosis, demand special training of stimulant prescribers and tracking of stimulant prescriptions. Otherwise, we will force the federal government to step in with tighter regulations.

The Anti-Aging Myth

Attached a link to an interesting article published in today's Miami Herald highlighting the proliferation of so-called anti-aging clinics in South Florida whose unscrupulous operators are peddling steroids and growth hormones. I also recommend reading the excellent commentary by Fred Grimm. I hope that my fellow colleagues will join me in the effort to curtail the (ab)use of steroids and growth hormone products which can have serious and detrimental health effects. We should point out those so-called "doctors" who are profiting from promoting the use of steroids for muscle-building and human growth hormone (hGH). We should make it clear to those "doctors" that federal law prohibits the use of such substances except for rare circumstances such as growth retardation. Instead, those "doctors" are promoting the use of human growth hormone therapy to treat patients suffering from low energy, increased fat or a slowing sex drive. Now is time to act and to speak up. Yours Bernd

Gun Safety

Attached a link to an article titled " The Pediatricians vs. the NRA" published on slate.com. We need to continue pushing for the implementation of common-sense gun safety measures and doctors play an important role to communicate this issue with their patients. Yours Bernd VISIT MY NEW WEB SITE AT www.bwollschlaeger.com

Guns,NRA and the Affordable Care Act

The tragedy of the horrific shooting in Newtown Connecticut gradually faded from the daily news. Sadly, this shooting will be followed by another one and we will continue to seek answers to why it happened and what we could have done to prevent another massacre. In my opinion we have to recognize that the National Rifle Association (NRA) tentacles of influence have penetrated all aspects of our lives. An article published in the Washington Post highlighted that the National Rifle Association successfully lobbied for the national health care law signed by President Obama in 2010 to include provisions restricting the ability of doctors and health plans to collect patient information about gun ownership.The language, pushed by the National Rifle Association in the final weeks of the 2010 debate over health care was discovered only in recent weeks by some lawmakers and medical groups and is drawing fierce criticism. The provision says that “wellness and prevention” portions of the health-care law “may not require the disclosure or collection of any information” relating to the “presence or storage of a lawfully possessed firearm or ammunition in the residence or on the property.” Further, the measure says the law cannot be used to “maintain records of individual ownership or possession of a firearm or ammunition.” It adds that the price of health coverage may not be affected by the ownership, possession or use of guns. The deal to add gun language to the health-care bill was struck so quietly that several top officials in the Obama administration and in Congress had no idea the passages had been added until approached by The Washington Post last week. Its important to understand that this questionable legislative compromise erected an almost insurmountable barrier to the type of research required to address gun safety and gun control issues vital for addressing the issues involved in the post-Newtown policy debate. Again, the NRA has skillfully implemented a gag rule into the health care law preventing physicians to contribute to the data collection of ANY gun related issue. As parents, responsible citizens and physicians we need to continue and intensify our struggle against the metastasizing influence of the NRA in our government and lives. Yours Bernd ADDENDUM: Attached the original wording contained in Sec. 1001\2717 PHSA t: PROTECTION OF SECOND AMENDMENT GUN RIGHTS.- "(1) WELLNESS AND PREVENTION PROGRAMS.-A wellness and health promotion activity implemented under subsection (a)(l)(D) may not require the disclosure or collection of any information relating to- "(A) the presence or storage of a lawfully-possessed firearm or ammunition in the residence or on the property of an individual; or "(B) the lawful use, possession, or storage of a firearm or ammunition by an individual. "(2) LIMITATION ON DATA COLLECTION.-None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used for the collection of any information relating to- "(A) the lawful ownership or possession of a firearm or ammunition; "(B) the lawful use of a firearm or ammunition; or "(C) the lawful storage of a firearm or ammunition. "(3) LIMITATION ON DATABASES OR DATA BANKS.-None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used to maintain records of individual ownership or possession of a firearm or ammunition. "(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR ELIGIBILITY FOR HEALTH INSURANCE.-A premium rate may not be increased, health insurance coverage may not be denied, and a discount, rebate, or reward offered for participation in a wellness program may not be reduced or withheld under any health benefit plan issued pursuant to or in accordance with the Patient Protection and Affordable Care Act or an amendment made by that Act on the basis of, or on reliance upon- "(A) the lawful ownership or possession of a firearm or ammunition; or "(B) the lawful use or storage of a firearm or ammunition. '(5) LIMITATION ON DATA COLLECTION REQUIREMENTS FOR INDIVIDUALs.-No individual shall he required to disclose any information under any data collection activity authorized under the Patient Protection and Affordable Care Act or an amendment made by that Act relating to- "(A) the lawful ownership or possession of a firearm or ammunition; or "(B) the lawful use, possession, or storage of a firearm or ammunition.