Guns and Public Safety

Now, not only doctors but also insurance companies are prohibited from asking question about gun ownership. Instead of focusing on reducing insurance premiums our representatives in Tallahassee are pleasing their NRA supporters and are obsessively defending alleged Second Amendment violations. For starters: SB 424 would allow state regulators to fine or impose penalties on auto or property insurance companies that "refuse to issue, renew, or cancel a policy" because the policyholder owns a gun. It also prohibits the insurance company from disclosing to third party if the policyholder has a gun. HB 255 is going further by allowing policy holders to sue if an insurer takes such action. On the Florida Senate Senate Banking and Insurance Committee as well as on the Florida House Insurance and Banking subcommittee only ONE Senator and ONE House committee member voted against it! Soon insurance companies have to remove firearm questions from their screening application. Policy holders can now stock their household with assault weapons and thousands of rounds of ammunition to prepare for WW III, or to shoot rowdy neighbors. But wait, it gets better. Soon you can have your own gun range in your backyard. What could possibly go wrong with that! This is insane!!! Yours Bernd

Weapons in Doctors Offices

Attached a link to an article titled " Two dead, third person in hospital after shooting in suburban West Palm" reporting a fatal shooting which took place in the waiting room of a doctors office in West Palm Beach. The shooting occurred during what has been a particularly violent week in Palm Beach County. It was the county’s fifth homicide since Monday and the sixth overall in 2014. It was also the second time this week that local authorities have investigated a murder-suicide, and the third time in seven days that gunmen shot at other people, then killed themselves. As a physician and owner of a busy family medicine clinic I have encountered several patients who carried concealed weapons (handguns, knives) in my office which I discovered during a routine physical exam. I am a gun owner and concealed weapon permit holder myself, but I consider carrying a weapon in a doctors office as inappropriate and potentially dangerous. The fact remains that most healthcare professionals are unarmed and feel intimidated by a patient carrying a loaded weapon. According to Florida firearms regulations a carry license is valid everywhere other than in a few specially-defined areas which include airports, schools, universities, courthouses, establishments licensed to dispense alcoholic beverages for consumption on the premises,career centers, any meeting of the governing body of a county, public school district, municipality, or special district and any meeting of the Legislature or a committee thereof Why should doctors office not be included in the long list of specially-defined prohibited areas"? Why should legislators enjoy the freedom of not being killed by gunfire but doctors should continue working under the threat of guns? Why do neither representatives of organized medicine nor legislators have the intestinal fortitude to stand up and denounce the NRA which blocks all reasonable gun safety measures? Meanwhile, I informed my patients that I do not permit the carrying of any kind of weapons in my office and do not care if my decision backfires. Yours Bernd

Medical Marijuana

Attached a link to an article titled "Florida lawmaker agrees to work to legalize medical marijuana high in cannabidiol" published in yesterday's Tampa Bay Times reporting that Florida legislators agreed to file a bill to legalize the medical use of marijuana that has a high content of the chemical compound cannabidiol to "treat" severe epileptic seizures in children. The families pleaded with lawmakers to legalize strains of marijuana such as "Charlotte's Web" saying it is their last, best hope of relieving the uncontrollable seizures in their medically fragile children. The strain is high in cannabidiol or CBD, the ingredient that controls seizures, but is low in tetrahydrocannabinol, THC, the compound that creates a high. Their emotional pleas convinced the chairman of the legislative committee of the Florida House to support such a bill. Naturally, any opponent of such a move will be considered a heartless and uncaring individual. Most probably, the medical ethics of of physicians opposing such a decision will be questioned, too. But lets consider the facts: Charlotte's Web is a strain of medical marijuana developed in Colorado by the Stanley brothers and featured in the 2013 CNN documentary "Weed", hosted by Sanjay Gupta. It is named after Charlotte Figi, who experienced an immediate and remarkable reduction of her epileptic seizures after her first dose of medical marijuana at five years of age. The sudden publicity of this specific strain of medical marijuana is based on anecdotal evidence only but is now being used to justify the use of medical marijuana in general. Well meaning proponents of clinical research point out that such clinical research is blocked by strict Federal laws. Therefore, they call for reclassification of marijuana to facilitate the kind of rigorous evaluation that’s needed to determine the appropriate, physician-supervised doses and uses of medical marijuana. But before we join the chorus singing the praise of medical marijuana we should step back and analyze the facts. I recommend reading an article published in the Epilepsy Curr. 2013 Mar-Apr; 13(2): 81–82 titled " Slim Evidence for Cannabinoids for Epilepsy" which concluded that no reliable conclusions can be drawn at present regarding the efficacy of cannabinoids as a treatment for epilepsy. The dose of 200 to 300 mg daily of cannabidiol was safely administered to small numbers of patients, for generally short periods of time, and so the safety of long term cannabidiol treatment cannot be reliably assessed. The authors base their assessment of the efficacy of marijuana, or one of marijuana's constituents in the treatment of people with epilepsy on an exhaustive search of the Cochrane Epilepsy Group Specialized Register (May 15, 2012), the Cochrane Central Register of Controlled Trials (CENTRAL issue 4 of 12, and the Cochrane Library 2012),MEDLINE (PubMed, searched on May 15, 2012), ISI Web of Knowledge. This Cochrane review searched for direct evidence that cannabinoids can prevent human seizures in studies using the only acceptable standard, the randomized controlled trial. The researchers identified four studies, with a total of 48 patients randomized to placebo or to 200–300 mg of cannabidiol per day. This particular cannabinoid has few psychotropic effects and is not a controlled substance. Overall, these studies demonstrate the short-term tolerability of this treatment, with the only noted adverse effect being drowsiness in one study. Except for one study that reported two of four treated patients becoming seizure free for 3 months, the studies either reported no benefit, or the effect was not clearly stated. Methods of randomization or determining outcome were inadequate or not clearly detailed.Marijuana itself has major shortcomings as an epilepsy treatment. Its psychotropic action can only be regarded as an adverse effect. It is a biological product containing multiple compounds with unclear, possible, anti- or pro-convulsant effects, delivered in varying amounts from dose to dose. Long-term safety has not been adequately investigated. The authors correctly stated that new treatments for epilepsy are sorely needed. Cannabidiol or other individual cannabinoids with minimal adverse effects could be extracted and given in precise doses in rigorously designed, blinded, randomized clinical trials to test efficacy and safety. In my opinion this is the only reasonable route for development of new antiepileptic drugs. Legislative efforts, as well intended they may be, cannot substitute for the gold standards of scientific evidence. Unfortunately, nobody seems to have the fortitude to stand up and to defend those principles in public. I am afraid that medical science will have to succumb to populism and the efforts to create quick fixes and miracle cures. But at what price? Looking forward to your comments. Yours Bernd

Judges Says No To Drug Test

The U.S. District Court handed Gov. Rick Scott a defeat on Dec. 31 when it struck down a law requiring drug screening of welfare recipients unconstitutional.The Miami Herald reported in a article titled "Scott vows to fight drug-test ruling" that federal judge Mary Scriven granted summary judgment on behalf of Luis Lebron, who at the outset of the 2011 case was a 35-year-old Navy veteran, college student and single father from Orlando. Lebron refused to submit to a drug test arguing that requiring him to pay for and submit to one is unreasonable when there is no reason to believe he uses drugs. Lebron was represented by the American Civil Liberties Union of Florida The judge rules that the mandatory urine drug test violate the Fourth Amendment's protection against unreasonable searches.In her ruling judge Scriven relied heavily on the 11th Circuit of Appeals opinion which cited previous U.S. Supreme Court rulings that restricted mandatory urine drug tests by government agencies to employees working at dangerous jobs or in jobs where school children were involved. Scott signed a law in 2011 to drug test recipients of Temporary Assistance to Needy Families. But the court issued a preliminary injunction a few months later. While the law was in effect from July through October 2011, about 2.6 percent -- or 108 of 4,046 people -- tested positive for drugs, the most common being marijuana. In my opinion an appeal will be an exercise in futility and a waste of precious tax payers money.

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