“We need to have much more education with respect to how the use of
marijuana products can negatively impact or help someone,” said Nora
Volkow, MD, director of the National Institute on Drug Abuse (NIDA). “The
problem is we do not have sufficient evidence that could help us mount those
programs in a way that’s actually required. At this point, I don’t feel the
evidence is sufficient to say, ‘We’re going to recommend that this product
should be used by this patient.'” For example, elderly patients who take
marijuana-containing products may be on a lot of other medications, and little
is known about potential interactions between marijuana and prescription drugs.
“So I do believe in the importance of expanding our knowledge so we can
develop educational training programs that are based on knowledge, not on
Making it Easier to Research Cannabis
Rep. John Sarbanes (D-Md.) noted that a 2015 survey of healthcare providers
concluded that the providers “perceive a knowledge gap related to cannabis
dosing, treatment plans, and different areas related to cannabis products, so
providers themselves realize the need for research and expertise to be
developed in this area.”
The hearing was held to discuss six bills on cannabis, several of which were
aimed at making it easier for researchers to obtain cannabis for research
purposes. Currently, the only cannabis legally available for research comes
from a single farm housed at the University of
Mississippi, and researchers who want to use it must get permission from
three agencies: the FDA, the Drug Enforcement Administration (DEA), and the
NIH. “We need to figure out a way to take advantage of different producers
of cannabis plants to evaluate the diversity of products out there, as opposed
to limiting us to the Mississippi farm,” said Volkow.
Rep. Kurt Schrader (D-Ore.) agreed. “The sad part is we’re not testing the right stuff,” he said. “I fail to understand why we have one bloody facility that is the sole nexus for research and analysis of CBD [cannabidiol] products. It seems to me we ought to be testing products on the marketplace.” Subcommittee chairman Anna Eshoo (D-Calif.) agreed. “I don’t understand why the three agencies before us can’t get this done,” she said, referring to NIDA, the FDA, and the DEA, which all had officials testifying at the hearing.
The Cannabis Research “Catch-22”
Several subcommittee members expressed frustration over what they called the
“Catch 22” problem that cannabis researchers face. “They can’t
conduct cannabis research until they can show cannabis has a medical use, but
they can’t demonstrate cannabis has a medical use until they conduct research.
It doesn’t make sense,” said Eshoo.
“You’ve got to help us figure out how we’re going to get out of this Catch
22,” Rep. Debbie Dingell (D-Mich.) said to the witnesses at the hearing.
“This lack of knowledge poses a public health risk.”
Rep. Michael Burgess, MD (R-Texas), the subcommittee’s ranking member, said
the latter “is going too far,” adding that “using our
congressional authority to override this may be a dangerous move, especially
given the lack of research.”
So far, only one marijuana-related drug has been approved by the FDA:
Epidiolex, which contains cannabidiol, was approved
in June 2018 for treating a rare seizure disorder in patients ages 2 and
Diverse Testimony from Both Sides of the Aisle
Both the witnesses and the subcommittee members seemed divided on
marijuana’s potential harms and benefits for patients. Volkow mentioned
research showing that cannabis exposure during pregnancy was associated with
low birthweight and preterm delivery, and added that it was also linked with
episodes of psychosis. She also said that there was some evidence that cannabis
may be useful in treating spasticity, multiple sclerosis, and pain, “but
otherwise there is little benefit for other indications for which patients are
Rep. Morgan Griffith (R-Va.) said that his support of medical marijuana
began some years ago when he learned that people were smuggling marijuana into
a Virginia hospital to help a terminally ill father who wanted to be feeling
well enough to spend time with his 2-year-old son. Years later, when he told
that story at a high school town hall, one student raised his hand and said,
“They did that for my daddy too.”
“These communities were 20 years apart, 30 years apart, yet doctors
were turning a blind eye to allow marijuana to be brought into the hospital
because they recognized that for those patients who are dying, that was the
only way they would get relief and get the nutrients they needed to spend a
little more time with their children,” Griffith said.
Rep. Greg Gianforte (R-Mont.) said he was opposed to efforts to “make any Schedule 1 drug legal without adequate research.” Instead, “we should focus on combating addiction,” he said.
It is well-known that people with Substance Use Disorder
(SUD) and Opioid Use Disorder (OUD) face a heavy stigma in society at large. For
instance, in Victoria, BC, while exceptional caregivers such as Corey Ranger, the
nurse are saving addicts’ lives, hostile bystanders often offer disdainful
suggestions such as “Oh, why bother? Just let them die!”
Indeed, it is not uncommon for the general public to regard SUD and OUD as examples of societal weakness and personal failure, rather than viewing the condition as a medical condition that is frequently combined with other chronic disorders. In many cases, those suffering from addiction are also subjected to negative attitudes from nurses, doctors, and other healthcare practitioners. As a nurse in one study says of SUD patients, “[they create] a cycle of problems,” where “the staff perceives them to be annoying or obnoxious…” Another nurse in the same study notes, “staff attitudes are obvious, you can’t really hide them that well.” It is acknowledged that “Stigmatizing attitudes among health professionals have been shown to be widespread, which has detrimental consequences for connecting persons with OUD to treatment.”
Nurses, Doctors and SUD; Nurses and Doctors with SUD
However, doctors’ tendency to protect colleagues with SUD, and the policy of theNCSBN that promotes a nonjudgmental, stigma-free approach to treatment of nurses with SUD (approximately 70% of nurses who seek treatment successfully return to practice) coexists with strong evidence that a substantial number of doctors and nurses have a negative attitude toward addicted patients. The consequences are as grave as they are incongruous; as a study in Canadian Nurse.com remarked, “perceived discrimination on the part of health-care staff was a major barrier to [patients’] seeking medical help, both for their substance abuse and for treatment of general and chronic conditions.”
Doctors and OUD: A Static System
“Fresh out of medical school, you can prescribe for pain relief any of the opioid medications that can lead to addiction, but you have to get a special waiver to treat addiction, a disease process. That just doesn’t make sense…”
–Dr. Sandeep Kapoor, director of the Screening, Brief Intervention and Referral to Treatment (SBIRT) program at Northwell Health
The situation of doctors is particularly unfortunate with regard to patients with OUD. The reaction of one doctor, when asked about the sparse availability of buprenorphine treatment, was a flat comment that “Most doctors don’t want to treat OUD or SUD patients.” A Statnews editorial on this topic concludes that a pervasive problem is that a) many doctors do not see addiction “as a brain disorder requiring treatment, but as a personal failing,” and b) “some physicians believe that medication-assisted therapy is little more than switching one addiction for another.”+
Even among those doctors who are willing to treat OUD patients, the problem is compounded by the fact that even now—in the midst of an opiate crisis—treating addicted patients with medications such as buprenorphine is highly regulated, requiring strict state and federal registration. To be permitted to prescribe, regulations require that doctors take eight hours of training (for NPs and PAs the requirement is 24 hours of training), after which they are required to register for a DEA waiver.
A further deterrent to the propagation of buprenorphine treatment is the inspection of office records by DEA agents (see within link, “What to Expect When the DEA Comes to Your Office”). An independent-minded physician—who may already be unenthusiastic about treating “addicts”—is unlikely to readily tolerate this sort of heavy-handed government interference in his or her practice. As it is, at present, despite the generally acknowledged opiate crisis, fewer than 7% of US physicians currently have DEA waivers for the prescription of one of the safest and most effective methods of treatment for opiate addiction.
Ties that Bind
This means that while the opiate crisis is raging, the hands of the practitioners who ought to be on the front lines of the fight are bound—both self-bound and bound by regulations. Doctors Kevin Fiscella and Sarah Wakeman ask in another StatNews editorial, “Would deregulation work?” They go on to note that “after France instituted this approach in 1995, deaths from opioid overdoses dropped nearly 80 percent.” Until attitudes among caregivers become more advanced, and until a proper deregulation movement for the prescription of buprenorphine gains national attention, attempts to stem the crisis are little more than a grand display of running in place.
Cannabis and politics are at an intriguing crossroads as we creep ever
closer to the next election year. Politicians must decide how to position
themselves on the hot-button issue of cannabis legalization. Many potential
legalization bills have been proposed in the House of Representatives but very
few have ever made it out of committee. National legalization bills have a
history of facing intense scrutiny in the houses of Congress. There are a
number of reasons for this but the vast differences in political opinions of
members of Congress makes compromise on any bill, let alone one about a hot
button issue like cannabis legalization, very difficult.
However, on Wednesday, November 20th, a new bill that would decriminalize cannabis nationally, allow states to make their own laws on full-scale legalization, and create the potential for expunging criminal records related to cannabis arrests passed in the House Judiciary Committee.
Chances of the Bill Passing
Though it is tough to envision a cannabis bill actually seeing the light of
day, there is hope for this most recent iteration. The bill already has 50
co-sponsors, bipartisan support from notable pro-cannabis legalization
Republicans like Matt
Gaetz of Florida, and passed the House Judiciary Committee with a vote of
24-10. It is always encouraging when Republicans and Democrats can agree on
legislation, especially when it comes to a potential cannabis legalization
bill. Recently, the House of Representatives passed the SAFE
Banking Act with bipartisan support. The bill allows for cannabis
businesses to bank safely and discreetly. Its passage shows the willingness of
Congressional Republicans and Democrats to work together to pass a cannabis
The House cannabis bill is undoubtedly an exciting moment for those in the legalization movement. As promising as the bill seems, it is unlikely that it will be passed without major changes. It may pass the Democrat-controlled House of Representatives, but will face an intense battle in the Republican-controlled Senate. As unlikely as the bill’s passage is, those investing in the cannabis industry seem to believe the bill has a chance to become a part of American law soon.
Impact On The Cannabis Industry
As news of the forwarding of the house cannabis bill was announced, cannabis
company stocks soared. The three biggest cannabis stocks, Canopy Growth, Tilray
Inc., and Aurora Cannabis all saw prices rise between 8% and 15% on Wednesday,
according to Reuters. Investor excitement is palpable, but some experts
warn about the long term future for the House cannabis bill. Alan Brochstein,
managing partner at New Cannabis Ventures, cautioned that the bill is, “such an
early step in a long process that there are no near-term implications for
The merits of the House cannabis bill will likely debated for the next few
months. Changes will be made and votes will be cast before anything is set in
stone. Whether or not this iteration of a legalization bill becomes law is
unknown, but the fact that some politicians continue to fight for cannabis
legalization is tremendously promising.
Four physicians and two others protesting their inability to vaccinate migrant detainees at the U.S. Customs and Border Protection (CBP) headquarters here were arrested last Tuesday for failing to comply with federal orders to disperse.
They were held for about an hour, according to some of those who were arrested.
The two groups of protesters — about 60 people in total — had gathered in two driveways leading to CBP headquarters for about an hour when one of the groups received a warning from federal officials that if they stayed in the driveway, they would be arrested, said Marie DeLuca, MD, an emergency room physician from New York who was one of those arrested. Some of the members had blocked the driveway by laying down across the road while others chanted, “No more death.”
“We stayed peacefully in the driveway entrances of their building and said that if they weren’t going to let us in to vaccinate against the flu, we were going to remain. They didn’t let us. Instead they chose to arrest members in one of the two groups,” DeLuca said.
She said her hands were secured behind her back with zip ties by officials from the Department of Homeland Security (DHS) as she and the other protesters were led into a conference room and told to wait. After about an hour following the protest, they were issued tickets with a court date for “failure to comply with the lawful direction of federal police officers or other authorized individuals,” and then released, she said.
A San Diego Union-Tribune reporter posted a video of some of those doctors being arrested.
At about 2 p.m. Tuesday, DHS’s press secretary tweeted a picture of the protesters
and said, “Of course Border Patrol isn’t going to let a random group of
radical political activists show up and start injecting people with
Other doctors arrested, who were part of the group Doctors For Camp Closure, included Mario Mendoza, MD, a former anesthesiologist who now lives in New York City and runs the organization Lifeundocumented.org; Hannah Janeway, MD, an emergency room physician in Los Angeles who helps run the Refugee Health Alliance; and Mathieu De Schutter, a pediatric hospitalist from San Luis Obispo, California. The non-physicians arrested were Rebecca Wollner of Jewish Action San Diego and Matthew Hom, a graduate student from Cerritos, California, who works with the group Never Again Action.
On Monday, the physicians began their three-day vigil and protest of federal immunization policies at the gate of the detention center in San Ysidro at about 11:30 a.m. They stayed until about 4:30 p.m. with no response despite repeated requests. Tuesday’s action took place nearby at the Chula Vista CBP headquarters.
DeLuca said the doctors and their supporters planned to return Wednesday to try one more time to administer the 120 influenza vaccines they brought with them for the detainees. They say it’s important for public health, not just to protect these detainees, but also everyone else they come in contact with.
Members of the groups chanted slogans and carried banners and signs
calling on federal officials to let them administer the vaccinations to
those inside. The vaccines were purchased with financial donations.
As trusted professionals in the eyes of the public, health providers are considered stewards of public health and safety.
Health providers are ethically bound to advance health holistically, and with climate change, this means translating information into advocacy. The effects of climate change call for the many roles that medical providers take on: first responder to disaster, risk educator of patients and public, and — in an almost exact reenactment of Florence Nightingale’s work — defender of clean water, nutritious food, and sanitation.
The scope of climate-related effects on human health is simultaneously as broad as global drought and as specific as increased incidence of skin cancers. Health providers are uniquely positioned to address the health implications of climate change, providing education within the context of direct patient care and speaking with authority on policy decisions that affect public health.
Climate Change and Human Harm
Scientists are still working to understand the full impact of climate change on human health; however, there are existing studies that show severe effects on human health as a result of environmental hazards. According to the National Institutes of Health, there are several key areas of concern regarding climate and health, and many opportunities for health providers to offer prevention and education.
THREATS TO RESPIRATORY HEALTH
Implications: Lung disease, allergies, and asthma will be worsened by longer allergy seasons and deteriorating air quality.
Health Provider Recommendations: Support staying inside on poor air quality days and remind vulnerable populations to adhere to medical treatment plans and medication.
Implications: Ticks and mosquitoes will be more active for longer and range farther.
Health Provider Recommendations: Encourage people to use bug repellent when outdoors or in any areas with insects. Monitor and record reports of disease outbreaks. Inform others about signs and symptoms of diseases and when to call a health care provider.
WEATHER-RELATED ILLNESS AND INJURY
Implications: Extreme temperature fluctuations affect outdoor laborers, children, pregnant women, and older adults and can cause pulmonary and cardiovascular problems and dehydration. In addition, increased particulate matter, ozone concentrations, and extreme weather events may trigger stress and respiratory issues that lead to heart disease.
Health Provider Recommendations: Educate about the risks of heat exposure. Ensure access to air conditioning for vulnerable or older adults and homeless populations. Also, encourage people to drink enough water throughout the day and not just when they feel thirsty.
MENTAL HEALTH AND STRESS DISORDERS
Implications: Extreme weather can be destructive to property and quality of life, often resulting in the loss of homes, belongings, and loved ones. Prolonged exposure to these stressful experiences can manifest psychologically as people try to navigate grief and loss with interrupted access to care.
Health Provider Recommendations: Encourage others to speak openly about their grief to reduce stigma. Identify gaps in mental health literacy and teach patients about signs and symptoms of mental health risks. In addition to educating, refer at-risk patients to a mental health provider as soon as possible.
Spreading the Word About Disaster Preparedness and Dangers
In a 2018 World Health Organization report on climate change and health, experts state that “globally, the number of reported weather-related natural disasters has more than tripled since the 1960s.” For this reason, it’s essential that health providers inform their communities about disaster preparedness and dangers. The best time to get involved is before a disaster; therefore, it’s critical for providers to leverage any one-on-one time with patients to address holistic health and emergency concerns. Special attention should be paid to those who may be vulnerable in the wake of disasters. For example, this could include people with chronic conditions, physical disabilities, or respiratory diseases; infants and children; pregnant women; and older adults.
Thin Ice: The Life-Threatening Effects of Climate Change
Air Temperature Change
Increase in heat exhaustion
Spread of disease vectors among animals, insects, and people
Increased movement of airborne allergens and diseases
Higher risk of respiratory illness
Loss of loved ones and pets
Water Temperature Change
Changes to coastal ecosystem health that will affect food supply and erosion
Increased likelihood of extreme precipitation, drought, or flooding
Water contamination due to harmful chemicals and pathogens
Malnutrition, especially for prenatal or early childhood development
A Rising Tide Lifts All Boats: Advocacy for Climate-Related Health Policy
Climate change may be politically polarizing, but illness and injuries seen by first responders and health providers are concrete outcomes and can translate into loss of life on a global scale.
In a 2018 report on climate change and health that accounted for continued economic growth and medical progress, the World Health Organization stated that “climate change is expected to cause approximately 250,000 additional deaths per year between 2030 and 2050.” These fatalities are projected to come from the following climate-related health complications:
— 38,000 due to heat exposure in older adults
— 48,000 due to diarrhea
— 60,000 due to malaria
— 95,000 due to childhood undernutrition
Health providers can draw awareness to this dire need for attention at the policy and community levels. They can also share firsthand experience and research. This is an ethical duty that can result in widespread support of strong public health programs and climate justice.
How to Get Involved in Climate and Health Policy
In addition to in-person education with patients, health providers can do a variety of things to spread awareness about climate and health policy in their communities:
Leverage social media. Share articles with verified, evidence-based information on social channels. Use hashtags related to climate and health that make your posts easier to find. For example, #ActOnClimate, #Go100Percent, #Renewables, #SaveThePlanet, and #ClimateChange.
Continue your education. Request or attend an educational presentation from a trained professional, then collaborate with community organizations to educate people in your area. Volunteer with climate- or policy-focused organizations to gain perspective.
Participate in civic engagement. Call your representatives to let them know whether you support specific legislation. And always, vote in local and national elections.
Organizations for Further Reading or Involvement
If you are a health care provider
looking to learn more about climate and health policy, you may wish to visit
the websites of these organizations.
Extending insurance coverage to immigrant children and pregnant women did not appear to influence whether they crossed state borders (known as in-migration) to acquire care, according to survey data.
Among 36,438 lawful permanent
residents with children, the average in-migration rate 1 year before public
health insurance was expanded to cover immigrants was 3.9% and 1 year after the
implementation, the rate remained essentially unchanged at 3.7%, reported Vasil
Yasenov, PhD, MA, of the Immigration Policy Lab at Stanford University in
California, and colleagues.
Similarly, among 87,418 women of
reproductive age, the in-migration rate 1 year before expansion was 2.7% and 1
year after it was 4.6%, the team wrote in JAMA Pediatrics.
“No Discernable Association” Between In-Migration and Insurance Expansion
“If an expansion of health
insurance coverage was associated with in-migration to another state, the
probability of in-migration would have increased in the treatment group
compared with the control group,” the researchers wrote. “There was
no discernable association between the in-migration from any state among the
treatment group relative to the control group and public health insurance
The authors compared the group of
immigrants with children with a control group of lawful permanent residents
without children. The proportion that migrated among immigrants without
children was slightly higher before and after expansion (4.0% and 5.9%,
respectively), but not significantly different from immigrants with children,
Yasenov and his team reported.
Meanwhile, among a control group of
post-reproductive women, the rate of in-migration was 3.5% and 3.9% in the
years before and after expansion, respectively, which was also not
significantly different than the group of women of reproductive age, the researchers
“We hope policy makers
concerned with spiraling costs and people flooding in from other states will
have the evidence they need to make a decision when thinking about extending
public healthcare benefits for legal immigrants in the U.S.,” Yasenov told
Findings Indicate Immigrants are Fleeing Violence and Corruption, Not Chasing Health Coverage
As of 2016, immigrants with children
were covered by public insurance in 31
states and pregnant immigrants were covered in 32 states. Many Democratic
candidates for the 2020 election support extending healthcare to undocumented
immigrants, a policy that has been suggested will increase the flow of
immigration within the U.S.
These null findings make sense in
the context in which most U.S. immigration takes place, wrote Jonathan Miller,
JD, of the Office of the Massachusetts Attorney General in Boston, and Elora
Mukherjee, JD, of the Immigrants’ Rights Clinic of Columbia Law School in New
York City, in an accompanying editorial.
Namely, many people coming to the
U.S. are fleeing from violence or political corruption in their home countries,
and “do not seek refuge in the [U.S.] because of potential access to
healthcare,” Miller and Mukherjee said.
“Making it easier for immigrant
communities to connect to and seek care from physicians will not radically
shift migration patterns. Instead, allowing access to the basic human right of
health care shows a common commitment to human decency for all who are in the
[U.S.],” the editorialists stated.
Immigrants Sampled Were Below 200% of Fed Poverty Thresholds
For this study, data were collected
from individuals residing in the U.S. from 1 to 6 years — but who were not
born in the U.S. and were not citizens — from the American Community Survey. Notably, the sample
was restricted to individuals who were below 200% of the federal poverty
thresholds to identify people who would qualify for public insurance if it were
extended, the authors noted. Immigrants on student visas, veterans, or those
married to U.S.-born citizens were excluded because they qualify for other
healthcare benefits, the team added.
The data were controlled for
personal characteristics like age, race/ethnicity, and marital status, as well
as things that varied by state and time such as cash assistance and economic
In total, 208,060 immigrants — mean
age of 33 years, 47% of whom were female — were included. About two-thirds
were Hispanic (63%), and the in-migration rate among the entire sample was 3%.
Overall, the likelihood that lawful
permanent residents would migrate to a state where public health insurance has
been expanded to cover immigrants was practically zero before and after
expansion was implemented (percentage change from -1.21 to 1.78), the authors
The likelihood was also close to
zero among lawful permanent-resident women of reproductive age when compared
with a control group of lawful permanent-resident post-reproductive women
(percentage change from -1.20 to 1.38).
In a model specifically looking at
whether public health insurance expansion would bring in migrants from a
neighboring state, no association was found between policy implementation and
the rates of in-migration of immigrants with children (–0.03 percentage points,
95% CI –0.5 to 0.44) or pregnant women (–0.02 percentage points, 95% CI –0.48
to 0.09), the researchers reported.
The primary limitation of the study,
they said, was the inability to account for time-varying factors that could
undermine the analysis, and it was also not possible to isolate states among
the border and determine whether there was an association between in-migration
and health policy specifically in these states. Lastly, the investigators said,
the association was not analyzed among county-level or city-level programs.
The study was funded by the Stanford Child Health Research Institute.
The authors and editorialists reported having no conflicts of interest.
Listen to the Chapter Podcasts for Jonas and Kovner's Health Care Delivery in the United States
Gain a better understanding of the current state of the US health care system and how it might impact your work and life.
You have Successfully Subscribed!
Join the editors of Evidence-Based Physical Examination: Best Practices for Health and Well-Being Assessment—Kate Sustersic Gawlik, Bernadette Mazurek Melnyk, and Alice M. Teall—to learn how an evidence-based approach lays the groundwork for the integration of wellness, health promotion, and disease prevention, ensuring patient safety and high-quality cost-effective care.