One Dad's Perspective

Okay, while our presidential candidates are debating, I thought I would link to an article by a former state legislator.  In "How I Helped Create a Flawed Mental Health System That Failed Millions -- and My Son," Paul Gianfriddo talks about his decades-long attempts to help his ill son, a young man who sounds to have mental health and educational needs that couldn't be met by a system with limitations.

Gianfriddo writes:

The 1980s was the decade when many of the state’s large psychiatric hospitals were emptied. We had the right idea. After years of neglect, the hospitals’ programs and buildings were in decay. But we didn’t always understand what we were doing. In my new legislative role, I jumped at the opportunity to move people out of “those places.” Through my subcommittee, I initiated funding for community mental health and substance abuse treatment programs for adults, returned young people from institution-based “special school districts” to schools in their hometowns, and provided for care coordinators to help manage the transition of people back into the community. 

But we legislators in Connecticut and many other states made a series of critical misjudgments that have haunted us all ever since. 

First, we didn’t understand how poorly prepared the public school systems were to educate children with serious mental illnesses in regular schools and classrooms. Second, we didn’t adequately fund community agencies to meet the new demand for community mental health services—ultimately forcing our county jails to fill the void. And third, we didn’t realize how important it would be to create collaborations among educators, primary care clinicians, mental health professionals, social services providers, and even members of the criminal justice system, if people with serious mental illnesses were to have a reasonable chance of living successfully in the community. 

During the twenty-five years since, I’ve experienced firsthand the devastating consequences of these mistakes.

The story about his son is heart-breaking and there is no happy ending.  I'll leave you to read the whole article and see what you think.  And if you'd like to check it out, Mr. Gianfriddo blogs, often about mental health issues, at Our Health Policy Matters.

Should State Legislators Determine Indications for Medical Treatment?

The FDA evaluates studies on medications and deems them safe enough to justify use.  They also determine the "indications" for using any particular medicine, and once that's done, physicians will often use a medication 'off label.'  That means that Medicine A was found to be safe (or relatively safe, because even over-the-counter meds can be fatal for the wrong person at the wrong time), and it works better than a placebo at treating Disease A, but some studies have found it useful for Disease B, but the FDA hasn't gotten to approving it for this yet, and perhaps never will, but docs use it for Disease B anyway.  This is very common with the SSRI's, where one has been approved for a condition, but maybe the patient isn't tolerating that one so well, so the doc uses another SSRI with a different side effect profile, even though that particular med has not been approved for that particular condition.  Just an FYI, the SSRI's are : Prozac Zoloft Paxil Luvox Celexa Lexapro.   


So the FDA says inhaled marijuana (as opposed to Marinol, a pill form of cannabis) has no medical uses and the discussion is ended.  It can't really be studied at this point, because it has no medical value so your local university can't grow or get any weed and do studies on it, because it has no medical value.  And the federal government says it's illegal.   I do believe that with 16 states disagreeing, that perhaps the FDA should reconsider this stance and repeat a study or two on inhaled cannabis for nausea induced by chemotherapy or anorexia in AIDS so that medical marijuana can be studied, monitored, grown in a pure regulated way, prescribed for a known and proven condition with some parameters like other medical interventions: 30 day supply, directions on how much and how often to smoke it (ah, the pharmacy could roll for you), reassessment so that if your doc decides to give it to you "off label" for your low back pain, and that pain is so much better but funny, you've stopped working, you lie on the couch all day playing Grand Theft Auto, and your life has virtually stopped, the doc can say, "Glad it's helped your pain, but it's put you into an apathetic, amotivational state and your life has now gone down the toilet, I'm stopping this so you can go back to work and pay the mortgage and feed those hungry children."  Or for us shrinks, "Funny, but you didn't have schizophrenia until you started smoking this stuff, let's stop it."  Obviously, if the person has become addicted (and yes, you can get addicted to weed), they'll get it illegally, but the same is true of benzos or opiates, and really medical marijuana just can't be any worse then the fiasco we've had in this country with oxycontin, especially when it gets mixed with a bit of also-legal Xanax and also-legal Vodka, and I can give you a long list of names of people who can no longer testify to this, famous and otherwise.  


So for the moment, the demand for legalized Medical Marijuana is left in the hands of our legislators.  Who better to determine medical indication, necessity, length of treatment, and methods of monitoring.  In Maryland, there was a study group led by the state's health secretary, Joshua Sharfstein.  The plan called for going slow, required training of docs to prescribe it, and required that it be distributed through academic centers.  Two legislators who are pushing bills to legalize medical marijuana called it Misguided and Heartless.


Delegate Glenn of Maryland has proposed House Bill 15, a Medical Marijuana Act.  It provides that marijuana could be used for a variety of conditions.  They include: 

(1) “DEBILITATING MEDICAL CONDITION” MEANS:
(I) A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION OR ITS TREATMENT THAT PRODUCES ONE OR MORE OF THE FOLLOWING:

1. CACHEXIA OR WASTING SYNDROME;
   
2. SEVERE, DEBILITATING, OR CHRONIC PAIN;
   
3. SEVERE NAUSEA;
   

4. SEIZURES, INCLUDING THOSE CHARACTERISTIC
OF EPILEPSY;
5. SEVERE AND PERSISTENT MUSCLE SPASMS, INCLUDING THOSE CHARACTERISTIC OF MULTIPLE SCLEROSIS OR CROHN’S
DISEASE;

6. AGITATION OF ALZHEIMER’S DISEASE;
   
7. ANXIETY; OR
   
8. DEPRESSION; OR
   

(2)
VIRUS (HIV);

“DEBILITATING MEDICAL CONDITION” INCLUDES:

1. (I)  CANCER;
   
2. (II)  GLAUCOMA;
   
3. (III)  POSITIVE STATUS FOR HUMAN IMMUNODEFICIENCY
   
4. (IV)  ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS);
   
5. (V)  HEPATITIS C;
   
6. (VI)  AMYOTROPHIC LATERAL SCLEROSIS;
   
7. (VII)  NAIL PATELLA;
   
8. (VIII)  POST–TRAUMATIC STRESS DISORDER;
   
9. (IX)  BIPOLAR DISORDER; OR
   
10. (X)  THE TREATMENT OF ANY OF THE ABOVE LISTED CONDITIONS. 
    
    
    On the positive side, the law does require that "compassion centers" to either grow or distribute marijuana be at least 500 feet from pre-existing schools.  Because children can't walk 600 feet?  
    
    I'm told this bill won't pass, but another one, with out the listed psychiatric indications for the use of medical marijuana, may well pass.  I might be more pro-MMJ if the stats didn't reveal that 2% of recipients in Colorado have cancer and AIDS, and that many people are prescribed marijuana by non-healthys for psychiatric reasons, including insomnia.  And if medical marijuana was distributed by a pharmacy with directions on how much and how often to use it.  The one-year toke your heart out cards with the boutique flavors all as part of "wellness" don't fly so well with me.  If people want marijuana to be legal, then legalize it, but this type of legislation puts physicians in the middle as an agent.  Really, if we were talking about people smoking a little during their cancer treatments, this just wouldn't be the issue that it is.
    
    Okay, so my questions for you:
    
    1) A person gets medical marijuana for back pain or anxiety or whatever.  He gets arrested.  Should it be continued in jail?  Prison not be such a bad experience if you get to be high the whole time?
    
    2) Shrink Rap readers don't really like uninformed consent with meds.  How do we feel about giving it to agitated Alzheimers patients and how would that work?  Can you smoke in nursing homes?  Do they have to taken outside in restraints?  Agitation is not usually associated with early Alzheimers.
    
    3) Do we think it's just a little weird that a state legislator is making laws listing which medical indications a drug should be used for?  I must have missed those lectures in residency where pot is the treatment for depression, etc.   Can legislators also decide that methotrexate should be legal for the flu?  I sort of don't get it.  
    
    Okay, my rant for the day.
    

Send a Message to Congress: Don't Cut Access to Healthcare for Medicare Patients

Medicare has been using a flawed formula to annually revise Medicare fees to all providers. The formula results in a larger and larger cut each year, which often gets temporarily "fixed" at the last minute. Due to the current dysfunctional Congress, the expectation is that it won't get fixed this time around, and so this year's cut -- 30%! -- will stay in place, resulting in many doctors, nurses, psychologists, social workers, and other providers to drop Medicare.

What we need is for them to repeal this flawed "Sustainable Growth Rate" (SGR) formula, and replace it with something that makes sense.

Please CLICK HERE to take a few minutes to let your elected representatives know what you think about this.

Thank you.

Florida Don't-Ask-Don't-Tell Gun Law Modified

Here's a follow-up to my March post about the Florida bill to outlaw physicians from asking their patients about access to firearms. Dinah later posted about the effects of the bill on pediatricians. The bill passed, though it was amended to remove the jail time and the potential $5M fine (a bit excessive?).

The Florida Medical Association originally opposed the bill, but now has expressed satisfaction with the compromise language. In March, Asher Gorelik, M.D., president of the Florida Psychiatric Society (FPS), expressed to Psychiatric News his membership's opposition to the bill, particularly “a great deal of concern about how this law would interfere with the ability of the healthy to properly assess a patient.” But in a recent follow-up interview, Gorelik stated that the new language in the bill “no longer interferes with the ability of a healthy to perform a risk assessment.

~Psychiatric Times

Doctors to Go to Jail for Asking Patients About Guns in the Home

Imagine the scenario where you are an ER physician, nurse, or social worker and a person is brought to the hospital by the police for making a suicidal threat.

"I want to die. My wife left me and our house is in foreclosure."--"Do you have any plans to harm yourself?""My dad shot himself when I was little. That's how I would do it."--"Do you have any firearms at home?""OFFICER! Can you arrest this social worker? He just asked me if I have guns at home."[officer]: "Come with me sir. You have the right to remain silent..."

This is the scenario that could actually happen if Senate Bill 432 passes in Florida. The bill makes it a felony to inquire about firearms access or to include any information about firearms access in the medical record, punishable by up to 5 years in jail and/or a $5 million fine. Excuse my French, but WTF?!

An article in the Psychiatric News by Bob Guldin explains that the bill was introduced in both the House and Senate at the suggestion of the National Rifle Association (NRA) to prevent intrusion into the constitutionally protected right to bear arms.

It has been shown that removal of firearms from the home reduces the risk of a completed suicide. So you'd think such a bill would get laughed out of the legislature? Florida child healthy and APA Assembly recorder said, "This bill is not a stunt... the financial power of the NRA in Florida will make it very difficult for sensible legislators to vote against this bill."

I note that a second version of the bill has been proposed, one that reduces the fine to a minimum of $10,000 for the first offense and a minimum of $100,000 for the third offense. It also reduces the offense from a felony to a "noncriminal violation" and compels the states attorney to pursue a possible violation or face professional misconduct charges. This version does permit certain health care providers to ask the question only in certain specific situations (e.g., an emergency "mental health or psychotic episode") but cannot tell anyone else other than the police. Apparently, a similar bill passed one house in Virginia five years ago before dying.

Next will be a bill that outlaws common sense.

********************

Clink comments: We've talked about issues related to guns before here, in Dinah's post "Guns and the Mentally Ill" and again when I mentioned a poster session that talked about gun ownership laws nationally. At my last American Academy of Psychiatry and Law conference I mentioned that 27 states have statutes with lifetime restrictions on gun ownership for people with mental illness. Other states have time limited restrictions on ownership, and some allow restoration of full rights contingent on a physician's documentation of recovery.

So now we have a dilemma: in states where you need a physician's certificate to buy a gun, how can that same physician then be banned from asking about ownership?? I can imagine the session in which a patient comes in to be "cleared" to buy a weapon.

MD: "Well, you're taking your medicine and your symptoms are all under control. You tell me you're feeling well and you'd like to buy that awesome weapon you've been dreaming about."

Gun buyer: "Yeah! I've done the research and I know exactly what I want."

MD: "I need to know whether you have cognitive skills and emotional stability to handle a responsibility like that. Tell me, have you ever owned a gun before?"

Gun buyer: "Awesome!! Now I can sue you for infliction of emotional distress for violating my Second Amendment rights. Those triple damages will really help me stock up my arsenal."

Bottom line: The NRA can't have it both ways. If they involve healthys in restoration of gun rights, they can't ban them for asking questions about ownership.