Is Medical Cannabis Overly Promoted In Minnesota?

 

Karl Marx wrote his famous metaphor about religion being an opiate for the proletariat in 1843:

“Religious suffering is, at one and the same time, the expression of real suffering and a protest against real suffering. Religion is the sigh of the oppressed creature, the heart of a heartless world, and the soul of soulless conditions. It is the opium of the people.”

He suggests in the next paragraph that the abolition of religion would rid people of the illusory happiness and it would be more consistent with the goal of real happiness for the people.  Marx’s formulation has not withstood the test of time. There is no more happiness now with widespread secularism than there was in Marx’s day.  Despite that fact - his metaphor survives and I thought about it quite a lot as I read through the Minnesota Medical Cannabis Program Report (MMCP) Anxiety Disorder Review.  The main difference of course is that cannabis is an equivalent metaphor only at the level of the idea of what medical cannabis can do.  When some writers suggest that religion can cause people to sleep and dream unrealistically, cannabis can physically do the same thing.  But it is promoted as doing many other things for many people – despite a profound lack of evidence.

The MMCP has been around for a number of years. I have taken the longstanding position that the medical cannabis concept is basically a way to legitimize cannabis and eventually get it legalized. I have also taken the position that physicians should not be involved in what is essentially a political maneuver.  The grandest aspect of that political maneuver has been the MMCP acting as a mini-FDA and coming up with their own indications for cannabis use. Initially, the idea was to use cannabis for the treatment of chronic pain and hospice care. I attended one of the early CME courses where most of the speakers were pain doctors and oncologists. Psychiatric input on these decisions has generally been minimal, despite the fact that psychiatric populations are at the highest risk from cannabis exposure and psychiatrists typically see most of the complications of cannabis.  The initiative to treat anxiety (in all forms) has not been approved by the MMCP and they state that was the reason for a more detailed look at the literature on cannabis as a treatment for anxiety and producing the report. 

Reading the report is an interesting exercise. It is not written very much from a scientific standpoint. They are very explicit about what they are considering as evidence.  For example they consider a literature search, a small panel of experts that does not really come to any consensus, and the experience of other states with medical cannabis and the indication of anxiety to be the basis for the report.  There are significant problems with all of those sources. 

 

The Research Matrix

At first the Research Matrix of papers included in the appendix looks impressive. There are 30 papers listing the reference, study type, total number of participants, dose and results.  Reading through the studies - some are single person case reports, some are reviews, and there are 15 studies listed as randomized controlled trials (RCTs). Looking at the RCTs there are probably one or two studies with an adequate number of participants to be adequately powered to show a statistical difference. Additional problems include the lack of an actual anxiety diagnosis.  In fact the diagnoses involved were frequently not anxiety related at all. Three observational studies at the end probably had the most merit and their results were equivocal. So the research studies really add nothing toward answering the question of whether medical cannabis should be used to treat anxiety and certainly nothing about the dose, delivery, or cannabis subtype.

Experience of Other States

Tables 1 summarizes the information about how other states have handled the question about medical cannabis and anxiety.  The states listed are Nevada, New Jersey, North Dakota and Pennsylvania.  In Nevada and North Dakota, the legislatures were petitioned to add anxiety (as DSM-5 Generalized Anxiety Disorder) to the medical cannabis formulary.  In New Jersey and Pennsylvania it was a commissioner decision. The Pennsylvania Secretary of Health was described as being “proactive” by suggesting that medical cannabis for anxiety was a “tool in the toolbox” and recommended duration of use, specific formulations, and avoidance in teenagers.  In all 4 states where cannabis was approved, anxiety quickly rose to the top or second most frequent indication for prescribing medical cannabis. None of the states collects any outcome data. 

What about other countries with more experience with cannabis like the Netherlands?  I contacted a colleague there who forwarded my questions to 2 other psychiatrists who were anxiety experts and doing active research in the area.  They responded that medical cannabis was not prescribed for anxiety and that there was a medical cannabis site for the Netherlands.  The site suggests that a CBD product is recommended. They had the same concerns about THC causing anxiety and psychosis.  A direct comparison of the indications for medical cannabis use comparing the Minnesota program to the Netherlands is included in the following table and linked directly to the respective web sites.

Medical Cannabis Qualifying Conditions

Minnesota   Cancer associated with severe/chronic pain, nausea or severe vomiting, or cachexia or severe wasting Glaucoma HIV/AIDS Tourette syndrome Amyotrophic lateral sclerosis (ALS) Seizures, including those characteristic of epilepsy Severe and persistent muscle spasms, including those characteristic of multiple sclerosis Inflammatory bowel disease, including Crohn’s disease Terminal illness, with a probable life expectancy of less than one year* Intractable pain Post-traumatic stress disorder Autism spectrum disorder (must meet DSM-5) Obstructive sleep apnea Alzheimer's disease Chronic pain Sickle cell disease Chronic motor or vocal tic disorder

The Netherlands   Pain, muscle cramps and twitching in multiple sclerosis (MS) or spinal cord injury; nausea, loss of appetite, weight loss and weakness in cancer and AIDS; nausea and vomiting due to medication or radiation treatment for cancer, HIV infection and AIDS; long-lasting pain of a neurogenic nature (cause is in the nervous system) for example due to damage to a nerve pathway, phantom pain, facial pain or chronic pain that persists after shingles has healed; tics in Tourette's syndrome; treatment-resistant glaucoma

 Expert Consensus

In terms of the professional consensus, the participants were described as  3 psychiatrists, a pediatrician, a person in recovery, a primary care physician, and a marriage and family therapist. On a scale of recommendations, there was one vote for non-approval, one vote in favor of a limited pilot study and follow-up outcomes, one vote for neutral not opposed, three votes in favor of considering for generalized anxiety disorder, panic disorder, and agoraphobia. No consideration is given to the experience of the physicians or the asymmetry of expertise. It appears to be a political approach to neutralizing the opinion of the group of physicians (psychiatrists) who essentially are left treating the complications of cannabis use disorder.  Those complications include acute mania or psychosis, anxiety and panic, chronic depression and amotivational syndromes, and significant cognitive problems.  Cannabis obscures whether the patient has a true psychiatric diagnosis or not.  It also destabilizes psychiatric disorders. That is the common theme I noted above.  This is really not expert consensus – it is a man-on-the street poll.

Apart from the very weak lines of evidence, some of the conclusions in this document are even worse.  There are basically 6 common themes:

1:  Protect the brain: There are longstanding concerns about the new timetable for brain development extending into the mid to late 20s. This is a peak period for drug experimentation and heavy use of alcohol and most substances. There appears to be consensus on this theme and I would agree.

2:  Safer alternative to benzodiazepines: the rationale here is much rockier.  The authors in this case cite the increase in benzodiazepine overdose deaths in the state of Minnesota, but the quality of this data is not clear.  I took a look at the data and contacted the Minnesota Department of Health about it – specifically if opioids were excluded as a primary cause along with fentanyl being sold as benzodiazepines. I was informed by an epidemiologist that a T42.4 code was present and the coding is not mutually exclusive. In other words, more drugs may be involved and fentanyl may have been involved. The death certificates and toxicology confirmations are dependent on the county medical examiner. The accuracy of the data is therefore in question. There are clearly ways to safely prescribe benzodiazepines.  Benzodiazepines are research proven alternatives for severe anxiety when conventional treatments have failed as a tertiary medication and cannabis is not.

In terms of addiction risk, the risk with cannabis is 8-12% overall and 17% for people who start using cannabis in their teens (1-6).  That compares with an addiction liability of about 10% with benzodiazepines (7).  Benzodiazepines are used by people who are taking multiple addicting drugs to amplify the effect, treat withdrawal symptoms, and treat the anxiety and insomnia that accompanies chronic substance use or opioid agonist therapy.  This population is often acquiring benzodiazepines from non-medical sources. There is no real good evidence that medical cannabis will replace non-medical use of benzodiazepines in that setting, since benzodiazepines are easily acquired from non-medical sources.

3:  Therapy is the standard:  Therapy is not the standard. The standard is whatever works for a particular practice setting.  Psychiatrists see people who have already seen a therapist and quite probably a primary care physician where their anxiety was diagnosed with a rating scale. That means they will have failed therapy and at least one or two medication trials. Psychiatrists are not going to start treatment by repeating ineffective therapies. In many cases, substance use including cannabis use is the main reason for the anxiety disorder in the first place.

4: Health Equity:  This was perhaps the most unlikely reason for cannabis use. To emphasize how far this document goes off the rails I am going to quote this section directly:

 “Known disparities exist in the level of care available for anxiety disorder among historically disadvantaged communities. Medical cannabis may offer these individuals the option for an alternative to current medications, however this view was not shared by all participants.” (p.15)

Are the authors of this document really suggesting that disadvantaged communities should settle for a substance that has been inadequately studied, has known severe medical and psychiatric side effects, and is associated with higher rates of suicidal ideation and suicide attempts in these disadvantage communities (14) rather than providing them with standard care? That statement to me is quite unbelievable. It is the first time I have seen a recommendation to use a prescription substance to address a social problem.  It may happen by default – but if you really want to promote health equity equivalence evidence based treatments are the only acceptable standard.

When  "an alternative to current medications" is mentioned cost is not discussed as a factor. In my discussions with people who have received medical cannabis from the Minnesota dispensaries, high cost was often mentioned as a limiting factor. This current price list from one of the dispensing pharmacies shows that nearly all of their products are much more expensive than the generic antidepressants used to treat anxiety disorders.

5: Limited research:  Cannabis advocates point to the lack of research due to the fact that cannabis is a Schedule 1 compound. That means there is no known medical use and a high potential for abuse. Since certain compounds have been FDA approved for specific indications, I anticipate that these compounds will be rescheduled.  That is one of many hurdles in researching cannabis.  A few of the others would include the issue of subject selection (cannabis naïve or not), placebo controls, specific form (THC:CBD ratio), type of drug delivery, and a general methodology that would capture a good sample of persons with an anxiety disorder in adequate numbers for the trial.

6: Harm Reduction:  The authors suggest that medical cannabis could serve to limit exposure to other more harmful drugs obtained on the street to treat anxiety like benzodiazepines. There is no evidence that this would occur given the availability and preference for non-prescribed benzodiazepines.  The issue of polysubstance dependence is complex.  A significant number of opioid users also use benzodiazepines. Despite a black box warning about respiratory depression from using that combination, the FDA has been clear that the medications can be prescribed together. Further, a recent study suggests that retention in a methadone maintenance program was twice as likely if the patients received prescription benzodiazepines as opposed to non-prescription benzodiazepines (10).  No such data exists for cannabis.

In terms of substituting cannabis for benzodiazepines the only study I could find was a retrospective observational study of new patients in a cannabis clinic. Over the course of 2 months 30.1% were able to stop benzodiazepine use and at 6 months that number had increased to 45.2%.  These authors (11) conclude

“Without dependable safety data and evidence from randomized trials for this cohort, cannabis cannot be recommended as an alternative to benzodiazepine therapy.”

 The conclusion of this paper suggests the options of maintaining the status quo or no approval for anxiety, approve for a limited number of “subconditions” defined as specific anxiety disorders, or approve for anxiety disorders.  They list the pros and  cons associated with each approach but not much was added relative to the above discussion.  There are a few comments that merit further criticism. The risks of maintaining the status quo are seriously overstated.  From reviewing previous tabulated data from the MN Medical Cannabis program, it is unlikely that any meaningful real world data will be collected. It is not possible to collect non-randomized, uncontrolled data on a substance that is highly valued and reinforces its own use that has any meaning. The results will predictably be like the comments solicited by this program that are 96% favorable. There are similar speculative predictions of the direct consequences of not providing medical cannabis in terms of not seeking therapy if using cannabis off the street, suicides due to not tolerating SSRIs, and patient harm from “illicit use”. Similar speculation occurs throughout the remaining bullets points and there seems to be a strong pro-medical cannabis for anxiety disorders bias.

To summarize, I am not impressed with the Minnesota Medical Cannabis Program report on the use of medical cannabis for anxiety. It clashes with my 35 years of clinical experience where cannabis has been a major problem for the patients I treated in community mental health centers, clinics, substance use treatment centers, and hospitals. It suggests a great potential for a substance that has been around and used by man for over 7 millennia.  You would think with that history, man would have realized by now that it was a panacea for his most common mental health problem – anxiety. The report also ignores the commonest role of cannabis in American society and that is as an intoxicant and not a medication.  Physicians should not be prescribing intoxicants.  You don’t need a prescription to go to a liquor store and purchase alcoholic beverages. If the real goal is to get cannabis out to the masses, the option is legalization of cannabis not medical cannabis.

 

George Dawson, MD, DFAPA

 

References:

1:  Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Exp Clin Psychopharmacol. 1994;2(3):244-268. doi:10.1037/1064-1297.2.3.244

2:  Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1-2):120-130. doi:10.1016/j.drugalcdep.2010.11.004

3:  Anthony JC. The epidemiology of cannabis dependence. In: Roffman RA, Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treat:ment. Cambridge, UK: Cambridge University Press; 2006:58-105.

4: NIDA. 2021, April 13. Is marijuana addictive?. Retrieved from https://www.drugabuse.gov/publications/research-reports/marijuana/marijuana-addictive on 2021, September 13.

5:  Moss HB, Chen CM, Yi HY (2012). Measures of substance consumption among substance users, DSM-IV abusers, and those with DSM-IV dependence disorders in a nationally representative sample. J Stud Alcohol Drugs 73: 820–828

6:  Perkonigg A, Goodwin RD, Fiedler A, Behrendt S, Beesdo K, Lieb R et al (2008). The natural course of cannabis use, abuse and dependence during the first decades of life. Addiction 103: 439–449 discussion 450–451.

7: Becker WC, Fiellin DA, Desai RA. . Non-medical use, abuse and dependence on sedatives and tranquilizers among U.S. adults: psychiatric and socio-demographic correlates. Drug Alcohol Depend. 2007; 90 2-3: 280- 7. DOI: 10.1016/j.drugalcdep.2007.04.009 PubMed PMID: 17544227.

 

Harm Reduction:

8: Okusanya BO, Asaolu IO, Ehiri JE, Kimaru LJ, Okechukwu A, Rosales C. Medical cannabis for the reduction of opioid dosage in the treatment of non-cancer chronic pain: a systematic review. Syst Rev. 2020 Jul 28;9(1):167. doi: 10.1186/s13643-020-01425-3. PMID: 32723354; PMCID: PMC7388229.

9: Shover CL, Davis CS, Gordon SC, Humphreys K. Association between medical cannabis laws and opioid overdose mortality has reversed over time. Proc Natl Acad Sci U S A. 2019 Jun 25;116(26):12624-12626. doi: 10.1073/pnas.1903434116. Epub 2019 Jun 10. PMID: 31182592; PMCID: PMC6600903.

10: Eibl JK, Wilton AS, Franklyn AM, Kurdyak P, Marsh DC. Evaluating the Impact of Prescribed Versus Nonprescribed Benzodiazepine Use in Methadone Maintenance Therapy: Results From a Population-based Retrospective Cohort Study. J Addict Med. 2019 May/Jun;13(3):182-187. doi: 10.1097/ADM.0000000000000476. PMID: 30543543; PMCID: PMC6553513.

11: Purcell C, Davis A, Moolman N, Taylor SM. Reduction of Benzodiazepine Use in Patients Prescribed Medical Cannabis. Cannabis Cannabinoid Res. 2019 Sep 23;4(3):214-218. doi: 10.1089/can.2018.0020. PMID: 31559336; PMCID: PMC6757237.

 

Cannabis and Psychosis:

12: Kuepper R, van Os J, Lieb R, Wittchen H, Höfler M, Henquet C et al. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study BMJ 2011; 342 :d738 doi:10.1136/bmj.d738

13: Murray RM, Mondelli V, Stilo SA, Trotta A, Sideli L, Ajnakina O, Ferraro L, Vassos E, Iyegbe C, Schoeler T, Bhattacharyya S, Marques TR, Dazzan P, Lopez-Morinigo J, Colizzi M, O'Connor J, Falcone MA, Quattrone D, Rodriguez V, Tripoli G, La Barbera D, La Cascia C, Alameda L, Trotta G, Morgan C, Gaughran F, David A, Di Forti M. The influence of risk factors on the onset and outcome of psychosis: What we learned from the GAP study. Schizophr Res. 2020 Nov;225:63-68. doi: 10.1016/j.schres.2020.01.011. Epub 2020 Feb 6. PMID: 32037203.

 

Cannabis Use and Suicide:

14:  Kelly LM, Drazdowski TK, Livingston NR, Zajac K. Demographic risk factors for co-occurring suicidality and cannabis use disorders: Findings from a nationally representative United States sample. Addict Behav. 2021 Nov;122:107047. doi: 10.1016/j.addbeh.2021.107047. Epub 2021 Jul 12. PMID: 34284313; PMCID: PMC8351371.

 

Cannabis Use and Life-Threatening Medical Problems:

15:  Ladha KS, Mistry N, Wijeysundera DN, Clarke H, Verma S, Hare GMT, Mazer CD. Recent cannabis use and myocardial infarction in young adults: a cross-sectional study. CMAJ. 2021 Sep 7;193(35):E1377-E1384. doi: 10.1503/cmaj.202392. PMID: 34493564.

16:  Parekh T, Pemmasani S, Desai R. Marijuana Use Among Young Adults (18-44 Years of Age) and Risk of Stroke: A Behavioral Risk Factor Surveillance System Survey Analysis. Stroke. 2020 Jan;51(1):308-310. doi: 10.1161/STROKEAHA.119.027828. Epub 2019 Nov 11. PMID: 31707926.

17:  Shah S, Patel S, Paulraj S, Chaudhuri D. Association of Marijuana Use and Cardiovascular Disease: A Behavioral Risk Factor Surveillance System Data Analysis of 133,706 US Adults. Am J Med. 2021 May;134(5):614-620.e1. doi: 10.1016/j.amjmed.2020.10.019. Epub 2020 Nov 9. PMID: 33181103.

18:  Desai R, Fong HK, Shah K, Kaur VP, Savani S, Gangani K, Damarlapally N, Goyal H. Rising Trends in Hospitalizations for Cardiovascular Events among Young Cannabis Users (18-39 Years) without Other Substance Abuse. Medicina (Kaunas). 2019 Aug 5;55(8):438. doi: 10.3390/medicina55080438. PMID: 31387198; PMCID: PMC6723728.

Pharmacokinetics and Adverse Effects of Cannabis:

19:  Schlienz NJ, Spindle TR, Cone EJ, Herrmann ES, Bigelow GE, Mitchell JM, Flegel R, LoDico C, Vandrey R. Pharmacodynamic dose effects of oral cannabis ingestion in healthy adults who infrequently use cannabis. Drug Alcohol Depend. 2020 Mar 21;211:107969. doi: 10.1016/j.drugalcdep.2020.107969. Epub ahead of print. PMID: 32298998; PMCID: PMC8221366.

20: Spindle TR, Cone EJ, Goffi E, Weerts EM, Mitchell JM, Winecker RE, Bigelow GE, Flegel RR, Vandrey R. Pharmacodynamic effects of vaporized and oral cannabidiol (CBD) and vaporized CBD-dominant cannabis in infrequent cannabis users. Drug Alcohol Depend. 2020 Jun 1;211:107937. doi: 10.1016/j.drugalcdep.2020.107937. Epub 2020 Apr 1. PMID: 32247649; PMCID: PMC7414803.

21:  Spindle TR, Martin EL, Grabenauer M, Woodward T, Milburn MA, Vandrey R. Assessment of cognitive and psychomotor impairment, subjective effects, and blood THC concentrations following acute administration of oral and vaporized cannabis. J Psychopharmacol. 2021 Jul;35(7):786-803. doi: 10.1177/02698811211021583. Epub 2021 May 28. PMID: 34049452. 

22:  Spindle TR, Cone EJ, Schlienz NJ, Mitchell JM, Bigelow GE, Flegel R, Hayes E, Vandrey R. Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis: A Crossover Trial. JAMA Netw Open. 2018 Nov 2;1(7):e184841. doi: 10.1001/jamanetworkopen.2018.4841. Erratum in: JAMA Netw Open. 2018 Dec 7;1(8):e187241. PMID: 30646391; PMCID: PMC6324384.

Vaping and Pulmonary Toxicology:

23:  Meehan-Atrash J, Rahman I. Cannabis Vaping: Existing and Emerging Modalities, Chemistry, and Pulmonary Toxicology. Chem Res Toxicol. 2021 Oct 8. doi: 10.1021/acs.chemrestox.1c00290. Epub ahead of print. PMID: 34622654.

24:  Tehrani MW, Newmeyer MN, Rule AM, Prasse C. Characterizing the Chemical Landscape in Commercial E-Cigarette Liquids and Aerosols by Liquid Chromatography-High-Resolution Mass Spectrometry. Chem Res Toxicol. 2021 Oct 5. doi: 10.1021/acs.chemrestox.1c00253. Epub ahead of print. PMID: 34610237.

25:  McDaniel C, Mallampati SR, Wise A. Metals in Cannabis Vaporizer Aerosols: Sources, Possible Mechanisms, and Exposure Profiles. Chem Res Toxicol. 2021 Oct 27. doi: 10.1021/acs.chemrestox.1c00230. Epub ahead of print. PMID: 34705462.

Epidemiology:

26: Lim CCW, Sun T, Leung J, et al. Prevalence of Adolescent Cannabis Vaping: A Systematic Review and Meta-analysis of US and Canadian Studies. JAMA Pediatr. Published online October 25, 2021. doi:10.1001/jamapediatrics.2021.4102

Prevalence of cannabis vaping by adolescents has recently increased for lifetime use, use in the past 30 days and use in the past year.

Maternal Cannabis Use and Anxiety in Offspring:

Rompala G, Nomura Y, Hurd YL. Maternal cannabis use is associated with suppression of immune gene networks in placenta and increased anxiety phenotypes in offspring. Proc Natl Acad Sci U S A. 2021 Nov 23;118(47):e2106115118. doi: 10.1073/pnas.2106115118. PMID: 34782458.

LaSalle JM. Placenta keeps the score of maternal cannabis use and child anxiety. Proc Natl Acad Sci U S A. 2021 Nov 23;118(47):e2118394118. doi: 10.1073/pnas.2118394118. PMID: 34789581.

Graphics Credit: The graphic at the top of this post is from Shutterstock per their standard user agreement.

 

 

To All Of The Opioid Epidemic Deniers........

I encountered an absolutely stunning piece the other day about how there really was no opioid epidemic.  The author's various arguments all centered on the basic idea that law enforcement and other special interest groups spread the lie about opioid use being epidemic so that they could increase law enforcement measures and make it more difficult for chronic pain patients to get access to opioids.  There are a lot of these conspiracy theories going around. There are active posters on Twitter who continue to beat the drum that this is a heroin or fentanyl problem and not a problem with prescription opioids. The same group will suggest that the problem is now benzodiazepine prescriptions - maybe even gabapentinoids! They make the false claim that "anti-opioid zealots" want to stop opioids for chronic non-cancer pain, even if it means that some of those pain patients will commit suicide. They continue to post debunked information about how a trivial number of pain patients become addicted to opioids if they are properly prescribed.

Time for a lesson about the opioid epidemic and how it evolved from the land of 10,000 lakes - my home state of Minnesota.  The graphics I am posting here are all from the Minnesota Department of Health and the Minnesota Department of Human Services.  In some cases the opioid involved overdose mortality is broken down into specific categories and in other cases it is just an aggregate number.  The first graphics I am going to post is on the epidemiology of admissions for substance use treatment from two time intervals for comparison.

These maps are county by county density plots of the rate of admissions from a particular county comparing 2007 to 2017.  There are certainly limitations using administrative data but on the other hand it is the only data available and I would not be surprised if there was not some reporting obligation by licensed treatment programs to the state.  The most significant limitation on admissions data is that services in the US are rationed and there are never enough openings or finances to treat the people who need it.  Treatment programs also open and close. There is the question about whether all admissions are captured.

Given those limitations it is clear that the rate of admissions form Minnesota counties of residents being being treated for heroin use, methamphetamine use and intravenous drug use (IVDU) have all increased significantly from 2007 to 2017. In fact, the total number of IVDU admitted in 2017 was about the same for both heroin (N=5148) and methamphetamine (4843) users.  By comparison, in 2007 the number for IVDU were about 20% of the current numbers with heroin admissions at 1008 and methamphetamine admissions at 798.  In a separate report speedballing or the injection of methamphetamine and heroin is discussed but there are no numbers given on people who are using both.

The first lesson from admissions data is that the total number of residents using this compounds per county and the rate of use per county are both increasing. The geography of the spread is also of interest.  Minnesota has 54 counties and only 7 are considered metropolitan or urban counties.  The rest are considered rural.  Large blocks of these rural counties have increasing numbers of residents being treated for heroin, methamphetamine, and IVDU.  To me that is an epidemic.

 Additional data looking at the epidemic in Minnesota comes from reference 2.  It is interesting because it is a direct comparison of deaths occurring in rural versus metro or urban counties.  It also looks at the types of drugs involved in the overdoses.

As can be seen in the above graphs, opioid and heroin overdoses both increased over the 16 years of the study period. In the Metro sample, the baseline rate of opioid overdose deaths was 43 Metro and 11 Greater Minnesota in 2000 and by 2016 this had increase to 256 and 138 respectively.  In the case of heroin overdose deaths the baseline rate was 1 Metro and 1 Greater Minnesota in 2000 and by 2016 the increases were to 110 and 40 respectively.  The rate of increase in opioid and heroin deaths in Greater Minnesota may have been impacted by the greater rate of increase in stimulant use and associated deaths.  This may imply greater availability of stimulants across a wider population area than opioids - but overdose deaths is an obvious problems for all of the compounds listed on these graphs.  According to my arithmetic that is a 9 fold increase in the death rate due to opioid and heroin overdoses over 16 years.

The final consideration is how is it that so many people started using heroin and fentanyl?  Many of the epidemic deniers seem to be suggesting that it just happened that way.  It was totally unrelated to opioid prescriptions.  If a clinician like me tells them that I have talked to hundreds of opioid users and I have heard initial use of heroin from exactly one person - they suggest that I don't know what I am talking about.  That is where this compelling graphic about opioid prescriptions comes in showing about an 8-fold increase in opioid prescriptions in the USA over about the last two decades. It would place opioid overdose deaths as about the 13th leading causes of death in the state.  Once an addiction starts, the economics of drug use is that most people can get heroin for considerably less than they can buy prescription opioids on the street.  That and the general characteristics of addiction lead to higher risk use of intravenous heroin and a greater potential for overdose.

Even though every data set has it's limitations, the alternate hypotheses by the epidemic deniers need to be considered as alternate explanations.  Conspiracy theories about people scheming to prevent the treatment of chronic pain and the "war on drugs" don't make any sense. If either explanation were true it would have to explain the explosion in opioid prescriptions in the 21st century and everything that unfolded since.

It does not.

The only reasonable public policy must stop these overdoses and explode the associated myth that excessive opioid prescribing is necessary for the treatment of chronic non-cancer pain.



George Dawson, MD, DFAPA


References:

1:  DAANES SUD Detox and Admission Trends CY1995-CY2017.  Minnesota Department of Human Services, 2018.

2:  Drug Overdose Deaths among Minnesota Residents 2000-2016.  Minnesota Department of Health Injury and Violence Prevention Section, 2018. Link


Graphics:

All graphics are from public documents from the Minnesota Department of Health and Minnesota Department of Human Services.

A Report From The Minnesota Medical Cannabis Program

I have described the Minnesota Medical Cannabis Program in a previous post.  It is a unique program because it does not provide smokable cannabis for medical purposes.  All of the cannabis is in a form that is vaporized, edible, absorbed through the oral mucosa, or transcutaneously after application to the skin.  It is produced by two companies and made into products of varying amounts of  tetrahydrocannabinol (THC), cannabidiol (CBD) .  In the original matrix from the first post there appeared to be a total of about 11 products based on the THC and CBD ratios. For the purpose of this report the cannabis products were classified base on ratios of cannabinoids and route of administration according to the following table:

The program came out with a report on the experience of patients with chronic intractable pain using the program this week.  They produce frequent reports and this is the latest. Although it is not a scientific study of the associated issues of pain relief it is interesting because of a number of considerations not the least of which is what happens when a state starts to manage a CSA Schedule 1 drug on their own and come up with their own process for certification and use.

The report details the cohort of patients who were qualified on the basis of intractable pain according to the following definition:  “pain whose cause cannot be removed and, according to generally accepted medical practice, the full range of pain management modalities appropriate for this patient has been used without adequate result or with intolerable side effects.” (p 4).

The report focused on the results and side effects of 2245 patients certified by various practitioners for intractable pain between August 1, 2016 and December 31, 2016. It contains basic demographics of the patients and practitioners as well as a breakdown of the possible origins of their chronic pain.  All of these details are available in the original report and I encourage any interested reader to find the details there.  I am interested in the type of medical cannabis being used and the outcomes.

These details are fairly interesting from a descriptive standpoint. For example, just using the product definitions there is a distribution of how the products are purchased.  The following bar graph illustrates the distribution of purchased products by THC and CBD content:

 
The report gets into more specific details about the types of THC and CBD products in each category and the average ingestion of these products per day in milligrams (mg). I am reproducing the first of a 4 page table here that contains progressively fewer patients in each strata:

It is apparent that very high THC products that are inhaled or ingested predominate the product distribution.  Although the largest single group of patients were averaging 81.5 mg/day THC and 0.6 mg/day CBD the range is significant from 4.4 to 553.8 mg/day THC and 12.2 to 1,439.2 mg/day CBD.

Patient and treatment providers were asked to rate their degree of benefit from the medical cannabis program on a Likert scale where 1 = no benefit and 7 - great deal of benefit.  Using that system 61% of the patients rated their experience as a 6 or 7 compared with 43% of the healthcare professionals rating the patient benefit as a 6 or 7.  Specific benefits were rated and the top three included pain relief (56%), sleep improvement (10%), and reduction in pain medications and side effects (7%). 

An area of interest in the report is whether or not the patient is reducing the amounts of other pain medications used in response to the use of medical cannabis. This question is asked to the certifying health care professionals.  For this report, 586 responses of a total of 692 were used to determine that pain medications were reduced in 58% of the cases and not reduced in 48% of the cases.  221 reduced an opioid with 127/221 reducing the opioid by 50% or more.  In addition, 16 reduced a benzodiazepine and 128 reduced a pain medication "other than an opioid or benzodiazepine" - but benzodiazepines are not pain medications.  The full list of medications reduced or discontinued are available in Appendix E.  Minnesota does have a Prescription Monitoring Program for controlled substances making it possible to quantify and confirm all of this data rather than depending on survey results.

The section of the report that I found most interesting was the section on a standard group of 8 symptoms followed in this patient group for improvement or no improvement.  These symptoms are listed in the tables below.

The response options are on a standard analogue scale where 10 is the worst possible symptom and 0 is the symptom is not present.  The report listed the results of this scale applied to intractable pain patients as shown in the table below.

It is an interesting report in that it gives improvements in symptoms over 4 months as well as the percentage of patients a 30% improvement in symptoms at some point in the initial 4 months, the percentage of patients who had a 30% symptoms improvement in the 4 month follow-up period, and the percentage of patients who had the 30% symptoms improvement and maintained it for at least 4 months.  Only 11% of the pain patients maintained a 30% improvement in pain symptoms over the 4 month follow up despite higher ratings of initial pain relief.  The most significant improvements were in nausea and vomiting.

Side effects were reported in the final section with about 10% of patient reporting severe side effects.  These side effects included somnolence, sedation, headaches, dizziness, lightheadedness, confusion, fatigue, abdominal pain, mental fogginess, inability to concentrate, anxiety, panic attacks, and insomnia.  Physical side effects were reported roughly twice as often as mental side effects and most were in the mild to moderate range.  A typical metric found in clinical trials - medication discontinuation because of side effects was apparently not determined.  In a series of statements included in the report, one patient stopped because of a lack of efficacy and there was a suggestion that stopping could occur for that reason or financial reasons but the data was not clear.

Although the current report is focused on intractable pain a couple of things seems clear.  First, these reports are not scientific.  There are no comparison drugs or placebos.  Medical cannabis is added in many cases to a combination of existing opioid pain medications and benzodiazepines.  In a purely qualitative sense, they do show what products are preferred by customers and these products contain significant amounts of THC.  Second, in the case of the 8 symptom rating pain relief from medical cannabis appears to be modest at best.  A significant number of patients acknowledged severe side effects, but were these side effects of the same level of severity that might be seen in a clinical trial?  In those patients who replaced opioids or to a lesser extent benzodiazepines - was that because the initial medications were ineffective for pain or because cannabis has superior effects on pain?

The most interesting part of the data to me is that fact that medical cannabis is highly promoted for chronic pain.  That promotion was initially political - for the purpose of legalizing medical cannabis.  Currently it takes the form of cannabis saving people from opioid overdoses and this report makes an attempt to record reduced amounts of opioids use due to the cannabis. The problem is that it is all survey data.  There are no standardized doses of cannabis and no attempt to determine a placebo effect.  Physicians used to reading clinical trials need to ask themselves: Is a patient interested in using medical cannabis in Minnesota capable of answering the questions in an unbiased manner?  Will their interest/belief in medical cannabis influence survey results? And if that is true - what does it mean that medical cannabis ends up with such a poor result for pain relief over a period of 4 months?  I have concerns about the survey results based on my interviews with thousands of cannabis smokers.  Although I am seeing people with significant addiction problems, I don't see the side effect frequency of insomnia, anxiety, panic, and paranoia that I am used to hearing hearing about.  And in this group, I can't help but wonder how many of them have significant addictions? I also don't see a discussion of the fact that many opioid users commonly switch to cannabis when the opioid supply runs low or they make an attempt to stop using. There are potentially several mechanisms occurring in this population in addition to pain relief and side effects.

Another issue indirectly addressed by this report is what happens when you do an end run around the FDA?  I have certainly been a critic of the FDA and its regulatory processes, but in the end there is always a study available for public discussion.  That study typically has much more information content about drug efficacy and tolerability than the current Minnesota study because of the scientific design.  This report is the type of data that you get when that regulatory hurdle is ignored.

The direction and legacy of medical cannabis in Minnesota seems to be contingent on the status of recreational cannabis.  The program has been criticized for being too expensive compared with smokable cannabis.  If Minnesota legalizes recreational cannabis, that may be the preferred route by many of the people in this program. Questions about the efficacy of cannabis in intractable pain remain unanswered despite all of the details in this report.



George Dawson, MD, DFAPA


References:

1:  Minnesota Department of Health Office of Medical Cannabis.  Intractable Pain Patients in the Minnesota Medical Cannabis Program: Experience of Enrollees During the First Five Months. Report

2: Desrosiers NA, Ramaekers JG, Chauchard E, Gorelick DA, Huestis MA. Smoked cannabis' psychomotor and neurocognitive effects in occasional and frequent smokers. J Anal Toxicol. 2015 May;39(4):251-61. doi: 10.1093/jat/bkv012. Epub 2015 Mar 4. PubMed PMID: 25745105.


Graphics:

All tables excerpted from reference 1 as a public document with no copyright.

Minnesota's Abandonment Of Severely Mentally Ill - Nearly Complete

For years I have been documenting the systematic dismantling of the public mental health system in the state of Minnesota.  A chronic unanswered question is how the midwest's most liberal state has come up with such a horrible system.  The most obvious answer is that the system is being run by people who do not have a clue about the treatment of mental illnesses.  A Governor's Task Force, convened a year ago has not put a dent into the further systematic deterioration.  This 30 year race to the bottom in terms of deterioration is why I was not surprised at all by the latest piece of bad news.

The Minneapolis Star Tribune published a story three days ago that St. Joseph’s Medical Center in Brainerd Minnesota stopped accepting patients who were being treated on an involuntary basis under civil commitment.  They cite an increased length of stay and safety issues. Both of these are valid concerns with people committed for treatment of a mental illness.  The system of hospital reimbursement put in place in the 1980s encourages rationing and absurdly short length of stays in inpatient psychiatric units.  People who have undergone civil commitment generally have more difficult to stabilize mental illnesses compounded by a lack of recognition that they have a problem.  Some of them are also violent and aggressive and those behaviors are directly attributable to the mental illness.  The article refers to an incident where one of these patients threw a wooden chair at a nurse and the next day six voluntary patients requested discharge.  This is a relatively mild incident compared to what is possible in acute inpatient settings trying to care for people with the most severe forms of mental illness.  The most important aspect of treating violent and aggressive patients is having an environment of highly trained people to work with them.

The reality of the situation is reflected by the balance of both acute care and public psychiatric hospital beds.  There are 145 hospitals in the state of Minnesota and 125 have 24 hour emergency departments. Thirty two of these hospitals have psychiatric units.  These community hospitals have a total of  1,124 inpatient mental health beds statewide. Nine hundred sixty of these beds are for adults, and 164 for children and adolescents.  On the public side, there are 194 public beds for patients with severe mental illnesses who are committed.  Only committed patients can be admitted to these beds.  According to the Treatment Advocacy Center states need about 50 beds for 100,000 people.  Minnesota has 3.5 per 100,000 public beds and 22.8 per 100,000 beds in community hospitals.  Notice that in a comparison to psychiatric beds in OECD nations, the national average in the US is 22 beds per 100,000.  The United States ranks 29 out of 34 countries ranked in terms of fewest psychiatric beds.  Beds in public hospitals are not equivalent to beds in community hospitals and the newspaper report highlights the differences.  Like most states Minnesota continues to lose beds largely because of mismanagement at the level of state government and what has been an implicit initiative to shut down the state hospitals system.

The bed situation is compounded by a number of factors besides the lack of beds.  There is inadequate housing for people disabled by severe mental illness and inadequate resources to help them live independently.  The average person is expected to come in and see a psychiatrist for a discussion of medication and whether or not their acute symptoms are in remission.  Treatment for combined severe mental illness and substance use disorders is practically non-existent.  The inpatient crisis got worse when legislators passed a very poorly thought out law allowing incarcerated mentally ill patients to be transferred to remaining state hospital beds as a priority over committed patients waiting for transfer in community hospitals. This was an initiative to correct the statistic that Minnesota incarcerates 1.2 people with severe mental illness for every 1 person that it hospitalizes. 

All of the usual commentators are appear in the article - the Commissioner of Human Services and an advocate.  The reader is told that everyone is troubled by this development and wringing their hands.      

Well I'm not.  The entire sequence of events has been observable and is totally predictable.

This is a system that has been severely rationed nearly to the point of near extinction by Minnesota lawmakers and bureaucrats.  It has been interfered with by advocates and in some cases by very bad hiring decisions of people who were supposed to correct the problem.  The only thing we have to show for 30 years of hand-wringing is a a non-existent system of care that does not start to pull resources together until after a person has gone through a civil commitment hearing.  Psychiatrists have been marginalized in the process in favor of administrators who come up with one bad idea after the next.  Managed care systems seem to only recognize dangerousness as an admission criteria to inpatient psychiatric units.  The impact of that bias on commitment frequency, damage to the physician-patient alliance, and damage to the inpatient milieu is probably significant but nobody is interested in studying it.

From the article, the problem is clearly solvable.  There are an estimated 4,000 patients a year who need these services and only 194 beds available to them.  They cannot be humanely treated in community hospital acute care units.  They can also not be humanely treated in group homes designed to be surrogate state hospital beds.  They receive the least humane treatment in jail. The solution is not to blame community hospitals who cannot treat the problem.  One of the issues not mentioned in the article is that the state hospitals have been so decimated - they also cannot treat the problem.  There are probably three community hospitals in Minnesota who have adequate staffing and professional resources to address this problem.  It is conceivable that many more of the remaining 28 community hospitals with psychiatric units will adopt similar policies if they can.  The administrative measure of saying that they can't do this is really not a solution because they really can't provide the necessary care.  The state should know this from their failed initiative to provide smaller local units for committed patients.  That initiative failed for the same reason that St. Joseph's Medical Center no longer accepts committed patients.  They cannot provide adequate care for severe mental illnesses especially when aggression and violence is involved. 

I have posted the solutions in the past and they are obvious. Today I just have three:

1.  Build facilities necessary for the humane treatment of people with severe mental illnesses. Staff these facilities adequately and develop continuity of care with local facilities  when patients are ready to be discharged.  Build these facilities as state-of-the-art facilities in metropolitan areas and not rural areas.  The time is past when people were sent away to the country with mental illness.  Modern mental hospitals need easy access to advanced diagnostic and treatment equipment as well as expertise that is only concentrated in large cities.

2.  Immediately stop arbitrary transfers from county jails to state hospitals, unless the incarcerated patients have been assessed by psychiatrists who agree that a state hospital setting is the best place for them to be. 

3.  Get out of the way of the people who were trained to work there and run them - psychiatrists, psychiatric nurses, and social workers.     


George Dawson, MD, DFAPA



References:

1:  Chris Serres. Brainerd hospital stops admitting patients with severe mental illnesses, citing state bottlenecks: Brainerd decision alarms officials, mental health advocates.  StarTribune November 1, 2017.

Supplementary 1: The image used for this post is of Dexter Asylum attributed to Lawrence E. Tilley [Public domain], via Wikimedia Commons. The original image was Photoshopped with a graphic pen filter.

Minnesota State Hospitals Need To Be Managed To Minimize Aggression

When is that going to happen?  How much time will it take?

According to new Minneapolis StarTribune article by Chris Serres the situation at the state's second largest state mental hospital has worsened to the point that it has caught the attention of regulators from the Centers for Medicare and Medicaid Services (CMS).  CMS put the state on notice that it at risk for losing $3.5 million in federal funding if they don't correct patient safety issues at the hospital by March 5.  The hospital is described as having experienced a "surge" in violence and aggression with associated injuries since the state Legislature passed a 48 hour rule mandating that jail inmates identified in as having mental health problems be directly admitted to Anoka Regional Metro Regional Treatment Center.  The jail inmates were given priority status over any civilly committed persons in community hospitals.  The article points out that there have been 38 aggression-related injuries involving 24 patients in 2013 and 48 aggression-related injuries involving 28 patients in 2014.  A direct assault on a staff person is described in the article.

I have a few suggestions for legislators, bureaucrats, and citizens of the State of Minnesota on how this can be resolved as soon as possible.  Let me preface this by saying that I have no special knowledge about what is happening at AMRTC apart from what is in the Seres article.  I am one of a handful of psychiatrists in the state who have worked in these settings and am qualified to comment on these issues.  I have a formal request in to the Department of Human Services to review a copy of the CMS report because I cannot find it on the Internet, the DHS web site, the CMS web site, or the office of the Inspector General.  My suggestions follow:

1.  Rescind the 48 hour rule to send unscreened jail inmates to AMRTC immediately:

Any psychiatrist could have provided consultation at the time on the reasons why this will not work, but the biggest reason is that psychiatric symptoms or even a psychiatric diagnosis does not necessarily mean that a psychiatric hospital is the best place for the patient.  Patients admitted to inpatient units are screened for psychiatric disorders and not on the basis of alleged criminal behavior.  In terms of logistics within the state hospital system patients who are dangerously aggressive have generally been committed as mentally ill and dangerous and generally sent to the Security Hospital at St. Peter. It is fairly common to encounter sociopathic and psychopathic patients in community psychiatric hospital.  It soon becomes obvious that apart from the personality disorder and the associated aggressive and inappropriate behaviors that there are no treatable problems.  This patients often become aggressive toward staff or exploit other patients and are immediately discharged from inpatient settings.  Inpatient psychiatric settings are not the correct place to address antisocial persons or in many cases antisocial persons even with a psychiatric diagnosis because of their danger to staff and other patients.

There is the associated issue of there being a strong incentive to send patients who may be difficult to work with but who are not psychiatrically ill to the hospital just because the rule exists.  Transfers like that always occur to psychiatric units if someone has carte blanche for admitting people and psychiatrists don't screen them.  Aggression can be minimized only when the entire unit is managed with a safety focus and that includes screening anyone with aggression who is admitted.

2.  Reanalyze the culture at AMRTC with an emphasis on staff safety:

It is really impossible to run a psychiatric hospital if the staff responsible for the care of the patients are threatened and/or burned out.  The article lead me to believe that both things are happening and compounded by the fact that hospital staff is being mandated to work extra hours.  In the initial stages that may require the presence of additional security staff.  I have seen similar situations where the level of antisocial and aggressive behavior on an inpatient unit became overwhelming resulting in a riot situation that required police intervention.  Some attempts at splitting up large state hospitals to smaller local facilities in the state have resulted in similar incidents.

A critical element of the culture that has come to light in recent years is the fact that there appears  to be a top down initiative in the management of state facilities.  Aggressive behavior has been an ongoing problem at state facilities.  Psychiatric input into that problem is not clear.  It is clear that in at least some cases, programs were implemented by management staff who have no expertise in managing aggression and violence in inpatient settings.

Like most psychiatric problems aggression is a treatable problem, but it has to be addressed directly.  It is best address in an environment that identifies it as a treatable problem immediately rather than an untreatable characteristic or one that has a root cause that must be addressed first.  There is not better way to treat aggression than identifying it as a primary problem that is incompatible with a therapeutic environment.

3.  Take a serious look at how inpatient psychiatric facilities are supposed to run:

State governments and managed care systems have both had deleterious effects on psychiatric care on inpatient units.  These management systems have a lot in common in determining what happens on the inpatient side.  The absolute worst case scenario is containment only.  People are basically held usually based on the premise that they are dangerous in some way.  Dangerous in this context generally means at risk for aggressive or suicidal behavior.  They are discharged when that dangerousness passes either by the administration of medication, the person resolving a crisis in their life, or until they convince staff that they are no longer dangerous.  This approach to inpatient care seriously dumbs down psychiatry, treats patients like widgets on an assembly line rather than individuals, and creates the illusion that anyone can do inpatient psychiatry.  Dangerousness after all is not a psychiatric diagnosis.  It also creates the illusion that an inpatient psychiatric unit is tantamount to incarceration or jail.  It leads to a correctional atmosphere in what should be a therapeutic hospital environment.  In a correctional atmosphere, the staff seem to be policing the patients rather than working with them on common goals.  This attitude has also led at least one state official to suggest that psychiatrists in this environment are optional.  A local mental health advocate has said the same thing.  If that is true - why is it that the state of aggression in this hospital has gotten to the point that the union representative in the article is suggesting that the institution is being run by the patients?


4.  Rexamine the funding and rationing of psychiatric care in Minnesota:

The article mentions a backlog of patients at AMRTC due to the fact that many of them cannot be discharged.  This has been a problem in Minnesota for as long as I can remember.  Patients are committed in acute care hospitals and end up waiting there too long for transfer to AMRTC.  Once they get to AMRTC they meet criteria for discharge and there is nowhere for them to go, largely because they still have chronic psychiatric symptoms that are socially unacceptable or that preclude their safety in the community.  Anyone who is covered by standard health insurance is no longer covered if they are committed to a state hospital.  People can end up undergoing civil commitment because their insurance companies do not provide the level of care that they require in the community.  The entire system of fragmented and rationed care can be viewed as a way for the government and managed care companies to minimize their funding of necessary care, especially in patients with complex problems.  A basic option here is to expand care based on treatment parameters rather than rationing criteria.  Develop treatment based and quality goals rather than rationing goals that provide minimal and frequently inadequate care.  One of the basic principles of community psychiatry is that the funding needs to follow the patient.  If patients are committed and transferred to state hospitals and they are on private insurance plans - those plans need to have continued financial responsibility for those patients.  If a patient with private insurance needs treatment in jail, those services need to be covered by private insurance rather than being shifted to law enforcement.  The entire system of rationing and cost shifting is also a strong incentive to transfer any mentally ill inmate to AMRTC because law enforcement is covering the cost of medical and psychiatric care.  

5.  Facilities for mentally ill inmates that recognizes their vulnerability:

One of the concerns that I have always had for any inmate with a mental illness, is that they are generally much more vulnerable to any form of manipulation or intimidation by career criminals and sociopaths.  The second concern is that many patients with mental illnesses end up in jail because they are symptomatic and/or confused and end up trespassing or in dangerous situations.  They are often not able to follow instructions by the police.  Some Minnesota counties have mechanisms to safeguard this population.  One of them is having them screened in jail for competency to proceed to trial by qualified psychiatrists and psychologists.  The resolution in those cases is that the patient is transferred to an inpatient psychiatric unit for stabilization and the pending legal charges are usually dropped.  They can frequently be discharged from the acute care hospital without transfer to a state hospital.  In cases where this does not occur, every effort should be made to segregate the vulnerable inmates who are mentally ill from the general jail or prison population.  The ideal situation would allow for more programming to prevent some of the common correctional problems like isolation that lead to increasing symptoms.    

These are a few suggestions to resolve the current problems with aggression noted to exist at at AMRTC.  Over the years that I have been following this story, there is also the question of what is really going on in these facilities?  Why are these problems so difficult to resolve when acute care hospitals have fewer problems and are dealing with more acutely agitated and frequently intoxicated individuals.  Why does the bureaucracy think they can resolve these problems without using psychiatric expertise or at least methods that have been proven to work in psychiatric institutions?  And what about the alternate and seemingly more permissive methods of dealing with aggression?  Can anyone come out with a comment on whether or not they have succeeded or failed?  There is a lack of transparency when it comes to seeking the answers to these questions.

These are all important questions that need to be answered.  I hope to receive the CMS report and make further comments on this situation.  There is a lack of transparency about what the state is doing to resolve this situation.  When the state assumes the care of mentally ill individuals - people who by definition are vulnerable adults, transparency is important to assure their adequate care and reassure the families of all of the patients admitted to this hospital.


George Dawson, MD, DFAPA




References:


1:  Chris Serres.  State psychiatric hospital in Anoka threatened with loss of federal funding.  Minneapolis StarTribune January 4, 2016.


Attribution:

The jail photograph at the top of this blog is by Andrew Bardwell from Cleveland, Ohio, USA (Jail Cell) [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons.  The URL is: https://commons.wikimedia.org/wiki/File%3ACela.jpg