Kentucky Doc Summer 2015

summer 2015 • volume 7 • issue 2 Ralph Alvarado, M.D. CITIZEN LEGISLATOR A passion for the practice of medicine and his quest to improve politically the practice life of physiciansThe Heroin Debate: Medical WinchesterBill Marijuana Clark Regional Read KY Doc Digital on Mobile Devices

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doc4CoKnetnetnutcsky| Su•mSmumemr e2r0210515 FROMTHEEDITORKMA Community Connector Program 05 Robert P. Granacher Jr., M.D., misunderstandings physicians may have when theyby David Bensema, M.D. M.B.A., Editor-in-Chief, Kentucky interpret this useful data derivation. Doc Magazine Please do not forget that LMS and Kentucky Doc have Welcome to the summer edition of underway their annual writing contest for practicing Kentucky Doc Magazine, the medical physicians, residents, and medical students. Each of magazine for physicians, edited and three potential winners will received $1000.00. If you written by physicians. Our cartoonist has started this plan to submit an essay, time is drawing near, as the issue with a cartoon which is aligned with an interesting winners will be announced in the upcoming fall edition pro-con contrast of “medical marijuana.” Danesh of Kentucky Doc. Also, letters to the editor may be Mazloomdoost, M.D. and Lowell Quenemoen, M.D. submitted at [email protected] debate the pros and cons of medical “weed”. or to Sampler Publications, 121 Prosperous Place, Suite KMA president, David Bensema, M.D. shares with 5B, Lexington, KY 40509. us an overview of the KMA Community Connector Program and discusses recent physician graduates of Robert P. Granacher Jr., this worthwhile KMA offering. He reveals how they M.D., M.B.A. then are involved in their respective communities after Editor-in-Chief the physician completes the training sequence. LowellPROFILE 06 Quenemoen, M.D. highlights Winchester and the Clark 08 Regional Medical Center, describing the integrationWinchester and the Clark Regional of this medical center’s services into the WinchesterMedical Center community, and the future plan to add a 45,000 squareby Lowell Quenemoen, M.D. foot service structure.Ralph Alvarado, M.D., Citizen Legislatorby Robert F. Granacher Jr., M.D., M.B.A.PHYSICIAN HEALTH & WELL BEING 10 Bob Granacher, M.D. portrays Ralph Alvarado, M.D. as our featured physician this edition. This physician-Keeping Perspective on Life’s Priorities statesman, in his dual roles of internist-pediatricianby John A. Patterson, M.D., MSPH, FAAFP and Kentucky state senator, has become the “go to” guy in the senate to understand and introduce medicalPROFILE IN COMPASSION 12 legislation. John Patterson, M.D. has contributed 14 suggestions to assist physicians in keeping a perspectiveCompassion is What Sustains Me: Carol Cottrill on life’s priorities while also providing care to theirby John A. Patterson, M.D., MSPH, FAAFP patients. Dr. Patterson further relates a ProfileThe Heroin Bill and Public Health in Compassion highlighting the benevolent andby Rice C. Leach, M.D., President, compassionate contributions of Carol Cottrill, M.D.Lexington Medical Society to the patients she has treated in the University of Kentucky Pediatric ICU.COMMUNITY NEWS 16 Current LMS President, Rice Leach, M.D. outlines his perspective on Kentucky Senate Bill 192, the “HeroinMAKING HISTORY 20 Bill.” He shares with us a public health model useful for operating a needle exchange program and alsoRobert Edwards and the first‘test tube baby’ methods for referring heroin addicts into public healthby Frank Kourt, Staff Writer department outreach systems.Medical Marijuana Debate 22 Last but not least, Tuyen Tran, M.D. educates us on the 23 standardized mortality ratio (SMR) and the commonPROSby Lowell Quenemoen, M.D.CONSby Danesh Mazloomdoost, M.D.Standardized Mortality Ratio (SMR) 24 StaffCommon Misunderstandingsby Tuyen Tran, M.D. Mailed to 100% of physicians licensed in Fayette County. John Brokamp: Mailed to 75% of doctor office managers & other decision makers in Fayette County Practices Publisher LIFESTYLE SECTION Janet Roy: 26 For advertising rates and to find out how to get your article published, please callHOUSE CALLS Director of Creative Services 859.225.4466 Kim Blackburn:TRAVEL 28 Media kits available for download at www.samplerpublications.com [email protected] Sales RepresentativeIreland’s Beautiful Dingle Peninsula Sampler Publications John Hoffeld:by Cory Hanson 121 Prosperous Place, Suite 5B Lexington, KY 40509 Sales Representative BUSINESS SECTION 30 © Copyright Kentucky Doc Magazine 2015. All rights reserved. AnyThe Difference Between a Business reproduction of the material in this magazine in whole or in part withoutand a Revenue Generation Model written prior consent is prohibited. Articles and other material in this magazine are not necessarily the views of Kentucky Doc Magazine. Kentucky Doc Magazine reserves the right to publish and edit, or not publish any material that is sent. Kentucky Doc Magazine will not knowingly publish any advertisement which is illegal or misleading to its readers. Kentucky Doc is a proud product of Sampler publications, Inc. www.samplerpublications.com

KMA Community docSummer 2015 • Kentucky 5Connector Program By David Bensema, engrained within our communities that they and on the Board of Directors of the Hope M.D. can only be changed through a united effort on Center; and When physicians talk, people multiple fronts. The more the public is aware • Gordon T. Tobin, II, MD, of Louisville, listen. The high esteem in of these initiatives, the greater the success will serves on the board of the Center for which physicians are held be. Interfaith Relations-Festival of Faiths. makes their leadership in That’s why we at KMA are excited about The KMA Community Connector Programthe community integral to addressing the the work of the nine 2014 graduates of the is a great way for physicians to enhance theirdisconnect between community leaders Community Connector Leadership Program. innate leadership abilities and develop a betterand sound health policy. The Kentucky Here are a few examples: understanding of policy, process, and gover-Medical Association’s Community Connector • Divya B. Cantor, MD, of Louisville, helped nance. To learn more, check out the informa-Leadership Program (CCLP) aims to help tion at www.kyma.org under the PhysicianKentucky physicians close that gap in their to educate legislators on clinical testing on Resources tab, or contact KMA staff membercommunities. newborns and testing for breast and ovar- Laura Hartz at 502-814-1386 or [email protected] in 2013, the KMA Community ian cancer; org and start your journey to leadership.Connector program is designed to make physi- • John A. Patterson, MD, of Lexington, Eighteen physicians from around Kentucky arecian leaders even better leaders. The program writes a monthly column for Health & participating in the 2015 KMA Communityprovides training to enhance community lead- Wellness Magazine, a health magazine in Connector Leadership Program. These physi-ership to ensure the voice of medicine is heard Lexington; cian leaders are involved in their communities,when decisions regarding health care are made. • Vaughn W. Payne, MD, of Louisville, was whether it be local governments, charities, orAs the 2014-2015 president of KMA, I am a speaker at the Heart Truth for Women other endeavors, as well as leadership rolesproud to have been a member of the inaugural program in southeastern Kentucky; and within medicine. They’ll be recognized at theclass of the CCLP in 2014. • Fred A. Williams, Jr., MD, of Louisville, 2015 KMA Annual Meeting August 28-31 atHealth care is undergoing tremendous trans- has given several health-related presenta- the Hyatt Regency Louisville.formation and many of the decisions affecting tions to students. The KMA Annual Meeting also will featurethat transformation are being made by people In addition to participation in a public educa- an all-day Kentucky Physician Leadershipoutside of medicine. Physicians can impact tion activity, physician leaders are involved in Academy with guest speaker Kevin Pho, MD,these changes at the local level, but they must a leadership role within and outside medicine a practicing board-certified internal medicinebe connected with local civic, business, and in their communities. Here is how some physician and a health care social media leaderpolitical leaders on issues related to medical members of the 2014 class of Community since 2004. He founded the popular website,care. The CCLP helps physicians make those Connectors are involved: “KevinMD.com,” and is co-author of the book,connections and become more involved in • Jiapeng Huang, MD, of Louisville, is chair “Establishing, Managing, and Protecting Yourtheir local communities. It provides a support of the Department of Anesthesiology at Online Reputation: A Social Media Guide forsystem and network to make Kentucky – and KYOneHealth and serves on the Board of Physicians and Medical Practices.”local communities – a healthier and better Directors of the Kentucky Chinese School; Completing the Kentucky Physicianplace to live. • Rice C. Leach, MD, of Lexington, is Leadership Academy is a requirement forGood individual health is vital to the health CEO of the Lexington-Fayette County participants in the Community Connectorof our communities. Physicians play a unique Health Department and is president of the Leadership Program. The ultimate goal is cre-and important role in achieving that goal. Poor Lexington Medical Society; ating a statewide network of physician leaders.health behaviors and related problems are so • Daneesh Mazloomdoost, MD, of That’s just what the doctor ordered. Lexington, serves on the Lexington Medical Society Administrative CouncilCardinal Hill“Cardinal Hill Home Care is an extension of the quality care offered by Cardinal Hill Rehabilitation Hospital” Serving Fayette, Franklin, Jessamine, Madison and Woodford Counties (859) 367-7148

doc6 Kentucky • Summer 2015Profile Winchester and the Clark Regional Medical Center By Lowell Quenemoen CRMC is approved for 79 beds and pro- Health with 5 rotating physicians along with M.D. vides essential services including Emergency experienced nurses, technicians and staff. Winchester is the county Care, Diagnostic Imaging, Surgery, Critical Current wait time averages 21 minutes with seat of Clark County named Care and Rehabilitation. Women’s Services average Within the ER tele-neurology is now for George Rogers Clark has been expanding with additional Ob/ available for early stroke diagnosis. and formed from por- Gyn coverage and over 700 deliveries this Future plans include the addition of anothertions of Fayette and Bourbon Counties, past year. CRMC CEO, Cherie Sibley, states 45,000 square foot addition which willparts of the original Virginia Land Grant. that two other areas cardiology and oncol- mirror the current Medical Plaza BuildingWinchester was founded in 1792 and cur- ogy are also enlarging. completed in 2012. This will provide furtherrently has a population close to 18,400 In cardiology two local cardiologists, clinical space as well as consolidating otherpeople with a county population of 35,620. Richard Dinardo and Charles Salters pro- hospital departments and services currentlyWinchester’s proximity to Lexington means vide diagnostics and care with invasive located off campus.that a significant number commute to work cardiology (caths and stents) performed Katy Hedge, Director of Marketing, alsoeach day and use Lexington services as well in Lexington at St. Joseph’s and UK. Dr. pointed out the acquisition of a mobileas medical services. Salters notes that chest pain and suspected clinical unit which will service outreachWithin the county, medical services are coronary insufficiencies can be monitored in screenings and possibly clinical services on aprovided by a number of primary care phy- Winchester but protocol mandates that any scheduled basis in some of the more remotesicians, nurse practitioners and physician s/t wave elevations on EKG prompts emer- rural areas.assistants as well as local subspecialists and gent transfer to Lexington. Cardiac rhythm Inpatient mental health and substancevisiting subspecialists serving outreach clin- disturbances are monitored locally with abuse/detoxification are available thru a sis-ics. More than 100 providers are included in-hospital monitoring, followed by Holter ter Life Point facility, the Bourbon Countyon the local hospital roster. Public health monitoring or longer duration event moni- Community Hospital’s affiliated Stonerissues are covered by a large county health tors. Pacemaker/defibrillator placements are Creek Behavioral Health Center.program which includes both the health done in Lexington. Public health services are provided by thedepartment as well as home health services, Clark County Health Department whichThe medical center for the community is Future plans include includes the health department as well asClark Regional Medical Center, a new facil- the addition of home health services and is directed by A.ity completed in 2012 and part of the Life Scott Lockard. Unlike traditional medicalPoint Health Group. Eight other Kentucky another 45,000 square services which focus on the health of thehospitals are part of Life Point which is foot addition which individual patient these services are directedheadquartered in Brentwood, Tennessee. will mirror the current at the health and quality of life of the com-These include Versailles, Paris, Georgetown, munity as a whole. The State Department ofMayfield, Somerset, Russellville, Maysville Medical Plaza Building Health which oversees local health depart-and Lebanon. The local hospital was estab- completed in 2012 ments is part of the Cabinet of Health andlished in 1917 and was acquired in 2010 by Human Services. Local health departmentsLife Point as a for-profit facility. In 2011 Life In addition the new medical building are one of three types: Independent, such asPoint joint ventured with Duke University contains a 6 bed infusion suite where IV Fayette, District which serve multiple coun-to form Duke Life Point, a service organiza- chemotherapy can be provided in a local ties or Single County where Clark Countytion providing advanced academic medi- community setting reducing travel time and falls.cine from non-profit Duke and operations discomfort for patients. The range of services provided includestrengths and capital from Life Point. As a In the ER emphasis has been placed on broad classes such as physical environmentnational presence Life Point now is affili- prompt efficient care provided by Team (air and water quality), social and economicated with 64 hospitals and Duke Life Point factors effecting the basics of survival andwith 11. The joint venture mirrors other clinical elements which involve the wholename brand facilities such as Mayo Clinic, community. In the first group issues of pol-M.D. Anderson and Sloan Kettering who areinvolved in similar partnerships.

docSummer 2015 • Kentucky 7lution, wells, sewage systems and inspections New pressures on the community health cuts and with the Affordable Care Act hasof food and health facilities fall. In the sec- system have included marked increases in seen further cuts in federal funds. To makeond are disaster preparedness and response, HIV and Hepatitis C as evidenced in rural up deficits local health taxes have beenhousing support and food assistance for Indiana and attributed to shared needles increased. Specific services are now beingfamilies. In the third are included specific in IV drug users. This was addressed in billed directly to Medicare, Medicaid, VAhealth screenings, vaccination programs, Kentucky with Senate Bill 192 funding and to private insurances. Also more privatecontagious infectious disease monitoring, needle exchange and now awaiting local and federal grants are being sought.family planning services and the HANDS approvals.program providing guidance and care for As with much of medicine there has beenfamilies with prenatal needs up to two year a major shift in financing in public health.olds. Mr. Lockard has noted 13 recent budget

doc8 Kentucky • Summer 2015 Ralph Alvarado, M.D., Citizen LegislatorBy Robert F. Granacher of Directors of St. Joseph Healthcare. Dr. offering him a place, and he chose that posi-Jr., M.D. M.B.A. Alvarado was a physician representative, and tion over the one from UCLA. while he was very interested in politics at the time, he had not yet been elected to office. After completing medical school, he decided His energy and passion for the practice of he needed a different perspective on medi- medicine and the attempts to improve the cine. His roommate’s girlfriend suggested practice life of physicians were immediately that he look at the University of Kentucky apparent during our interactions. His energy Medicine-Pediatrics program (her father Stephen Hawking famously said, “Science is not only was born in Lexington.) Ralph a discipline of reason, got a “gut feeling” about Kentucky but also, one of romance when he visited Lexington forand passion.” When one first meets Ralph interviews. He matched at theAlvarado, M.D., he or she is University of Kentucky, and thestruck by his passion for the prac- rest is history. He and his wife,tice of medicine and his quest to who is a practicing occupational therapist, had their first childDr. Alvarado is a pediatrician-improve politically the practiceinternal medicine specialistlife of physicians.I met with Dr. Alvarado recently practicing in Winchester, Kentuckyin the physician’s lounge at St. with hospitalization privileges at the end of his residency. Dr.Joseph East in Lexington. I Alvarado received financiallearned that he was born and in Lexington at St. Joseph East. assistance from Clark Memorialgrew up in Pacifica, California, He is currently a member of the Hospital the last year of his resi-near San Francisco in the Bay Kentucky Senate, and is one dency in 1998, and he entered aarea. He and his family later solo practice in Winchester. Hemoved to the San Jose area of hired an APRN after his firstCalifornia. After finishing high year and has been the managerschool, he noted that San Jose of only three physicians in the of his practice since. In 2001, hewas drastically changing. It obtained a new partner, and theywas morphing from farming to Kentucky Legislature. now have a practice with threehigh-tech. His interest and skill physicians, three nurse practitio-in science were fostered by the ners, and one physical therapist-environment in which he found nurse practitioner. In 2002, hehimself as a high school student. and pursuit of goals is infectious to those moved his admitting privileges to St. JosephDr. Alvarado is a pediatrician-internal around him. East due to the superiority of neonatal ser-medicine specialist practicing in Winchester, Ralph obtained much of his political acu- vices offered there. His partners have a satel-Kentucky with hospitalization privileges in men from listening to stories from his father lite office at Hamburg in Lexington.Lexington at St. Joseph East. He is currently about the local politics he pursued in his In 1797, Thomas Jefferson wrote to A.a member of the Kentucky Senate, and is native country of Costa Rica. His father Campbell that legislators should be “notone of only three physicians in the Kentucky left Costa Rica for the United States in office-hunters, but farmers whose interestsLegislature. He is the first Hispanic per- 1963 and was sponsored by a University of are entirely agricultural. Such men are theson to become a member of the Kentucky California at Berkley entomologist to come true representatives of the great AmericanLegislature. to this country. Dr. Alvarado’s mother is a interest and are alone to be relied on forI had the privilege of first meeting Dr. native of Argentina, and thus, Dr. Alvarado expressing the proper American sentiments.”Alvarado when we both served on the Board has Central American and South American While farming clearly is not the principle occupation of citizens of the United States cultural heritage. After high school, presently, it is clear that Jefferson believed he attended col- that the best political representation for ITS TIME, NOW! lege at Loma Linda citizens was that of the non-career politi- University and cian. Dr. Alvarado follows this admonition completed college and was called to politics by the medical in three years. By tort reform bills, which came up in the 2003 then, he had decided Kentucky Legislature. He felt he needed to to attend medical be more involved in the political process as school. One hour a physician in order to make change. The after receiving his Clark County Republican chairperson invit- notice of acceptance ed him to get involved in the local political to UCLA Medical process. He ran for the Kentucky House in School, Dr. Alvarado 2004 and narrowly lost. He reran in 2006 received a call from and lost badly at the end of President Bush’s the dean of the med- term. He was a bit amazed at the challenges ical school at Loma of the process when signs were placed onwww.medicalbariatrics.com Photo by Earlane Cox Linda University his lawn referring him as the “N”-word.

docSummer 2015 • Kentucky 9This caused him to develop cold feet for for physicians. He now feels himself fully focus for his next Kentucky Senate term,politics for a period, until he was asked to prepped for the next term in the Senate. He he told me it would be the Maintenancerun for the Senate in 2010. He and his wife has learned how his leadership operates, of Certification Bill that he hopes to bringlooked for counsel within their faith, and he and he feels that his experience was very forth, as he sees physicians being at risk ofdecided to run. He won the primary, but in much like his first year of residency, which having their Kentucky medical licensurethe general election, he ran out of T.V. adver- was about learning how the processes in tied to whether or not they are completingtising money. He lost that election to R.J. the hospital worked in order to improve the maintenance of certification. His goal is toPalmer, a Democrat. He was asked to run efficiency of his educational experience and forestall this nexus through the legislativeagain in 2012. care of patients. process.His greatest challenge came prior to winning I asked this physician citizen legislator how Overall, Dr. Alvarado presents a remarkablehis first election. His wife was diagnosed he maintains balance in his life. Ralph is so picture of a family man of faith, as a passion-with breast cancer, and she underwent imbued with energy and passion that it begs ate physician providing the best of pediatricreconstructive surgery and chemotherapy. the question of whether he can balance as and internal medical care to his patients,They both met the challenge, and he also many plates as he appears to be doing. He while improving the political health of phy-won his current position in the Kentucky has become very supportive of his wife and sicians in Kentucky through his efforts inSenate. her advocacy for all cancer, and particu-As a freshman senator, he has distinguished larly breast cancer, in women. He has great our state legislature.himself as the first Hispanic person to serve physician partners in his medical practicein either House of the Kentucky legislature. (one is a Republican, and the other is aEvidence of his political skills occurred Democrat). When he is in the legisla-when he attended a caucus where Medicaid tive session, his partners cover for him,insurance representatives were the speakers. and then he covers their nursing homeHe publically debated with these persons, patients on weekends when he returnsand the room exploded in applause for his from Frankfort. He also has foundskilled arguments. As a result, he was asked ways to assist himself financially thatto be the point on Senate Bill-6. He also do not require the continuous callspoke in favor of Senate Bill-4 (the Informed demands and structure of medicalConsent Bill). Dr. Alvarado has become the practice. For instance, he is the statego-to-guy in the Senate on medical issues. medical director of the new MedicareOne of his future political goals is to Advantage plans. He is still practicingdevelop a plan wherein the governor will be three clinic days weekly, and he makesrequired to choose nominees presented by hospital rounds at St. Joseph East. Hethe Kentucky Medical Association, to sit on attends rounds in the nursing home hethe Kentucky Board of Medical Licensure. covers on Wednesdays and Saturdays.(Currently, the governor can select entirely He has had to reduce time demandsphysicians not selected by the Kentucky somewhat. For instance, when he wasmedical profession to serve on the board elected to the Senate, he had to resignfor the KBML if he chooses.) He also plans himself from the Kentuckyto push for SB-83, which will require peer Medical Association Boardreview protection of physicians practicing of Trustees. When Iin hospitals. In addition, he will be working asked him what heon SB-87, which is the Fair Contracting Bill intended to have as his majorDr. Alvarado has become the go-to-guy in theSenate on medical issues.

doc10 Kentucky • Summer 2015Physician Health and Well Being Keeping Perspective on Life’s Priorities By John A. Patterson Clear signs of stress she recognizes in herself them to begin this process as early as pos- M.D., MSPH, FAAFP include sleep loss and low energy. In addi- sible in their medical education and medical Tom Broster has practiced tion, her wife picks up on such things as facial practice. Finding an author or particular book for 28 years as part of Central expression and a lack of personal presence in that reminds physicians of the meaning of Kentucky Anesthesia, a pri- relationship. As newly-weds, she is trying to their work is helpful. She frequently re-reads vate anesthesiology group work out a balance between being a conscien- the tiny chapters of physician Rachel Remen’sat Baptist Health Lexington. As president of tious academic physician and being present two books- Kitchen Table Wisdom and Mythe group since 2001, he describes his busi- in her marital relationship at home. She really Grandfather’s Blessings. They help us remem-ness and administrative responsibilities as the experiences the stress-reducing benefit of regu- ber the reason we went into medicine and togreatest source of his stress- not his patient care lar exercise 5 days most weeks and wishes she cultivate a sense of gratitude for the opportu-responsibilities. could work it in every day.. nity we have as physicians to do meaningfulHe knows he is experiencing stress when he She wants to do more in the area of prayer work.sleeps poorly, feels tired and fatigued and when and meditation, which she believes help her About the Authorhe loses his temper. In especially stressful keep life’s priorities in proper perspective. Her Dr Patterson is past president of the Kentuckytimes, he has felt anxious, frustrated, worried favorite yoga class was one that stressed center- Academy of Family Physicians and is boardand fearful about the future. When he experi- ing and contemplation rather than exercise. certified in family medicine and integrativeences these signs of stress, he knows it is time She often turns off her phone while walking holistic medicine. He is on the family practiceto talk with physician colleagues, friends, the dog in the morning and adopts a prayerful, faculty at the University of Kentucky College ofneighbors and his wife to get another perspec- contemplative, grateful relationship to every- Medicine and the University of Louisville Schooltive or reassurance on issues that are creating thing around her. of Medicine. He operates the Mind Body Studiohis stress. Playing golf and getting regular exer- She advises medical students and residents in Lexington, specializing in stress-related chroniccise help. Swimming laps helps clear his mind to keep life in balance, be truly present in disease and burnout prevention for helping profes-and helps him relax. Family and church help. their limited time with family and friends, sionals. He can be reached through his website atHe has two sons currently in medi- get physical exercise and custom design their www.mindbodystudio.orgcal school at UK. His advice for own unique self-care model. She encouragesthem and for physician colleaguesregarding self-care, stress manage-ment and burnout prevention is tocreate a network of family, friendsand colleagues as a supportivecoping strategy. Getting fresh per-spectives from this trusted socialnetwork can make all the differencein the world. He has learned thatsometimes his original plan isn’tnearly as good as one suggested bysomeone he trusts.Keisa Bennett is on the fac- Tom Broster Keisa Bennettulty of the University of KentuckyDepartment of Family andCommunity Medicine. Before sherealized that teaching is her realpassion, she experienced chronic,low level stress trying to build aresearch-oriented career. Eventhough there is more involved inher new teaching responsibilities,she now feels happier and morefulfilled as her work now feels moreinfused with personal meaning.

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doc12 Kentucky • Summer 2015Profile in Compassion Compassion is what sustains me Carol Cottrill By John A. Patterson she would use in caring for her daughter and She learned how to practice compassion- M.D., MSPH, FAAFP later during 18 years as medical director of ate medicine more from relationships with It seems so fitting that UK’s pediatric ICU. Her daughter’s illness classmates and patients than from the formal Carol Cottrill’s medical introduced her to wonderfully compassion- medical curriculum. She says, ‘whether it’s specialty is the hearts of ate doctors and nurses who cared for sick a fellow student or a patient, you have to children- both physical and children as their life’s work. become human to one another. People needemotional. Her career path began when her When her daughter died after Cottrill’s first to know you’re on their side. You do that4th child was born with congenital heart year of medical school, she felt isolated from with compassion. Compassion is when wedisease. her classmates, who did not know how to both put a part of ourselves out there andGrowing up on a family farm, she learned talk to her about death, dying, loss and grief. we somehow touch one another.’to balance compassion and necessity, a skill She finally took the initiative, reached out to Cottrill worries about our growing reliance them and felt comforted. on technology. ‘If you are looking at a com- puter instead of a patient’s eyes, both of you

docSummer 2015 • Kentucky 13are missing something important. Doctors by their teachers in medicine. Her ICU consultation. In the process of this selflessneed to be refueled. You can’t go at a tre- conversations with parents of dying children service, she continues to be sustained by themendous pace and not get something back. always included a resident so they could mutual compassionate interactions with pro-I am refueled by what patients give back to learn how to communicate with compassion. fessional colleagues, her young patients andme. Compassion is what sustains me.’ Her office staff says, ‘She can calm a cry- their families.She believes compassion flows in both direc- ing child better than we can. She gives us a About the Authortions and needs to be cultivated in medical shoulder to cry on after a hard day.’ She gives Dr Patterson is past president of the Kentuckytraining to enrich the doctor-patient rela- gas money to poor parents. She has taken Academy of Family Physicians and is boardtionship and the quality of physicians’ lives. into her home, and even adopted, children certified in family medicine and integrative‘Patients will give you compassion but you in desperate family circumstances, often to holistic medicine. He is on the family practicehave to first give yourself to them. Practicing ensure a comfortable death. A former patient faculty at the University of Kentucky Collegemedicine without compassion is drudgery- is now a pediatric cardiology fellow and calls of Medicine and the University of Louisvillejust putting in your time. Neither you nor Cottrill ‘my second mom.’ Ed Todd, retired School of Medicine. He operates the Mind Bodythe patient is psychologically benefited and cardiac surgeon, longtime colleague and Studio in Lexington, specializing in stress-such physicians are apt to abandon the pro- friend says ‘she’s the closest thing to a saint related chronic disease and burnout preventionfession.’ I’ve ever known.’ for helping professionals. He can be reachedJust as she learned compassion from her Cottrill uses a wheelchair now due to the through his website at www.mindbodystudio.orgloving family and the kind nuns in Catholic pain from spinal surgery and severe arthri-school, she believes medical students and tis. Despite this, she makes regular missionresidents need to see compassion modeled trips to South America to provide cardiac Now and then, we don’t get all the time we wanted With Hospice you can make the most of the time leftWhether it’s a fellow (859) 296-6100 The day we enter your lives, thestudent or a patient, (800) 876-6005 Hospice team treats you with theyou have to become respect, kindness, and dignityhuman to one another. www.hospicebg.org typically reserved for one’s own family. — Carol Cottrill • Providing medical care and symptom management in the home, nursing facility, assisted living facility and Hospice Care Center • Joint Commission accredited • Medicare/Medicaid certified • Counseling and bereavement services provided to the community, as well as to Hospice families • Dedicated hospice unit Hospice makes this unfamiliar journey one filled with comfort, dignity, and compassion © stock.xchng

doc14 Kentucky • Summer 2015The Heroin Bill andPublic Health By Rice C. Leach, M.D., Senate Bill 192, the “heroin bill”, passed municable disease program, (2) a way to President, Lexington by the Kentucky General Assembly is in accept referrals from outside for the needle Medical Society response to the rapidly increasing number exchange and related services and (3) a way This brief note is to share of deaths from overdose in Kentucky and to develop a referral network for patients general information about related issues. It authorizes health depart- needing infectious disease or substance needle exchanges and the ments to operate needle exchange programs abuse services. The initial planning includedpeople it will serve. It is not intended to be a and to refer patients for help so the LFCHD consultation with the Kentucky Departmentdetailed analysis of SB 192 but it is an over- and the Board of Health decided early on to for Public Health, national substance abuseview of what is happening at the Lexington- act. The department has produced a prelimi- experts and persons experienced in operat-Fayette County Health Department nary design to operate an exchange at the ing needle exchange programs in Cincinnati(LFCHD) and it offers some insight into health department and is reviewing it with and other cities. We learned quickly thatthose who use drugs. the appropriate community partners. From the take home message is: get started, get as the outset the department decided to focus many clean needles on the street as you can, on (1) a needle exchange as part of the com- keep it simple, don’t be overly prescriptive, be flexible and build trust with the people you serve. Communicable disease control: The health department has expertise in communi- cable disease control and the problem is real. Kentucky has the worst statistics in the country for hepatitis (over 7 times the national average for the rate of hepatitis C and 4 times the rate of hepatitis B) and needle exchanges have been shown to be an effective way to interrupt their spread among drug users and into the general population as sexually transmitted diseases and they increase health care costs. Referral for other services: Health depart- ments are expected to accept referrals from emergency medical services and emergency departments and to expedite access to treat- ment for infections and for drug abuse. Part of the challenge in meeting these expecta- tions is that health departments are expected to do these this without using any state or federal public health funds. That means that communities develop effective partnerships to manage the potential increase in cases. In Lexington the preliminary design is being reviewed by law enforcement, hospitals, mental health organizations and others including heroin addicts to determine what needs to change before we start. The com- ments from partners have not been com- pleted but we do have some input from drug users. We interviewed drug users incarcer- ated in Lexington on drug related charges and got very good advice. These men and women emphasized the need to make sure

docSummer 2015 • Kentucky 15that the participants bring in their needles to program because the rehab programs won’t in to treatment for some and that some ofbe exchanged otherwise they will toss them take them until they are ‘clean’. All of them the participants join the ranks of those whosomewhere in a park or some other public wished they could kick the habit and all of have successfully quit. One has to hope soplace. They told us to make sure that law them said that a needle exchange program because this drug abuse problem is erodingenforcement officials won’t penalize them will not increase the number of addicts- our state’s future human capital.for taking part in the needle exchange pro- -people who are going to be addicts will dogram and to make sure that department staff so with or without needle exchanges.can be trusted to maintain confidentiality. One of the inmates, a young woman inSome noted that many people in emergency her early twenties spoke about the humandepartments talk down to them so they side of drug abuse—a side that rarely getsdon’t come in for help with things like infec- media attention. Her poem about her expe-tions; instead they wait until we are so sick rience follows. She described drug abusethat they have to be admitted. They said that as she sees it so I share it with the reader.the lack of access to detoxification centers Perhaps needle exchange can be an entryis a barrier to entering a drug rehabilitationGoodbye Heroin Kentucky’s Leading Hair ReplacementHeroin, FacilityI’m writing this let to tell you goodbye.I loved you oh so so much, • Genetic Hair Lossthat you even made me cry. • ChemotherapyI would do what I had to do just to get high. • AlopeciaI promised myself that I wouldnever ever tell you goodbye! • Cosmetic Hair ReplacementThe feeling you gave me was quite a thrill,And the first time I shot you, 859.263.9811we made that sweet deal.When I used you once- you said you’d let me go, Hair Institute offers several surgical and non-surgical hairBut I used you twice – And I gave you my soul! restoration options, including Virtual Reality®, full and partialFrom that moment I promised you, that we prostheses, hand-knotted wigs, and human hair extensions.would always be a whole, andthat I would never ever then - Laser Light Hair Therapy - Full Cranial Vacuum ProsthesesLet You Go. - Surgical Hair Restoration Options - Enhancements and IntegrationsEven if I died doing you, you would follow me tomy grave, 1795 Alysheba Way Suite 7101Because you stuck with me down that Long, Lexington, Kentucky 40509Dark, Lonesome road we paved!So one thing I know, is when I gave you my soul, I lost HAIR REPLACEMENT • HAIR RESTORATION • HAIR EXTENSIONSall feeling, and even mysense of hope. AMERICAN Professional • Confidential • MeticulousI didn’t care about anything, but keeping you HAIR LOSS www.hairinstitutelexington.comaround because I knew I would COUNCILnever have to feel down as I shot you.You only made me feel well, other than that youcaused me nothing but HELL!Now here I sit in this big ol’ cell with nothingto do but sit here and DWELL!Now I know that I can never again pick you up.Because if I do, the next timeI will truly be stuck.So this is why I have to tell you goodbyeAnd I never again wanna get highBecause the next time I knowFor sure I will die!! ®

doc16 Kentucky • Summer 2015 ANNOUNCEMENTS AWARDS NEW STAFF EVENTS AND MORE EMAIL [email protected] TO SUBMIT YOUR NEWSHospice of the Bluegrass and Andy Saint Joseph East Achieves National Lexington Clinic Hosts MultipleBarr for Quality Hospice Care Bariatric Surgery Accreditation Presentations During Month of AprilHospice of the Bluegrass CEO Liz Fowler and Lexington, Ky. (May 11, 2015)—Saint Joseph East, LEXINGTON, Ky. – May 6, 2015 – In April,other hospice leaders met with Congressman Andy part of KentuckyOne Health, has been accredited Lexington Clinic hosted multiple presentationsBarr to advocate for increased access to high quality as a comprehensive center under the Metabolic for physicians, providers and staff. These presenta-hospice care. The meeting took place during the and Bariatric Surgery Accreditation and Quality tions provided a unique opportunity for those inNational Hospice and Palliative Care Organization’s Improvement Program (MBSAQIP), a joint pro- attendance to further their knowledge on issues2015 Management and Leadership Conference. gram of the American College of Surgeons (ACS) surrounding the medical community. The presenta- and the American Society for Metabolic and tions included:Pictured are: Amanda Weitekamp (Hospice of the Bluegrass); Bariatric Surgery (ASMBS). Melissa L. Currie, M.D., Medical Director andDebbie Jones (Hospice East, Winchester); Liz Fowler; Division Chief, Kosair Charities Division ofRepresentative Andy Barr; Susan Swinford (Hospice of the Lexington Clinic and Walaa Ayoub, Pediatric Forensic Medicine, and Peter W. Hester,Bluegrass); and Phil Marshall (Hosparus, Louisville) MD, PhD: Bone Density Scans M.D., Lexington Clinic orthopedic physician pre- sented continuing medical education (CME) pre-Lexington Clinic Orthopedic “With DXA units, like the one we recently installed sentations, “Pediatric Abusive Head Trauma” andSurgeons Present at Annual Meeting at Lexington Clinic, physicians are able to do “The Clinician’s Role in Concussion Assessment a quick, painless and non-invasive scan of the and Management.”W. Ben Kibler, M.D., F.A.C.S.M., and Trevor W. patient’s bone density,” said  Walaa Ayoub, M.D., International physiotherapist, Dakshika Govan,Wilkes, M.D., both Lexington Clinic orthopedic Ph.D., Lexington Clinic endocrinologist. “During presented on the key aspects of her role as ansurgeons, presented a continuing medical education this scan, we focus on the hip and spine, and extended scope physiotherapist within an inte-(CME) instructional course at the annual national although osteoporosis involves the patient’s entire grated musculoskeletal service, along with a patientmeeting of the Arthroscopy Association of North body,  scanning at these two sites can help us not case study.America (AANA). only diagnose a patient with osteoporosis but also Jeff Morris, M.D., M.B.A., F.A.C.S, F.R.C.S.C, a predict fractures at other sites throughout the rest physician coach with the StuderGroup gave a CMESpecifically, the CME course focused on shoulder of the body.” presentation, “The Positive Patient Experience:injuries to the scapula, clavicle and AC joint. The A DXA scan is an enhanced form of an X-ray which Why Should I Care?”two surgeons collaborated with Dr. Ben Rubin, a focuses on bone density, but with less radiation Owen Dahl, F.A.C.H.E, C.H.B.C, L.S.S.M.B.B., ansurgeon from Southern California on the presen- used – less than one-tenth the dose of a standard independent MGMA consultant hosted “Medicaltation. Approximately 500 attendees were at the chest X-ray. It is performed on an outpatient basis Group management Association (MGMA) Leanannual meeting, held in April. and is usually completed within 10 to 30 min- Six Sigma Yellow Belt Certificate Program.” utes. A DXA scan is considered the most accurate For more information about the presentations or method available for diagnosing osteoporosis and Lexington Clinic’s CME program, please contact fracture risk. Simonton- Alexander at 859.258.6114 or psimo@ lexclin.com Dakshika Govan, an extended scope physiotherapist from the United Kingdom, spoke with attendees about the key aspects of her role within and Integrated Musculoskeletal Service.

docSummer 2015 • Kentucky 17 Lexington Medical Society Physicians caring for the community since 179926th AnnualBB&T/Lexington Medical Society Golf OutingRegister NowWednesday, August 26, 2015University Club of Kentucky12:00pm Lunch1:00pm shotgun start Everyone registered to play golf is entered to win an Apple Watch Sport, no purchase is necessaryAll proceeds to benefit the Lexington Medical Society Foundation.Each year the LMS Foundation distributes grants to over a dozen local non-profitorganizations, including Surgery On Sunday, Baby Health Service, Camp Horsin’ Around,God’s Food Bank, and Faith Pharmacy.Format: Shamble Tournament (play best drive then play own ball to the hole)Teams: Put together own Foursome or Committee will help form teams White Tee Sponsorship: $2,500 + foursome & 2 mulligans Hole Sponsorship with 4 players: $1,000 Hole Sponsorship: $500 Foursome: $500 Individual Players: $150Sign up for more information. Go to lexingtondoctors.orgPoint of contact: Cindy Madison, [email protected] (859) 705-0003

doc18 Kentucky • Summer 2015nTaekkwedyioruuecrtlliiioffnee.iFnnAaaST! IIff yyoouu’’rree rreessttlleessss aanndd rreeaaddyy ffoorr aa cchhaannggee iinn yyoouurr lliiffee,, ttaakkee tthhee ffiirrsstt sstteepp aanndd eennrroollll aatt SSppeenncceerriiaann CCoolllleeggee.. WWhheetthheerr yyoouu’’rree sseeeekkiinngg aa ddiipplloommaa,, cceerrttiiffiiccaattee oorr aassssoocciiaattee ddeeggrreeee,, wwee ooffffeerr aa vvaarriieettyy ooff pprrooggrraammss iinn tthhee hheeaalltthhccaarree aanndd technical fields. No matter which area interests you most, you’ll find that all of Spencerian’s programs are career-driven with one goal in mind: to help you achieve success…and we’ve been doing it for over 120 years. Enroll now! Classes Start Soon! 859-223-9608 | 800-456-3253 | spencerian.edu1155 77 55 WW II NN CC HH EE SS TT EE RR RR OOAA DD || LL EE XX II NN GG TT OO NN ,, KK YY 44 0055 0055HMMPMRLMHMCMHPMMMRMMCLMMMHiihhllaaeeEEmmaaeeeeeeeeeeeeiinnddllaassddddddddddddAAeeiiiiiillssttiiiiiiiiiiiiccbbooLLttccccccccccccaaeehhaaTTllooaaaaaaaaaaaaggddooccllHHttlllllllllllleeggLLaaooMMCLACALMCAACMCCiiaarrTTmmaaccddlloosseeeeaabbiiAAhhbbssnnmmddTTddyyssRRooRRiieeooiieessssiiiiccrrnneeiirrccEEttaarrccnnaaaaaaaaiiaaggaahhggmmiittllppPPllnnssttooeennSSSSooyyRRttRRttbbrroopprrppTTrraayyuuaaOOllyyeehheeddoottrrAAccGGcceeTTiissggiivviioossiieerreeaaRRaayyeessaaggccmmlllliiAAiippttrrMMhhssssiiaaeeMMttyyeettnnaaaappnnssooSSnnnnhhttllaa::ttooyySSggggppeeyyeemmcciieeaannlliittsstt SCBTCECCCC(C(EBCTCCSAAyyllooooooooooEEiieeoorrssmmmmmmmmmmCCccccmmtthhHHeettpppppppppprriieemmNNoottuuuuuuuuuuddeennttttttttttssIIcciieeeeeeeeeeCCiiccMMttccrrrrrrrrrraaAAuuEEaaIIGEGARAERllrrLLnnnnEEnnnnaaiieerrffddPPaannggaallggoopp,,eeppiiggggiiRRrraaCCnnnnddmmhheeiiiiOOnniieeeerrvvmmiiDDaacceeeeeeGGiieellttrreerreeDDRRii&&iiiissrroonnnnnneeiiiiAAggnnnnttggMMggssMMnnggiiTTTTeeggeeDDeeSSTTccnncceecchh::rrhhaahhccaaffhhnnnnnnttnnooiiooiinnccoollllooaaggoolllloogggg))ggyyyyyy For more information about program successes in Fgorardmuoarteioin froartmesa, tpiolancaebmoeunttprraotegsraamndsuocceuspsaetsioin s, gprleaadsueavtiosint srapteensc, eprlaiacne.medeun/tprraotgersaamnsduoccceussp.ations, please visit spencerian.edu/programsuccess.Spencerian College is accredited by the Accrediting Council forSInpdSeenppceeenrindaencnCetoCrlolielagleengiessCaaconcdrlelSdecithgeodeoblsiysthaecAcccrreedditiintgeCdoubnyciltfohre Accrediting Council for Independent Colleges and Schools.IndSeppeenndecnet CroilalengesCaondllSechgoeolsis accredited by the Accrediting Council for Independent Colleges and Schools.

docSummer 2015 • Kentucky 19 As a Physician in the U.S. Air Force, you’ll have one job: treat patients. We’ll give you all the support you need so you can be the doctor you were meant to be. For more information, contact your local recruiter or visit airforce.com.Call 1-800-588-5260 or E-Mail: [email protected] ©2014 Paid for by the U.S. Air Force. All rights reserved.

doc20 Kentucky • Summer 2015Making History Robert Edwards and the first‘test tube baby’ By Frank Kourt, Staff Writer be fertilized outside the body, and developed a with terminal illnesses as the result of unsuccessful Today in vitro fertilization, the cultural medium in which such fertilization could experimentation. fertilizing of eggs outside the body take place, Nevertheless, the two researchers pressed on. in a petri dish, is often a viable In 1968, Edwards contacted Dr. Patrick Steptoe, a Their perseverance paid off when they were option for infertile couples who British gynecologist who was one of the pioneers approached by Leslie and John Brown, a couple are unable to conceive a child, but of laparoscopy, a surgical technique that could who had been trying to have a child for nine years.it didn’t become a reality until July 25, 1978 when enable the eggs to be removed from the ovaries, The in vitro fertilization was completed, the fertil-Louise Brown, the first “test tube baby” was born, and a collaboration was born. ized egg was implanted in Leslie Brown’s bodydue, in large part, to the determination of fertility While Edwards managed to fertilize a human egg and a healthy girl, Louise Brown, was delivered byresearcher Robert Edwards. in 1969, the success was very limited, in that the c-section on July 25, 1978 after a full-term preg-Edwards, a British physiologist, was born in 1925 egg failed to develop beyond a single cell division. nancy.in Batley, Yorkshire, England. He began his studies The researchers continued their work over the Edwards and Steptoe founded Bourn Hall Clinicin agriculture at the University College of North next decade, refining their techniques in an effort in Cambridge, England in 1980, and trained gyne-Wales (UCNW), after his discharge from the to fertilize viable eggs and implant them in the cologists and cell biologists from around the worldBritish Army in 1949. He soon became interested womb. By using the laparoscopic technique, in the new technique.in animal reproduction and transferred to the col- Edwards and Steptoe were able to extract eggs Edwards served as scientific director of Bourn Halllege’s zoology department. He earned a Bachelor that had matured in the ovaries, providing a better Clinic from 1988 to 1991, and as head of researchof Science degree, then a Doctor of Science chance for successful in vitro fertilization. until his retirement, while Steptoe served as medi-degree from UCNW, followed by a Ph.D. from Edwards’ and Steptoe’s work continued for ten cal director until his death in 1988.the University of Edinburgh’s Institute of Animal years, during which they were criticized on a Edwards won the Nobel Prize in medicine for hisGenetics. number of fronts, from arguments that in vitro in vitro fertilization work in 2010. Steptoe wouldDuring his research career, as early as fertilization was “unnatural” and was, essentially presumably have shared the prize, but Nobels arethe 1950s, Edwards became “playing God”, to assertions that the process would not awarded posthumously.fascinated with the create infants that might be deformed and afflicted Edwards died April 10 of this year at the age of 87concept of fertilizinghuman eggs in the lab- at his home near Cambridge, England.oratory as a potential Since the successful birth of Louisetreatment for human Brown in 1978, millions of couplesinfertility. throughout the world have ben-Through painstaking efited from the work of Robertand lengthy studies, Edwards and his fellow researcher,Edwards came to Patrick Steptoe.understand howhuman eggs could

docSummer 2015 • Kentucky 21 1775 Alysheba Way, Suite 201 859-278-5007 www.FPALex.comDAYSEVENINGSWEEKENDSFOR YOUR HEALTH Family Practice Associates has flexible day, weekend and evening hours that you can count on to accomodate your family’s busy schedule. Contact us today to schedule your appointment.WHAT WE DO ? OUR SERVICES Quality patient focused healthcare for your entire OUR PROVIDERS family in a friendly environment. Comprehensive primary care services for children and FPA has 9 Board Certified physicians with adults of all ages, including acute and preventive specialties in Family Practice, Pediatrics and Internal medicine. Medicine. We also have 3 certified Nurse Large modern office with highly trained staff and Practitioners with experience in family medicine. on-site laboratory. Secure online patient portal for easy access to your test HOURS results, medical information and communication with your provider. FPA offers flexible office hours Mon – Fri 8:00AM – 4:30 with Evening hours on most days. SaturdayFor over 30 years, the mission of Family Practice Associates morning appointments are available for sickhas been to provide preventive, diagnostic, and therapeutic patients.health services with attention to individual need. We arededicated to giving family-centered care from birth to later LOCATIONyears in an affordable, high quality manner. FPA is located in the Hamburg area with easy access from I-75 and Man O’ War Blvd.

doc22 Kentucky • Summer 2015 Medical Marijuana DebatePROS By Lowell Quenemoen derivatives and two are currently available in Cannabinoids have been used to treat glau- M.D., Neurology(ret) the US, Dronabinal (Marinol), a synthetic coma since it has been shown to reduce Growing up in the “Age of THC, and Nabilone (Cesamet). In the intraocular pressure. The benefit of one Aquarius”, the culture of UK Nambiximols (Sativa) is available and cigarette lasts about 4 hours and therefore sandals, beads and “grass”, contains a THC:CBD ratio of 1:1. Recently requires multiple doses leading to cognitive many Americans have Epidolex, a 98% CBD compound has been changes. In addition arterial hypotensioncontinued their interest in “weed” as a rec- developed in the UK. Pharmacologically, may be induced putting the optic nerve atreational product and more recently as a cannabinoids work through the endocan- risk.medicinal product. A Gallop poll in 2013 nabinoid system which is spread through thereveals that 38% of Americans have tried brain and the spinal cord. CB-­‐1 receptors Cannabinoid’s effects on the CB-‐­2 recep-marijuana at some point in their are located in central terminals (hippocam- tors are thought to have an anti-­‐inflam-lives and 7% continue to do so. The highest pus, basal ganglia and cortex) and peripheral matory effect leading to trials in ulcerativeuse is in the 56-‐­65yo group at 32% of the nerves and CB-­‐2 receptors in immune colitis and other inflammatory GI disease.total users and the second highest is in the cells and lymph tissue. The CB-­‐! receptors Positive results have been claimed for fibro-under 25yo group at 25%. inhibit neurotransmitter release while the myalgia but no benefits in rheumatologicalIncreasingly there has been pressure to legal- CB-­‐2 receptors influence cytokine release diseases proven.ize recreational marijuana (currently legal in and cell migration.Colorado, Washington, Oregon and Alaska In 2014 Koppel et al reviewed multiple Recent studies suggest relief of chronic neu-as well as the District of Columbia but com- articles (1948-­‐2013) looking at the use of ropathic pain and, for patients on chronicmercial sales are banned there.) Medical cannabis in multiple neurologic diseases opiates, the possibility of reducing dosesmarijuana is legalized in 20 states and Guam. ie.MS, movement disorders and epilepsy. with the addition of cannabis. The AMA hasThe US federal government continues to list Thirty four studies were looked supported the use of cannabinoids in spas-it as a Schedule 1 substance and is therefore at and the effectiveness of oral cannabis ticity reduction in MS, in appetite stimula-outlawed. In Kentucky, a non legalized state, extract(OCE), Nambiximol and THC tion, in reduction of nausea and vomitingthe possession and/or sale of less than 8 oz evaluated. and for pain relief.is a misdemeanor as is the cultivation of less In MS, spasticity and central pain were effec-than 5 plants but more than that is a class tively treated with OCE with the other two In psychiatry, a recent Cochran review sug-D felony. Medical marijuana is licensed in compounds being probably effective. gests that CBD has some antipsychotic valueIsrael, Canada and the Netherlands. Bladder dysfunction had a positive benefit and may be helpful in chronic anxiety statesThe use of marijuana for medical purposes with Nambiximol. but no benefit with the and possibly PTSD.has largely been anecdotal since it was others. No clear benefit was seen in L-‐­Dopamade illegal in 1970 with the passage of the induced dyskinesias, Touretts tics, All things considered, the future role ofControlled Substances Act and research has cervical dystonia or epilepsy. medical marijuana depends on more Classbeen restricted. Negative side effects includ- In 2015 Knezevich et al did a meta-­‐analysis 1 studies using rigorous methodologying addiction potential, impact on neuro- of 7 published articles using cannabis in the with adequate numbers of study patients.cognitive performance, mood disorders, treatment of refractory epilepsy. The con- Cannabinoids will need to be more refinedpsychosis, cardiovascular, pulmonary and trolled trials were randomized but small, to facilitate standardized dosing and placebothe potential for accidental overdose have averaging 9 patients. Standard doses of 200 effects related to psychotropic elementscontinued to temper trials and acceptance. mg of CBD were used in aerosol. Statistical minimized. Physician willingness to pre-The medicinal use of cannabis dates back benefit was not demonstrated. More recent scribe is only going to follow if clear benefitto 2700 BC in China and it was used as an studies published by Devinsky et al report is shown and the agents are no longer out-analgesic in the West in the late 1800s. Of success using Epidolex with reduction of lawed at the federal as well as the state level.note, it was sold as an OTC until 1937 when more than 60% refractory seizures in Dravet A recent case in Colorado, a marijuana legalthe Marijuana Tax Act was enacted. and Lennox-­‐ Gastaut syndromes. state, involving a quadriplegic Dish employ-Cannabis includes two species, C. sativa Application of cannabis to headache was ee using medical marijuana for severewhich is psychotropic and stimulating and studied by Napchan et al in the journal spasms, resulted in his losing his job afterC .indica, the more sedating. Although more Headache in 2011. They reviewed the testing positive in a work mandated drugthan 100 compounds are found in cannabis pathophysiology of migraine and cluster screen. Again there may be medical benefitthe two most studied are THC (Delta-­‐9-‐­ headache and speculated on a deficiency realized but zero tolerance policies will dis-tetrahydrocannabinol) which is psychoac- in the endocannabinoid system since suade many from using it because oftive and CBD (Cannabidiol) which is not. anadamide, an endogenous CB receptor legal and economic risks. In recreational use, product with higher active compound was present in reduced THC levels have been promoted with an levels in the CSF. This in turn activated References:average concentration in 1996 0f 2.2% and the trigemino-­‐vascular nucleus triggeringin 2008 was 9.9%. CBD has been selectively headache. A number of case reports and 1. Peckham, Carol: Do Physicians Usereduced from .24% down to .08%. Efforts anecdotal studies have claimed success with Marijuana? Medscape. Feb 05, 2015have been made to synthesize cannabis cannabis for the refractory headache. 2. Kleber, HD et al: Physicians and Medical Marijuana. Am J. Psychiatry 169:6 June 2012 3. Koppel, B.S. et al: Systematic Review: Efficacy and Safety of Medical Marijuana in Selected PROS Continued on Page 31

docSummer 2015 • Kentucky 23CONS By Danesh few physicians prescribing high quantities industrial accidents, injuries, and absentee- Mazloomdoost, M.D. are conditions similar to the opiate epidemic ism20. Heavy users share lower income, Since the early 1990s, scien- and pill mills seen in Kentucky. greater welfare dependence, unemploy- tific publications on medical The benefits of marijuana legalization are ment, and low life satisfaction21-23. Kentucky cannabis have increased often touted as both good for local tax rev- already ranks among the nation’s highest from 70 per year to over enue and cost-cutting because of decrimi- rates of disability24; legalizing marijuana1000 per year. As medical interest in the nalization. However, in the context of cur- risks increasing its availability and indirectlyendocannabinoid system has evolved, so rently legal substances such as alcohol and raising disability rates further.have political and financial interests in order tobacco, the evidence conflicts with theory.to fast-track legalization, thus trumping the In Wisconsin, the revenue collected from Proponents of marijuana often deny adverserigorous methodology of studying a drug alcohol and tobacco tax averaged to $700 psychoactive properties, such as addic-and its adverse effects. Raw opium, coca million per year, while the costs (motor tion and psychosis, citing anecdotal cases.leaves, and mustard gas all have derivatives vehicle accidents, hospital admissions, fetal Similarly, one may argue not everyone whothat are prescribed with medical benefit but effects and treatment, arrests, and addiction tries alcohol becomes addicted. Yet, mari-they rarely, if ever, prescribed in raw form. treatment) totaled $11.3 billion, a 16-fold juana addiction rates among adults averageSimilarly, cannabinoids have potential bene- difference7. 10%, while teens show higher rates at 20%,fits but, unrefined, may also pose significant In the criminal justice system, there is an and daily users at 40%25-27; all are higherpublic harm. impression that prisons are overflowing rates than alcohol use disorder28. Signs ofMarijuana is composed of 500 different because of marijuana incarcerations. These physical addiction noted by Marijuanacompounds, of which over 60 are consid- statistics can be misleading. Any charge (e.g. Anonymous participants include insomnia,ered active ingredients1. Two have been the rape, murder, robbery) that also includes depression, vivid nightmares, anger/irrita-focus of research, Cannabidiol (CBD) and a marijuana charge may be quoted as a bility, headaches, and anorexia29. Because ofdelta-9-tetrahydrocannabinol (d9THC). marijuana-related offense, thus inflating marijuana’s lipid solubility, symptoms mayCBD demonstrates medical interest and the numbers. In reality, only 0.1% of state take weeks to develop following abstinenceis being studied in seizure disorders, pain, prisoners are incarcerated for marijuana pos- and last up to 3 months. In addition toinflammation, dementia, and cancer treat- session while drug traffickers encompassed addiction, there are indeed notable risks forment. d9THC, on the other hand is psy- 99.8% of federal drug charges8. Most posses- psychosis. The variables contributing to anchoactive with limited medicinal use. Often sion charges are directed to drug courts for individual’s vulnerability to schizophreniathe ratio of d9THC to CBD is used to rehabilitation services. Legalization could are undergoing investigation. However,determine the recreational versus medicinal actually increase marijuana-related charges those who have genetic propensity toproperty of a crop, but even when maxi- for the same reasons that alcohol, a legal schizophrenia show 6-fold higher rates ofmizing CBD, crops still carry half to equal substance, outnumbers marijuana arrests by psychotic breaks with marijuana use, andratios of d9THC2. The concentration and 4:19,10. For example, Washington State saw a teen exposure has the greatest risks30-32.bioavailability of these compounds also vary sizeable increase in marijuana-related DUIfrom one plant to the next, among different arrests following legalization11. While marijuana has active ingredients withplant generations, and with altered delivery Legalization normalizes, and consequently therapeutic potential for the endocannabi-methods. Therapeutic effects are addition- increases, marijuana demand12. Terming noid system, it currently has ill-defined ther-ally complicated with dose-dependent marijuana medicine further connotes apeutic ranges, adverse effects, or contra-effects that may contradict each other3. harmless and beneficial attributes. Lobby indications. Consider the impact opiates hadFurthermore, without regulation, pesticides, interests often marginalize the many adverse in devastating Kentucky communities. Insynthetic fertilizers, additives, and microbes effects of marijuana. While the spectrum of evolving this epidemic, the medical commu-could all be present within distributed medi- effects from each individual active ingredi- nity caved to the soft science presented bycal products without clinician or patient ent is undergoing investigation, the meta- special interests on its safety profile and effi-awareness. effect of raw marijuana shows detrimental cacy. Marijuana has the potential for similarThe media often sensationalizes failures effects on memory, coordination, substance problems if distribution circumvents vettedin conventional medicine as a rational for abuse, and mental health, particularly for scientific processes and overlooks the harmslegalization. Even though these cases evoke vulnerable populations such as adolescents. of unintended consequences. Ultimately,sympathy, they are not representative of Memory and IQ are proportionally affected liberalization of marijuana under the guisethe average medical marijuana recipient. in correlation to age of onset, duration of of medicine conveys a message of safety andFollowing legalization in California, the use, and frequency of exposures to mari- endorsement that defies the objective scruti-average recipient was a 32 year old white juana13-17. This effect is particularly harmful ny engendered in medicine. As practitioners,male, of whom 50% had a life-time preva- to adolescents, who irreversibly lose an aver- we must maintain our professional standardslence of cocaine use and 75% of metham- age of 8 IQ points, theoretically because of for all substances.phetamine use4. Vague diagnoses such as inhibited synapse formation18. These effects “chronic pain” are most commonly cited as are even more pronounced in utero even at References:the rationale for use5. In Colorado, 50% of low doses and infrequent exposure19.the entire state’s medical marijuana scripts Adverse effects continue throughout life. 1. Mechoulam, R. and S.H. Burstein, Marijuana;were generated by 1% of prescribing physi- Marijuana smokers show higher rates of chemistry, pharmacology, metabolism andcians6. Ill-defined diagnoses coupled with a clinical effects. 1973, New York,: Academic Press. xiv, 409 p. CONS Continued on Page 31

doc24 Kentucky • Summer 2015 Standardized Mortality Ratio (SMR) Common MisunderstandingsBy Tuyen Tran, M.D. As early as 1847, Ignaz Semmelweis observed hospital, or vice versa. Death in modern hos-Since the Institute of Medicine’s (IOM) that women delivered by physicians and pitals is relatively rare (5-10%), and forensicreport in 1999, To Err is Human, multiple medical students had a much higher post- clinical analyses of these deaths show thatstakeholders (government agencies, accredi- delivery mortality than midwives (13-18% only 5% are attributable to unsafe care3. Thus,tation bodies, payers, hospitals, providers, vs 2% respectively)2. (The differences were mathematically, due to the low rates of occur-and the public) have responded with vari- related to lack of hand washing.) Interest rence, only 8% of hospitals with unfavorableous metrics to monitor and interventions in comparing outcomes among healthcare risk adjusted SMR (ratio >1) will truly beto implement. They wanted to improve the providers certainly predates the IOM report. more “unsafe” than the average hospital. Onhealthcare and positively effect changes to Of particular interest is the adjusted standard- the other hand, of the hospitals with favor-prevent the annual avoidable 98,000 deaths ized mortality ratio (SMR, also known by able SMR, 10 out of 11 of these hospitalsand 1 million injuries related to medical various other names such as Risk-Adjusted may actually be more “unsafe” than the aver-errors1. Stakeholders demanded positive out- Hospital Mortality Ratio). It is a comparison age hospital. The reason is that most qual-comes and they wanted providers account- of the observed number of in-hospital deaths ity issues may result in injury or prolongedable. As the chanting of “First, do no harm!” to the number expected based upon the hos- hospital stays; but, they do not cause death4.continued, hospitals and providers became pital’s case mix. Ratios greater than 1 suggest Most unsafe practices do not cause death andmired in performance measures and report unsafe healthcare and ratios less than 1 sug- most deaths are not the result of unsafe care.cards. But, are these metrics valid? gest safe practices. The thought process forMortality is comprised of three variables: 1) “risk-adjustment” is that if the contributions Of course, one preventable injury is one toopatient risk-factors (case-mix), 2) random from patient case-mix factors are removed, many! Despite the tremendous allocation ofchance, and 3) quality of care. Despite the the residual unexplained variation is related resources into the improvement of qualitybest attempt at risk-adjustment, the calcula- to quality of care. This is perfect! First, the and safety, the fact is that patients are need-tions cannot account for unmeasured and/ end point is concrete and everyone would lessly harmed as a complication of receivingor immeasurable factors. That is, the outputs consider the outcome of death important. healthcare5. Unfortunately, there are no reli-of risk adjustment regression models depend Second, the information is readily available able tools to accurately measure the quality ofupon the input variables, which can vary from most administrative databases. Third, care for physicians, hospitals, or populations.widely. For example, comorbidities (morbid the ratio allows for inter-hospital compari- And until these valid metrics are found, ten-obesity, dementia, and heart failure, level of sons. Finally, the data are amenable to statisti- sion will continue to mount among thosefrailty and disability) which impact mortality cal analyses and graphical displays to facilitate who seek safe quality care (public), thoseestimates are inconsistently documented. interpretation. who have the obligation to protect the public There is the inevitable desire to conclude that (policy makers), and the providers who do a favorable SMR (ratio < 1) indicates a safe wish to deliver safe and quality healthcare. There is the References inevitable desire to conclude that 1. Kohn LT, Corrigan JM, Donaldson MS, eds. a favorable SMR To err is human: building a safer health system. (ratio < 1) indicates Washington, DC: National Academies Press, a safe hospital, or 1999. vice versa. 2. Best M, Neuhauser D. Ignaz Semmelweis and the birth of infection control. Qual Saf Health Care 2004; 13:233-4. 3. Scott IA, Brand CA, Phelps GE, Barker AL, Cameron PA. Using hospital standardized mortality ratios to assess quality of care – proceed with extreme caution. Med J Aust. 2011;194:645-648 4. Girling AJ, Hofer TP, Wu J, et al. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modeling study. BMJ Qual Saf. 2012;21:1052-1056. 5. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124-34.

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doc28 Kentucky • Summer 2015 • Lifestyle SectionTravelDingleIRELAND’S BEAUTIFULPeninsula By Cory Hanson Tucked away in Ireland’s southwest corner, near the equally beautiful but maybe more famous Ring of Kerry, is the Dingle Peninsula. Though small and out of the way, this rocky peninsula offers a look at some of the best natural and cultural treasures in Ireland, largely unspoiled by big cities and tourist crowds.

docLifestyle Section • Summer 2015 • Kentucky 29Dingle Town the harbor for a chance to see this ment, and the nearby Blasket Islands, famous, friendly dolphin. home to a small population of Irish-The peninsula gets its English name For a free look at Fungie and the speaking fishers and farmers until afrom its largest village. Dingle town stunning scenery on the Dingle and forced evacuation in the 1950s.and the western half of the peninsula Ring of Kerry coasts, visitors with Farther along, the route passesare technically in a Gaeltacht area, good walking shoes can head east through the small village of Dunquinan Irish cultural preserve established on a well-maintained coastal trail (Dún Chaoin in Irish), the west-to keep alive the Irish language and all the way to the mouth of the bay, ernmost settlement in Europe, as ittraditional way of life. It’s referred where the dolphin can be seen enter- reaches the northwest corner of theto locally by its Irish name, An taining the many Fungie-watching peninsula and more scenic clifftopDaingean. boats. From the lighthouse, the trail and island views.The village is known throughout continues along a steep cliff, offering As the road loops back to DingleIreland and the rest of Europe as beautiful views of Dingle town and town, visitors can see the very well-a haven for great traditional Irish Macgillicuddy’s Reeks, the highest preserved Gallarus Oratory. Thismusic. Many of the village pubs offer mountains in Ireland, on the Iveragh mysterious building is believed to belive music sessions every night of Peninsula, better known as the Ring an early Christian church, but littlethe year, some featuring well-known of Kerry. is known as to its exact date or use.Irish music stars. Prices of food and The stones of the oratory are stackeddrink are cheaper in the village than The Slea Head Drive perfectly to create a durable andin Ireland’s larger cities, so even bud- waterproof structure without need ofget travelers can find a warm seat by From Dingle town, most visitors mortar.the fire and enjoy a pint and some embark on an unforgettable car or The entire Slea Head Loop takes halffine music, which usually kicks off at bicycle trip around the well-marked a day by car, a full day if done by bicy-about 9:30 p.m. Slea Head Drive. This circular coastal cle. After a long day out seeing someDingle Bay is also famous for a local route combines ancient human-made of Ireland’s most beautiful coastlineanimal celebrity, a bottlenose dolphin monuments with breathtaking natural and early Celtic and Christian heri-named Fungie. In the mid-1980s, for beauty for an unforgettable experi- tage, weary travelers are always readyreasons unknown, this lone dolphin ence. for ceol agus craic, music and goodmade residence in the sheltered bay, At Slea Head, the southwestern times, in one of Dingle town’s fineand has been entertaining tourists corner of the peninsula, drivers can traditional pubs.ever since. Every year, a fleet of local stop to see the distant Skellig Islands,boats takes thousands of visitors into home of an ancient monastic settle-

doc30 Kentucky • Summer 2015 • Business SectionBusiness The Difference Between a Business and a Revenue Generation ModelOne of the most critical skills needed in start- also highly invested in short-term revenue gen- and maintaining assets, such as education, skilling and managing a business is the ability to eration activities, but the difference is that they development, tangible property, and customerdistinguish between business activities and do so through a careful management of assets relations, and minimizing liabilities, such as byrevenue generation. Many people assume and liabilities, making sure each activity builds paying off debt, carrying insurance, and keep-that, since the primary purpose of a business up the core business structure and limits risk ing up-to-date with pertinent laws and regula-is usually to make money, definition of the to an affordable level. One of the most famous tions. For a business to remain viable, it needsmoney-making operations is all that is needed examples of how this works in application to account for the handling of all related assetsto create a business plan. This false assumption is McDonald’s. While McDonald’s is known and liabilities in figuring its operating costs ascan cause a lot of heartache when costly prob- worldwide for its hamburgers, its core business it grows and not just the amount of cashflowlems arise that could have been prevented with is actually real estate. The corporation acquires needed to support current revenue systems.better planning. and invests in high-value commercial property Revenue systems are still of great importance  as a primary asset, and the selling of hamburg- to fund these investments, but no one particu-Nearly any given method of profit is highly ers is its system of revenue generation to fund lar system should have resources overcom-dependent on temporary market condi- its continued maintenance and growth. In the mitted to it that would make it too costly totions, such as resource availability, consumer worst case scenario for the company, if the change or replace if the market it depends ondemand, and competition from other busi- fast food market were to tank into complete changes.nesses. A pure revenue generation model tends disfavor, it might suffer a temporary setback  to maximize gains by optimizing itself for the from devalued food inventories but would still As a business grows and becomes more stable,current market, making it extremely competi- retain its primary asset of land value to fall it can afford to optimize more or even use tem-tive and profitable for the short term but at back on to bring in emergency funds and begin porary market conditions to convert surplusthe cost of inflexibility and possible insolvency a new revenue generation system to survive. inventory or by-products into trendy, shortwhen market conditions change. In short, rev-   shelf-life items to produce additional capitalenue generation systems consume resources and customer goodwill without having toand labor in exchange for immediate profit, Profit Comes from the invest in long-term production. The key thingbut if some of that profit isn’t reinvested back Right Balance of Both is to understand the difference between theseinto developing other more permanent gains, two concepts to not make the mistake of over-nothing of lasting value is produced, and the   investing in a revenue system or underinvest-business will fail when the market no longer Some form of income is a given necessity ing in a business.needs the services it has optimized itself for. for running any business, so there’s nothing  wrong with starting out primarily focused onA true business model, on the other hand, is revenue generation. The determinant factor ispurposefully designed to be a long-term struc- what you do with the revenue as it comes in.ture for profitability that is capable of weather- A fully functional business model allocates aing significant market changes. Often they are significant portion of income to developingAmazing SmileDowntown Dentistry is the place to get anAnna E Newman DMD Saturday & Evening hours available 859.987.5550 Emergencies & Walk-ins Welcome 436 Main Street Paris, KY 40361 Childcare www.downtowndentistryparis.com

docSummer 2015 • Kentucky 31Join the Medical Marijuana debate:www.facebook.com/KENTUCKYDOC PROS continued from Page 22 Neurologic Disorders. Neurology April 29, 2014 Vol 82, No 17 1556-­ ‐15634. Yadov, V et al: Complementary and Alternative Medicine in Multiple Sclerosis. Neurology 2014; 82: 1083-­‐10925. Napchan, U. et al: The Use of Marijuana or Synthetic Cannabinoids for the Treatment of Headache. Headache 2011; 51 (3): 502-­‐5056. Wilsey, B. et al; Low-‐­dose Vaporized Cannabis Significantly Improves Neuropathic Pain. J. Pain 2013; 14: 136-­‐1487. Schatman, M.E.: Medical Marijuana: The State of the Science. Medscape. Feb 06, 2015 CONS continued from Page 23 and changes in hippocampal protein expression following exposure. Neuropsychopharmacology, 2008. 33(5): p. 1113-1126.2. Silva, T.B., C.Q. Balbino, and A.F. Weiber, The relationship between 18. Meier, M.H., et al., Persistent cannabis users show neuropsychologi- cannabidiol and psychosis: A review. Ann Clin Psychiatry, 2015. 27(2): cal decline from childhood to midlife. Proceedings of the National p. 134-41. Academy of Sciences, 2012. 109(40): p. E2657-E2664. 19. Campolongo, P., et al., Developmental consequences of perinatal can-3. Wallace, M., et al., Dose-dependent effects of smoked cannabis nabis exposure: behavioral and neuroendocrine effects in adult rodents. on capsaicin-induced pain and hyperalgesia in healthy volunteers. Psychopharmacology, 2011. 214(1): p. 5-15. Anesthesiology, 2007. 107(5): p. 785-96. 20. Zwerling, C., J. Ryan, and E.J. Orav, The efficacy of preemployment drug screening for marijuana and cocaine in predicting employment4. O’Connell, T.J. and C.B. Bou-Matar, Long term marijuana users seek- outcome. JAMA, 1990. 264(20): p. 2639-2643. ing medical cannabis in California (2001-2007): demographics, social 21. Fergusson, D.M. and J.M. Boden, Cannabis use and later life outcomes. characteristics, patterns of cannabis and other drug use of 4117 appli- Addiction, 2008. 103(6): p. 969-976. cants. Harm Reduct J, 2007. 4: p. 16. 22. Brook, J.S., et al., Adult work commitment, financial stability, and social environment as related to trajectories of marijuana use beginning in5. Sabet, K.A. and E. Grossman, Why do people use medical marijuana? adolescence. Subst Abus, 2013. 34(3): p. 298-305. The medical conditions of users in seven U.S. states. Journal of Global 23. Macleod, J., et al., Psychological and social sequelae of cannabis and Drug Policy and Practice, 2014. 8(2): p. 1-26. other illicit drug use by young people: a systematic review of longitudi- nal, general population studies. Lancet, 2004. 363(9421): p. 1579-88.6. Ray, D.E., Medical Marijuana Regulatory System: Part II. Department 24. Erickson, W., C. Lee, and S. Von Schrader, Disability Status Report: of Public Health and Environment Department of Revenue; Office of United States. Ithaca, NY: Cornell University Employment and the State Auditor, June 2013. Disability Institute (EDI).(2012). 25. Anthony, J.C. and K.R. Petronis, Early-onset drug use and risk of later7. MacMaster, D., Legal Marijuana Will Generate Heavy Costs. Addiction drug problems. Drug and alcohol dependence, 1995. 40(1): p. 9-15. Professional, 2014. 26. Lopez-Quintero, C., et al., Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine:8. Office of National Drug Control Policy: Answers to Frequently Asked Results of the National Epidemiologic Survey on Alcohol and Related Questions about Marijuana. http://www.whitehouse.gov/ondcp/ Conditions (NESARC). Drug and alcohol dependence, 2011. 115(1): frequently-asked-questions-and-facts-about-marijuana. p. 120-130. 27. Hall, W. and L. Degenhardt, Adverse health effects of non-medical can-9. Armentano, P., Marijuana Prosecutions For 2010 Near Record High. nabis use. The Lancet, 2009. 374(9698): p. 1383-1391. National Organization for the Reform of Marijuana Laws. http:// 28. National Survey on Drug Use and Health (U.S.) and S.A.M.H.S. norml.org/news/2011/09/19/marijuana-prosecutions-for-2010-near- Administration, Results from the 2013 National Survey on Drug Use record-high. and Health : Summary of National Findings. 2014, Dept. of Health and Human Services, Substance Abuse and Mental Health Services10. FBI, Crime in the United States. Criminal Justice Information Services Administration, Office of Applied Studies: Rockville, MD. Division of the Federal Bureau of Investigation, 2010. Table 29(http:// 29. Marijuana Annonymous, Detoxing from Marijuana. https://www. www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-in-the- marijuana-anonymous.org/literature/pamphlets/detoxing-from- u.s.-2010/tables/10tbl29.xls). marijuana, 1992. 30. Radhakrishnan, R., S.T. Wilkinson, and D.C. D’Souza, Gone to Pot - A11. Couper, F.J. and B.L. Peterson, The prevalence of marijuana in sus- Review of the Association between Cannabis and Psychosis. Front pected impaired driving cases in Washington state. Journal of analytical Psychiatry, 2014. 5: p. 54. toxicology, 2014. 38(8): p. 569-574. 31. Di Forti, M., et al., Confirmation that the AKT1 (rs2494732) genotype influences the risk of psychosis in cannabis users. Biol Psychiatry, 2012.12. Pacula, R.L., et al., Risks and Prices: The Role of User Sanctions in 72(10): p. 811-6. Marijuana Markets. B E J Econom Anal Policy, 2010. 10(1). 32. Caspi, A., et al., Moderation of the effect of adolescent-onset cannabis use on adult psychosis by a functional polymorphism in the catechol-13. Battistella, G., et al., Long-term effects of cannabis on brain structure. O-methyltransferase gene: longitudinal evidence of a gene X environ- Neuropsychopharmacology, 2014. 39(9): p. 2041-2048. ment interaction. Biol Psychiatry, 2005. 57(10): p. 1117-27.14. Rubino, T. and D. Parolaro, Cannabis abuse in adolescence and the risk of psychosis: A brief review of the preclinical evidence. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 2014. 52: p. 41-44.15. Rubino, T., et al., Changes in hippocampal morphology and neuroplas- ticity induced by adolescent THC treatment are associated with cogni- tive impairment in adulthood. Hippocampus, 2009. 19(8): p. 763-72.16. Gleason, K., et al., Susceptibility of the adolescent brain to cannabi- noids: long-term hippocampal effects and relevance to schizophrenia. Translational psychiatry, 2012. 2(11): p. e199.17. Quinn, H.R., et al., Adolescent rats find repeated Δ9-THC less aversive than adult rats but display greater residual cognitive deficits

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