July/Aug 2023 GCMS Journal

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EDITOR'S PAGE

by Jim Blaine, MD

The inspiration for this Journal issue began on Saturday April 1 in Kansas City at the 165th MSMA Annual Convention with the presentation of Roneet Lev, MD entitled: " Marijuana/Cannabis Guidance for Medical Providers: Follow the Science".

This San Diego Emergency Physician/Addiction Specialist knows what she is talking about; she is the Vice President of the International Association on the Science and Impact of Cannabis. She is also the former Chief Medical Officer at the White House Office of National Drug Control Policy.

Dr. Lev updated us all in KC about the risks of current marijuana including the fact that it is not the 4% THC of 1995; it is now up to seven times stronger. She enlightened us on the fact that concentrated products such as vapes, dabs, and shatter can have concentrations near 90%. She told us that 3 in 10 regular users have marijuana use disorder (addiction), and that marijuana can cause brain damage in users under 25 especially if they start young and use regularly. Please check out her article, You, Your Patients, and Weed Guidelines for Healthcare written especially for GCMS in this issue. Her friend Laura Stack from Colorado has written an article for MSMA, "Marijuana Killed My Son! Doctors, Let Me Tell You Something About the Dangers of Cannabis". Her article is reprinted in this issue with the kind permission of MSMA, and Dr. John Hagan, MOMED Editor.

Colorado legalized Recreational Marijuana in 2012 along with a 30% tax; a significant portion of which goes to the Colorado Marijuana Tax Cash Fund which funds health care, health education, substance abuse prevention, and treatment programs. Missouri, by contrast, legalized Recreational Marijuana in December 2022 with a 6% tax, the lion's share of which goes to pay for 'operational costs, salaries, and legal fees'. A smaller portion goes to public defenders, veterans, and treatment programs. Virtually nothing goes to public education on the myriad of risks present in today’s marijuana offerings. However, the Springfield City Council has placed a 3% marijuana tax on the ballot August 8, with the proceeds going to public safety, mental health services, housing, and substance abuse. The GCMS Executive Council unanimously endorsed this effort and this resulted

in the taping of several videos highlighting risks of Marijuana recorded by Drs. Kayce Morton, David Barbe, J.T. Rogers, and Sanjay Havaldar. These 15 second videos were aired on KY3 newscasts for the four days preceding the election. GCMS also distributed Facts About Marijuana flyers to area newspapers, and churches; this resulted in at least two NewsLeader stories. Many thanks toKurt Larson (Safe & Sober), and Ron Penney for their financial support of the KY3 ads. The Marijuana tax increase passed 70% to 30%.

Next, local attorney Kurt Larson reminds us why the developing brain makes our youth particularly vulnerable to the effects of stronger-than-ever marijuana and other dangerous substances, and why the stakes are higher than ever been before when it comes to kids experimenting in this post-pandemic environment. Larson shares how for 20 years the nonprofit " Safe and Sober " has delivered state-wide prevention to get the word out to students and their parents. Our next article travels over a thousand kilometers off the coast of Ecuador to the Galapagos Islands for a amazing journey through the eyes of Dr. Mike Ashley and his lovely daughter Mary Beth.

Cox Health President and CEO Max Buetow is a strong supporter of physicians, and our need for more physicians in our community. He points out in his article that non-US international medical graduates (IMGs) face an unnecessary barrier under the federal Conrad State 30 Program that unfairly limits the IMGs due to the extremely low waiver cap.

I recently heard Dr. David True give a talk to GCMS physicians at the GCMS Highland Springs meeting and was impressed with his commonsense presentation that helped demystify Rheumatology workups. His article on Raynaud’s Phenomenon proves that he writes as good as he talks.

Dr. Victor Pace, former GCMS Co-Editor now practicing in St. Louis, writes about, " The Value of Our Medical Society" in his Pace’s Post. In this informative article, Victor recognizes many of the public health efforts in the GCMS past. It is the primary reason we exist!

PRESIDENT'S PAGE

by Sanjay Havaldar, MD

“I’ve got a man who has swallowed a toothbrush”!

This was the start of a recent Saturday morning call. The call was from the ER doctor and while unusual, was not completely unexpected. Because my partner had taken care of the same man a week earlier and I had already heard the war stories from the endoscopy staff. He was a 57-y man who had been transferred from the psychiatric ward after swallowing a pencil. My partner had removed the pencil the week before and the man was admitted to the hospital with close supervision. Two days later, he swallowed a toothbrush requiring another EGD by the same partner during the night. It was a difficult procedure because of food in the stomach and patient agitation requiring multiple assistants. After the procedure, he was observed in the ICU on a Precedex drip for severe agitation and eventually sent home.

Five days later, he swallowed a toothbrush (second time ) after getting into an argument with a relative online. Even though my procedure was done with anesthesia assistance, it was still quite difficult due to the length of the tooth brush. Before the procedure, I shared my concern with the patient about risks of perforation during the procedure, especially if he kept swallowing objects. He was quite aware of this and shared that he had already required surgery at a different hospital after swallowing a fork. Luckily, the toothbrush was removed without complications and the patient was eventually discharged from the hospital without problems.

Curious about his need for 3 EGD’s within a week, I reviewed his chart and I noted that his encounters with the health care system were frequent and ongoing. He had numerous hospitalizations at another hospital in the city for years and had just been discharged from an inpatient psychiatric facility before coming to our system. Within the past 2 years, he had multiple trips to our ER with agitated behavior, suicidal ideation/ attempts, and previous foreign body ingestions.

He is in a demanding situation: battling multiple psychiatric conditions (listed diagnosis include bipolar disorder, borderline disorder, antisocial personality disorder and PTSD) and being homeless at times.

Yet, the patient may have contributed to some of the problems himself as well. He had been a resident of an assisted living facility and had eloped several times by pulling the fire alarm. He has had multiple evaluations by psychiatrists, including during the two most recent hospitalizations. He was provided with all his psychiatric medications when discharged after the first toothbrush ingestion with transportation to a shelter with nighttime sleeping arrangements. He has also been assigned a court-appointed guardian.

Many of the ER visits were initiated by police who occasionally had to bring him in handcuffs. He was described as spitting and cursing with violent behavior directed at physicians, staff and security personnel with combative behavior noted at inpatient psychiatric wards as well. Manipulative behavior has been noted as well: frustrated with a long wait in the ER reception area, he swallowed a plastic knife so that he would be brought back immediately. During one of the ER visits, a psychiatrist concluded that inpatient psychiatric therapy may not be helpful since his issues were felt to be behavioral.

Obviously, this is a frustrating situation—many community resources have been enlisted to help this man but have not been effective. While he remains at risk of serious complications from the repeated ingestions, this is also taking a toll on the community of caregivers: the police and EMS staff who have to bring him in to the ER, the staff and other residents at the assisted living facility as well as the staff at the ER and psychiatric units. Extreme cases such as these contribute to burn out and divert care from other patients. While all of us strive to be compassionate and nonjudgmental in the care of our patients, it becomes more challenging in certain cases.

One can only hope that at some point, one of the interventions for this man can be successful before he suffers irreparable harm.

YOU, YOUR PATIENTS, AND WEED GUIDELINES FOR HEALTHCARE PROVIDERS

by Dr. Roneet Lev, MD

Your patients use marijuana, perhaps even your colleagues. Face it, people get medical advice not just from you. They listen to Dr. Google, social media and their friends. Marijuana/ cannabis is legal for recreational or medical use in many states and is highly commercialized. In 2020, an estimated 57 million Americans used cannabis in the past year. Like health risks associated with alcohol and tobacco, there are health risks associated with cannabis use. Whether you are for or against legalization of marijuana, you need to know the science to best advise your patients. The following is evidencebased guidance and some case examples to consider for patients who use marijuana.

Nomenclature

Marijuana refers to the plant and cannabis refers to the over 540 chemicals in the plant. The medical literature uses both the terms marijuana and cannabis. The main psychoactive component of cannabis is delta-9-tetrahydrocannabinol (THC). A non-psychoactive cannabinoid in the cannabis plant is cannabidiol (CBD). The definition for hemp was set by Congress as products with less than 0.3% dry weight delta 9-THC. This was a poor definition that resulted in the sale of dangerous products. Delta 8 and Delta 10 THC technically meet the definition of hemp, because they don't contain delta-9 THC. However, these products have never been tested on animals, let alone humans, and have caused serious reactions and even death of a child. The new delta THC products are synthetic, not plant based. The FDA has issued a warning on these products that they do not regulate. Congress will need to fix their problem definition.

FDA Guidance

If patients want to know whether marijuana or CBD is safe, I direct them to the FDA label. The FDA has researched and published adverse effects and warnings for pure THC and CBD when approving the medications. FDA approved THC is called Dronabinol or Marinol, and FDA approved CBD is sold as Epidiolex. The information in this drug labeling is applicable to THC and CBD that patients may take, although drug purity and dosage from a dispensary does not meet the same standards of a pharmacy.The FDA warning for Dronabinol includes neuropsychiatric adverse reactions, hemodynamic instability for patients with cardiac disorders, seizures, paradoxical nausea, vomiting, and abdominal pain. The FDA warning for cannabidiol includes hepatocellular injury, somnolence and sedation, suicidal ideations, and withdrawal seizures.

Potency

As a young doctor I never saw marijuana poisoning in the emergency department. Today, I treat marijuana poisoning every shift. The reason is increased use and increased potency. Cannabis products sold at dispensaries have been

genetically altered for high percentage or milligrams of THC. The smoked plant products may have THC at 17 – 30%. The concentrated products such as vapes, dabs, and shatter, can have concentrations near 90%. In comparison, the marijuana plant of 1995 averaged 4% THC. The maximum dose of FDA approved Marinol is 20 mg. A 1990's 1 gram joint had an average of 50 mg. Today's joint is 4 times as strong or 200 mg. A package of edibles may be 100 mg which has a 5-fold increase in physiologic effect, or the equivalent of ten old time joints. Concentrates can be as strong as over 100 1990's joints, resulting in stimulant effects.

Contaminants

People believe that nice packaging or a nice store means a clean product. In a study from UC Davis, 20 out of 20 legal dispensaries were found to have contaminants in their plantbased products. Fungal contamination with cannabis flower is well known. Cross contamination can occur to the edible products. Therefore, the CDC has issued a warning against smoking cannabis for organ transplant recipients and those with other immunocompromising conditions. This is important when cancer or immunocompromised patients ask about using marijuana verses opioids. Opioids are safer in terms of reliable dosages, avoiding lung irritation, and avoiding contaminants. In a recent study, CBD and cannabidiol products have been found to be contaminated with lead, cadmium, arsenic, mercury, and phthalates. I teach my patient to look for a USP seal when buying vitamins and supplements. That is the only reliable method of insuring product integrity.

The Growing Brain

As a health professional, you can change a young person's life trajectory with education. I teach patients that they probably don't want to stunt the growth of their brain. Brain development continues past bone development, into the mid 20’s, with final myelination occurring in the frontal cortex and pruning of neuronal pathways. The incomplete frontal lobe development results in poor executive functioning and several traits like impulsivity and sensation-seeking that are associated with the risk of developing a substance use disorder. Substance exposures to the growing brain are up to 7 times more likely to result in addiction than for older adults. While the legal age for drinking alcohol or consuming cannabis may be 21, the scientific age for preventing addiction is 25 years or even older.

Pregnancy and Lactation

The Surgeon General has issued a warning against using cannabis products while pregnant. The American College of Obstetrics and Gynecology similarly advises against using cannabis products during conception, pregnancy, and

lactation. THC has known genotoxic effects, and both men and women should ideally abstain from cannabis while trying to conceive. There is increasing evidence of correlations between fetal exposure to cannabis and worse maternal and fetal outcomes. Longitudinal findings from the Adolescent Brain Cognitive Development (ABCD) Study who an association of mental health burden with prenatal cannabis exposure from childhood to early adolescence.

Pediatric Safety

Marijuana related hospital encounters in children under the age of 6 increased 13.3-fold in 2018 compared to 2004, with 15% requiring intensive care treatment. Our Children's hospital in San Diego reports two poisoning a day with an average age of just two years old. They studied babies who were poisoned and found the number one product was edible gummies, and the number one source was mom. Cannabis products should be locked away from children. Ideally the products would be in child proof containers.

Geriatric Safety

I treated an older man who was given a brownie by his grandson with good intentions for sleep. Grandpa slept well, too well. He had to be admitted with encephalopathy. In a study of California emergency department visits, adults over age 65 were found to have a 1804% increase rate of cannabis associated emergency visits from 2005 to 2019. This rise can be due to cardiac, pulmonary, or GI effects. Older patient may have reduced metabolism of cannabis and more susceptible to drug interactions.

Drug Interactions

I treated a man with internal bleeding who was admitted to the hospital 3 times, each time requiring transfusions. He used marijuana for years without a problem, but that was before he was started on Plavix for his cardiac stents.Both THC and CBD are metabolized by the cytochrome P450 system and therefore may interact with many medications. There are many pain medications and psychiatric medications that interact with CBD and THC. THC and CBD used with blood thinners present a risk of spontaneous bleeding. I tell patients who have a constellation of symptoms to go on line with their phone and go to Drugs.com. I direct them to the drug interaction checker. Entering cannabis for THC or cannabidiol for CBD allows them to read interactions symptoms for themselves. It is a powerful tool.

Cannabis Induced Psychosis

Not everyone who smokes tobacco will develop cancer, heart disease or emphysema, but it is a known risk factor. Similarly, marijuana is a risk factor for psychosis which can turn into permanent schizophrenia. Cannabis is known to cause neuropsychiatric symptoms according to the FDA drug label for low concentration THC. High potency THC has a greater association with psychosis. Large European studies associated high potency THC, defined at over 10% concentration in plant-based products, with 5 times increase odds ratio of developing a psychotic disorder. A review published in

Lancet of 10 studies including 7390 patients showed a doseresponse between frequency of cannabis and risk of psychosis. Furthermore, states with liberal cannabis laws have increased psychosis associated with cannabis. Using statistical models, 30% of cases of schizophrenia among men age 21-30 might have been prevented if they were not addicted to marijuana. Patients with underlying schizophrenia, bipolar or depression should be advised to avoid THC. Explaining to patients that their mental health crisis may be related to THC could have a positive impact in their recovery.

Cannabis Associated Suicide

In Colorado and San Diego, the number one drug found in people who died by suicide under the age of 25, the age of the growing brain, is marijuana - more than alcohol.

Cannabis Use Disorder

Marijuana is addicting. The risk of addiction is greater with younger age of onset and increased frequency. Cannabis use disorder is defined using the same DSM V 11-point criteria as alcohol use disorder or opioid use disorder. Cannabis use disorder occurs in 9% of those who experiment with marijuana, 17% in young people, and up to 30% of daily users. Not all people who use marijuana will end up using fentanyl, but nearly all people who use fentanyl, started their journey into drugs with marijuana.

Cannabis Withdrawal

Cannabis withdrawal is reported by up to 30% of regular users and in 50-90% of heavy users. Many cannabis users do not believe they suffer from withdrawal until they understand that the symptoms of cannabis withdrawal are different than alcohol or opioid withdrawal. The common symptoms of cannabis withdrawal are irritability, anxiety, insomnia, and headache, and significant cravings for marijuana. Typically, these symptoms last for about 2 weeks after cessation.

Cannabis Hyperemesis Syndrome

Every shift I make the audible diagnosis of scromitingscreaming and vomiting. There is no sound like it. Patients are miserable, retching, vomiting, complaining of abdominal pain, and writhing on the gurney. The reaction is in contrast to patients with a surgical abdomen who are still in order to avoid pain. There are reported deaths with Cannabis Hyperemesis Syndrome (CHS) caused by electrolyte imbalance. CHS is associated with long-term cannabis use, typically of smoked product. The etiology is based on inundation of THC on the cannabinoid receptors causing the neurons to act irradicably. The cure for cannabis hyperemesis syndrome is cessation of marijuana use, which is easier said than done since people with this disorder most likely have an addiction. Patients with CHS may be in denial of their addiction. It is therefore helpful to explain that withdrawal symptoms include anxiety and insomnia but should last only two weeks. Hot showers can help with mild cases, but antipsychotic medications may be needed in severe cases. It is important to avoid opioids and benzodiazepines to prevent additive addiction. It is also best to avoid radiation and procedures. Many

have been exposed to multiple abdominal CT scans without a solid diagnosis. I give patients a copy of their CT scan and instruct them to share it with doctors in the future so that they avoid excessive harmful radiation.

Cardiovascular Health

I treated a 50-year-old woman who was scromiting and was asking for Haldol. She also had chest pain that I initially thought was from retching, but her troponin was high and she suffered an "NSTEMI". (Non-ST-Elevation Myocardial Infraction). Patient with cardiovascular disease should be cautioned about cannabis use related to their individual medical diagnosis, per American Heart Association. THC acts as a stimulant and has been associated with myocardial infarction, cardiac arrhythmias, and stroke like symptoms. Heart and stroke patient should be cautioned against using marijuana to protect their heart.

Pulmonary Health

Smoking and vaping of any product is detrimental to pulmonary health. Smoked cannabis products can contain similar toxins to tobacco products. EVALI, (Electronic Vaping Associated Lung Illness) was an epidemic before the COVID pandemic. Cases of EVALI still occur in people who vape marijuana products. In an interesting study of CT scans, marijuana smokers showed higher rates of emphysema than tobacco smokers. Another study of second hand emission rates, cannabis joints produced 3.5 times the emission of a Marlboro cigarette.

Opioid Use Disorder and Pain

Cannabis is contraindicated in patients who have an opioid use disorder according to the American Society of Addiction Medicine. Concurrent marijuana and long-term opioid use does not improve pain. Cannabis use increased the risk of opioid use disorder in a study of 34,653 participants. The International Association for the Study of Pain states that there is lack of evidence from high quality research on using cannabis for pain, and does not endorse the use of cannabinoids to treat pain. The American Pain Society is permissive for physicians to try cannabis for pain in patients with a favorable risk-benefit profile, but warns that monitoring use should be similar to monitoring opioids.

Anesthesia

Surgeon and Physicians involved in medical clearance before surgery should be familiar with the presurgical marijuana screening guidelines. Patients who use cannabis can have poor pain control and increased complication with surgery. The American Society of Regional Anesthesia and Pain Medicine (ASRA) released guidelines in 2023 on marijuana. Their guideline contains several recommendations, including a Grade A recommendation for universal screening of patients for cannabis use and postponing elective surgery in patients who have acute cannabis intoxication. Grade C recommendation is delaying non-emergent surgery for a minimum of 2 hours after cannabis smoking because of the risk of MI.

Drugged Driving

Research shows that people should wait 4.5 hours after smoking cannabis before getting behind the wheel. They may have impairment without realizing it. For edibles, the time frame is longer. Drugged driving is a public health issue that is growing. Marijuana users were about 25% more likely to be involved in a crash than drivers with no evidence of marijuana use. The National Highway Traffic Safety Administration published information on Drug-Impaired Driving. In a study of 191 regular cannabis users who smoked 5.9%, or 13.4% delta-9-THC cigarettes, simulated driving worsened in the THC group compared to controls. The results were unrelated to THC content, use history or blood THC concentration. Driving impairment was indistinguishable from placebo at 4.5 hours post consumption.

Documentation

Please list all applicable drugs, including cannabis in your diagnosis. Don't stop at the first or second drug. List them all.

Government health policy and budget rides on our ICD-10 coding and diagnosis. I am guilty of being frustrated by finding the correct diagnosis on the computer and settling for a code that may not be accurate. But I witnessed how billions of dollars are riding on our documentation. If fentanyl and opioids are coded, there is more spending on opioids. If there is no methamphetamine or marijuana coding, it appears that it is not a problem. The results of a drug screen are not evaluated by the epidemiologists who provide data for health policy, the decision making is all based on diagnostic coding. If a patient has psychosis, a history of schizophrenia and is not taking their medication, and tests positive for THC and methamphetamine, list all of the above in your diagnosis: "psychosis, schizophrenia, cannabis poisoning, methamphetamine poisoning, medication noncompliance". ICD-10 codes are still in development for the various cannabis associated diagnosis. If you cannot find the cannabis related ICD10 code, select “Cannabis poisoning” as a default diagnosis along with chest pain, atrial fibrillation, vomiting, or other condition. You can also select "cannabis use."

References

• The International Academy on the Impact and Science of Cannabis, IASIC has a medical library with many references of the adverse events of cannabis.

• NIH – National Center for Complementary and Integrative Health. Cannabis and Cannabinoid What you Need To Know

Dr. Roneet Lev practices emergency and addiction medicine at Scripps Mercy Hospital in San Diego and Vice President of IASIC, the International Association on the Science and Impact of Cannabis. She is the former Chief Medical Officer at the White House Office of National Drug Control Policy. You can follow her podcast, High Truths on Drugs and Addiction.

MARIJUANA KILLED MY SON! DOCTORS, LET ME

TELL YOU SOMETHING ABOUT THE DANGERS OF CANNABIS

by Laura Stack

Reprinted with permission.

Marijuana, legal for recreational use in Colorado since 2012, killed my son Johnny Stack at age 19. He started using at 14, obtained from a friend’s older 18-year-old brother, who had a medical marijuana card. Johnny got his own medical marijuana card at 18 years old from an unknown doctor, and he had no medical or mental conditions—he just wanted to get high with his friends. Today’s marijuana, very high in THC (Tetrahydrocannabinol, the euphoria producing-addicting substance in cannabis products) is destroying the health and social structure of my state Colorado. Marijuana, whether obtained with a medical marijuana card or purchased for recreational use, could kill you, your child, your patients, and it will lay waste to the health of Missouri. As physicians and as parents, you must not let this happen. I thank your medical journal Missouri Medicine for this unique opportunity to address physicians directly. Let me tell you about my deceased son Johnny and the marijuana-caused morass that the Centennial State is becoming.

Colorado Goes to Pot

Colorado passed a medical marijuana law in 2000, and in 2012, Colorado was the first state to legalize recreational marijuana (HiTHCpot). Many people believe the false narrative that because marijuana is legal, it must be safe and harmless. By 2014, HiTHCpot was appearing in high schools. My son, Johnny, was 14 at that time. Five years later, he died by suicide after becoming psychotic from ‘dabbing’ HiTHCpot (no other drugs in his system). Johnny had been diagnosed with “THC abuse – severe” by a psychiatric hospital.

Devastated by his death, I formed a nonprofit, Johnny’s Ambassadors (www.johnnysambassadors.org). I began research on HiTHCpot and wrote a 300-page book with 176 scientific citations, The Dangerous Truth About Today’s Marijuana: Johnny Stack’s Life and Death Story (see sidebar). In Johnny’s memory, I will go anywhere to speak with anyone who will listen about the epidemic of HiTHCpot and the misery, poor health, and death it causes.

High THC Concentrates

Hash oil is a concentrated cannabis extract that can be smoked, vaped, eaten, or rubbed onto the skin. Hash oil products first appeared around 2010. Medical pot dispensaries began to carry early versions of known as budders, saps, and waxes (Figures 1 and 2). They weren’t common in 2012 when voters in Colorado legalized recreational marijuana. But by 2015, these novel high-potency waxes and extracts were being used by high schoolers. The Colorado Department of Public Health and Environment started tracking “dabbing” on its annual Healthy Kids Colorado Survey (HKCS). I’d never heard

Missouri State Medical Association (MSMA)

of concentrates and didn’t know a “dab” of marijuana from a dance move. In fact, it wasn’t for another two years until Johnny left for Colorado State University (CSU) that we found a HiTHCpot “Nectar Collector” in his dorm room and said, “What is this stuff ?”

Dabs and Dabbing

Have you ever heard of dabbing? No, not the hip-hop dance! “Dabs” are extracted concentrates of tetrahydrocannabinol or THC, the chemical (cannabinoid) in marijuana that makes users “high.” The 2019 HKCS reported 10.2% of high school students use dabs, and of those who admit to using marijuana, 52% report dabbing—a nearly 70% increase in only two years.

Here’s how dabs are made: Cannabis flowers are run through a solvent such as butane, ethanol, or propane. The THC leaves the plant material and dissolves into the solvent. The concentrated THC solution is filtered to remove most of the solvent and dried in a tray. The result is a sticky, bronze-colored oily substance that looks like beeswax or earwax. These can be additionally processed into distillates, which are more pure THC oils and extracts. Dabs are a chemical, not a plant, and they are highly potent, containing up to 99% THC. Dabs are typically heated on a hot surface with the vapors inhaled through a dab rig or dab pen.

Dabs are usually called by their consistency, such as shatter, wax, budder, crumble, live resin, or pull ’n snap (Figure 1). Many advocates, usually in states like Colorado and Nevada where recreational marijuana use is legal, defend dabbing as no worse than smoking pot. But they’re full of it. Dabbing carries a lot more risk for mental illness and addiction than smoking. And its levels of THC aren’t regulated or restricted. Dabbing isn’t the only way high-potency marijuana is delivered. There’s also:

Smoking

This refers to the dried flowers of the marijuana plant. In practice, it could include seeds, bits of stems, and shredded leaves as well. Users often refer to any cannabis plant matter by the catch-all terms flower, herb, bud, or grass. Until the 1990s, THC potency in herb averaged 3-5%; now, it varies between about 12-25%, depending on the cannabis strain, with an average of 18.8% in 2019.1 Growers continually increase herb potency through selective breeding, and they boast strains from 69.4% THC. It’s usually smoked using a pipe or a bong or rolled into a joint or a blunt.

Eating (Edibles Such as Candy and Brownies)

Edibles are made either directly with the dried flower or with

THC concentrates, so potency varies widely. In Colorado, one serving in an edible is measured in milligrams (mg) rather than percentages, and is 10 mg THC per serving. However, not all states are regulated. Be aware that one package (such as a candy bar) could contain 1,000 mg or more, so the serving size consumed is extremely important.

Vaping (Such as Oil and Distillates)

Users vape high-THC oil in a pen. Distillates go through extra refinement processes to remove additional compounds.

Once the THC has been distilled, it is re-condensed, and the finished product can be anywhere from 15% to 99% pure THC. Distillates like these are usually vaporized, but users also put them under the tongue, dab them, smoke them, ingest them in a capsule, or infuse them into an edible.

Other Products (THC-Infused Soda, Tampons, Suppositories, Toothpicks, etc.)

The pot industry has created countless ways to get THC into the body through any opening.

Doctor, what you really need to know is this — even today’s more potent marijuana plants contain 28% THC2 or higher (with one grower boasting over 40%), while the weed hipsters rolled in the ’70s and ’80s was 2-5% THC. Dabs are more than three times more potent than the strongest marijuana plant. A dab is no longer a plant. Dabs aren’t natural; they are potent, potentially lethal chemicals. Dab is to marijuana what crack is to cocaine. Depending on potency, one dab is like smoking three to five joints at once. For example, an edible brownie contains one serving of THC which is 10 milligrams. In a variant like Shatter, that is 65% THC, one gram is actually 650 milligrams of THC!

The write-up on a bag of “Scooby Snacks Shatter” reads:

marijuana may impair your ability to drive a car or operate machinery. This product was produced without regulatory oversight for health, safety or efficacy. This product complies with testing requirements. This packaging is child resistant. This product is intended to be inhaled.”

High Potency THC Users Are Getting Younger and Younger

In addition to no regulatory oversight, here’s what’s worse dabbing has become popular among very young people.3 Many kids start dabbing by age 14. Most of the time, their parents don’t have a clue. You see, dab vapor doesn’t have the skunky smell most marijuana smoke has. It may not even have a scent at all, so kids can do it behind their parents’ backs at home and their teachers’ backs in school. Vaping THC doesn’t always make your breath stink in the same way tobacco and grass do, so they don’t have to be quite as sneaky. Vaping devices can look just like nicotine vaping devices, so check the cartridges. They may tell you they are “just vaping,” but be aware they could be vaping THC. “Vaping” can refer to nicotine or THC while dabbing is only marijuana (Figure 2).

“There may be long term physical or mental health risks from use of marijuana including additional risks for women who are or may become pregnant or are breastfeeding. Use of

Maybe you think young users are just being typical teens. Maybe you think marijuana is harmless because it’s legal. Maybe you think your child is getting straight As, so marijuana can’t be affecting him/her. Or your kid wouldn’t do that because you go to church. Well, I used to think all of that, too. Until the mid-to-late age 20s, a person’s brain is still developing,4 and intoxicants can damage brain development. Hence, one reason why 21 is the legal age for alcohol, pot, and cigarettes (except “medical” marijuana when the legal age is 18 and an oxymoron) is because people don’t actually get a prescription. It’s recommended “off label.” But numerous medical studies show dabbing can slow mental development and cause depression5 as well as trigger schizophrenia.6 And these mental illnesses can lead to suicide.7 My Johnny only realized that connection weeks before his death.

Compared to heroin or crack, marijuana has a lower addic-

Figure 2. Dabs are typically heated on a hot surface with the vapors inhaled through a dab rig or dab pen. Dabs are now used frequently by high schoolers and increasingly elementary students in Colorado and other legal recreational marijuana states.

Figure 1. Shatter marijuana is also known as BHO. It is a hash oil concentrate produced by the use of butane solvent to derive high THC levels from the marijuana plant.

tion rate, but the danger is today’s high-potency pot is extremely hazardous to the developing mind. It’s highly addictive8 with dabs being like pot on steroids. There’s also a high rate of psychological addiction among young people. Sure, maybe they could stop, but they enjoy the high so much, they don’t want to stop. It doesn’t take an addiction to dabbing to hurt you. For some who have tried dabbing, it took just one hit to put them in the hospital with life-threatening effects or cause psychosis.9 My 51-year-old girlfriend landed in the mental hospital for three weeks from hallucinations caused from hitting a dab pen twice. This doesn’t even account for all the damage dabbers do to their families10—often accidentally, sometimes fatally.

The Retail Marijuana Public Health Advisory Committee (RMPHAC) 2020 report,10 which is part of the Colorado Department of Public Health and Environment, issued this statement:

“The RMPHAC reviewed the relationships between adolescent and young adult marijuana use and cognitive abilities, academic performance, mental health, and future substance use. Weekly marijuana use by adolescents is associated with deficits in academic and cognitive abilities, even 28 days after last use. Weekly use is also associated with failure to graduate from high school or complete a college degree. Adolescents and young adults who use marijuana are more likely to experience psychotic symptoms as adults (such as hallucinations, paranoia, and delusional beliefs), future psychotic disorders (such as schizophrenia), and suicidal thoughts or attempting suicide. Evidence shows that adolescents who use marijuana can become addicted to marijuana, and that treatment for marijuana addiction can decrease use and dependence. Additionally, those who quit using marijuana have lower risks of adverse cognitive and mental health outcomes than those who continue to use. Marijuana use is also associated with future use and use disorder for tobacco, alcohol, and other drugs. Adolescent use of marijuana with higher THC concentration (>10% THC) is associated with continued use and development of future mental health symptoms and disorders.”

A joint study from the University of Michigan and Brown University11 found higher potency marijuana to be more addictive than low potencies. It is associated with a higher risk of cannabis use disorder (CUD) or marijuana addiction in young users. Researchers found that regular pot users who first tried marijuana when the national average THC levels held at 4.9% had almost twice the increased risk of developing symptoms of cannabis use disorder within a year. But those who started regularly using pot when national average THC levels were 12.3% had a 4.8 times higher risk of cannabis use disorder. And yet the state of Colorado continues to allow these high-potency THC products to be sold with no regulation or limitation on potency.

In a nutshell, marijuana harms adolescents in these ways:

Marijuana dependence12

Decreased IQ13

Increased risk of addiction with higher potency14

Increased odds of using other drugs15

Death from throwing up16

More likely to drop out of school17

Possible psychosis and schizophrenia18

Decreased fertility rates19

Lowered motivation to do things20

Possible paranoia and thoughts that others intend to harm you21

Health damages22

Poor driving skills23

My Johnny’s Suicide Was Caused by Dabbing

Three days before Johnny killed himself, he came over for dinner. He lived in our condo a couple miles down the street and would often pop in for a home-cooked meal. “I need to tell you that you were right,” he said to me. “Right about what?” I asked. “Right about the marijuana. You told me weed would hurt my brain, and it’s ruined my mind and my life. You were right all along. I’m sorry, and I love you.” He died by suicide

three days later, a victim of an acute psychotic episode. After he died, we recovered his journal, where he had just written, “the mob is after me.”

So doctor, if you think today’s high-potency marijuana is benign, I hope this article gives you some new information. Please become one of Johnny’s Ambassadors and help us save our youth from the harms of marijuana. And do what you can to keep high THC concentration chemicals from becoming legal for potentially deadly ‘recreational’ use. Don’t let Missouri go to pot!

References

1. National Institute on Drug Abuse. Marijuana Potency. 8 July 2020, www.drugabuse.gov/drug-topics/marijuana/marijuana-potency.

2. Stuyt, Elizabeth. “The Problem with the Current High Potency THC Marijuana from the Perspective of an Addiction Psychiatrist.” Missouri Medicine, vol. 115,6 (2018): 482-486.

3. Gillespie, Claire. “’Dabbing’ Pot is The New Dangerous Trend Among Teens—Here’s What to Know.” Health.com, 18 Feb. 2020, www.health. com/condition/smoking/dangers-of-dabbing-pot.

4. Gogtay, Nitin, et al. “Dynamic mapping of human cortical development during childhood through early adulthood.” Proceedings of the National Academy of Sciences of the United States of America, vol. 101,21 (2004): 8174-9. DOI: 10.1073/pnas.0402680101.

5. NIDA. “What are marijuana’s long-term effects on the brain?” National Institute on Drug Abuse, 8 Apr. 2020, https://www.drugabuse.gov/ publications/research-reports/marijuana/what-are-marijuanas-longterm-effects-brain. Accessed 13 Mar. 2021.

6. Di Forti, Marta, et al. “Daily use, especially of high-potency cannabis, drives the earlier onset of psychosis in cannabis users.” Schizophrenia bulletin vol. 40,6 (2014): 1509-17. DOI: 10.1093/schbul/sbt181.

7. Price, Ceri, et al. “Cannabis and suicide: longitudinal study.” The British Journal of Psychiatry: the Journal of Mental Science, vol. 195,6 (2009): 492-7. DOI: 10.1192/bjp.bp.109.065227.

8. Lopez-Quintero, Catalina 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 and Alcohol Dependence, vol. 115,1-2 (2011): 120-30. DOI: 10.1016/j.drugalcdep.2010.11.004.

9. Hlavinka, Elizabeth. “Meta-Analysis: Even One THC Hit Carries Risk for Inducing Psychosis.” Medical News and Free CME Online, MedpageToday, 17 Mar. 2020, ww.medpagetoday.com/psychiatry/generalpsychiatry/85472.

10. https://georgespicka.weebly.com/marijuana-links.html.

11. Thompson, Dennis. “Study: Today’s Stronger Pot Is More Addictive.” WebMD, 17 Dec. 2018, www.webmd.com/mental-health/addiction/ news/20181217/study-todays-stronger-pot-is-more-addictive.

12. Volkow, Nora, et al. “Adverse Health Effects of Marijuana Use.” New England Journal of Medicine, vol. 370, no. 23, 11 Apr. 2016, pp. 2219–2227., DOI: 10.1056/NEJMra1402309.

13. Meier, Madeline H., et al. “Persistent Cannabis Users Show Neuro-

psychological Decline from Childhood to Midlife.” PNAS, National Academy of Sciences, 2 Oct. 2012, www.pnas.org/content/109/40/E2657.

14. Barrington-Trimis, Jessica L., et al. “Risk of Persistence and Progression of Use of 5 Cannabis Products After Experimentation Among Adolescents.” JAMA Network Open, American Medical Association, 3 Jan. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC6991277/.

15. Fiellin, Lynn E., et al. “Prior Use of Alcohol, Cigarettes, and Marijuana and Subsequent Abuse of Prescription Opioids in Young Adults.” Journal of Adolescent Health, vol. 52, no. 2, Feb. 2013, pp. 158–163., DOI: 10.1016/j.jadohealth.2012.06.010.

16. Nourbakhsh, Mahra, et al. “Cannabinoid Hyperemesis Syndrome: Reports of Fatal Cases.” Journal of Forensic Sciences vol. 64,1 (2019): 270-274. DOI: 10.1111/1556-4029.13819.

17. Lynskey, M., and W. Hall. “The effects of adolescent cannabis use on educational attainment: a review.” Addiction (Abingdon, England), vol. 95,11 (2000): 1621-30. DOI: 10.1046/j.1360-0443.2000.951116213.x.

18. Marconi, Arianna, et al. “Meta-analysis of the Association Between the Level of Cannabis Use and Risk of Psychosis.” Schizophrenia Bulletin, vol. 42,5 (2016): 1262-9. DOI: 10.1093/schbul/sbw003.

19. Gundersen, Tina Djernis, et al. “Association Between Use of Marijuana and Male Reproductive Hormones and Semen Quality: A Study Among 1,215 Healthy Young Men.” American Journal of Epidemiology, vol. 182,6 (2015): 473-81. DOI: 10.1093/aje/kwv135.

20. University College London. “Cannabis reduces short-term motivation to work for money: Smoking the equivalent of a single ‘spliff’ of cannabis makes people less willing to work for money while ‘high’.” ScienceDaily. ScienceDaily, 1 September 2016, www.sciencedaily.com/ releases/2016/09/160901211303.htm.

21. Freeman, Daniel, et al. “How Cannabis Causes Paranoia: Using the Intravenous Administration of ∆ 9 -Tetrahydrocannabinol (THC) to Identify Key Cognitive Mechanisms Leading to Paranoia.” OUP Academic, Oxford University Press, 16 July 2014, academic.oup.com/schizophreniabulletin/article/41/2/391/2526091.

22. NIDA. “What are marijuana’s effects on lung health?” National Institute on Drug Abuse, 8 Apr. 2020, https://www.drugabuse.gov/publications/research-reports/marijuana/what-are-marijuanas-effectslung-health. Accessed 13 Mar. 2021.

23. Compton, Richard. “Marijuana-Impaired Driving A Report to Congress.” National Highway Traffic Safety Administration, July 2017, www.nhtsa.gov/sites/nhtsa.dot.gov/files/ documents/812440-marijuana-impaired-driving-report-to-congress.pdf.

WHY THE GALAPAGOS?

by Mike Ashley & Mary Beth May

Why the Galapagos? Simple. Charles Darwin. Everyone reading this is steeped in Biology and knows about evolution and the survival of the fittest. Combine this with the current rage in ecotourism and you have a trip to the Galapagos. The islands did not disappoint.

The Galapagos are a group of islands (an archipelago) 630 miles west of the mainland of South America. They are part of Ecuador. They are due south of Springfield about 2,220 miles (same meridian, 92 degrees west).

The archipelago straddles the equator with most of the islands south of the equator by 1 to 2 degrees and several north of the equator. They consist of 8 major islands, 20 minor islands, and about 200 rocky projections above sea level of the Pacific Ocean. They are volcanic in origin. Several have been pushed up by earthquakes, and have sedimentary characteristics. The oldest are 3.5 million years old, and the newest have been formed in 2018. Because of their location, and the prevailing ocean current they are isolated, and have only been discovered by Man in the last 400 years, and populated by Man in the last 100 years. The flora and fauna have colonized the islands, and have evolved outside the influence of the rest of the world until Man arrived.

The isolation of these islands, and the unique environment have given rise to a biologic paradise. Man’s influence began about 400 years ago. Whalers, and later, pirates were the first visitors. Up until then the animals had never had contact with Man. Consequently, they had no fear; much to their detriment.

The sailors took advantage, and replenished their stores of meat on their whaling trips. They easily captured the tortoises, and used them for fresh meat. The tortoises can live for up to a year without food or water, and are a source of vitamin C. The whalers thus had fresh meat, and avoided scurvy. To keep the animals from wandering around the ship they turned the turtles upside down, and the turtles couldn’t right themselves or move; very cruel. However; the largest tortoises weighed up to 600 pounds, and could potentially do a lot of damage if they were loose on a ship.

The turtle population became depleted, but no extinctions occurred until permanent human settlements, and invasive species were introduced to the area. Goats, and cattle could crush the eggs. Rats would eat the eggs. There were originally 14 species of turtles, and, by 1957, this was reduced to 9 species. One island had only 8 individuals left (2 males, and 6 females). Genetic variation was very limited. The local people realized they had a terrible problem, and formed an ecology system to save the turtles in 1957. There was a backlash from farmers, commercial fishermen, and most of the local population. The

Blue-footed booby

Giant Galapagos tortoise

Ecuador government ended up making the islands a National Park with 98% of the islands’ land now included. The decision had not been easy or popular. Currently, the economy and the popularity of the Galapagos are 99% based on eco-tourism. The COVID 19 pandemic wreaked havoc on the tourism industry and only returned to normal recently.

Let’s return to Charles Darwin. He was a student forced by his father to become a medical student……, but he hated medical school. He wanted to drop out. He spent four months of his second year studying natural history of animals, and then quit school to become a naturalist. He embarked on a round the world voyage. The voyage lasted 4 years and 10 months. He spent 30 days of that 5 years in the Galapagos in 1831. He secured specimens of many different flora and fauna. This included 25 finches. These 25 finches were shot by his assistant, and preserved for later study. They were identified as 24 separate species arising in defiant habitats on the islands and had developed different characteristics. The beaks were adapted to the food supply available. Those eating thick walled seeds had thick stout beaks, Those feeding on insects in crevices had long narrow delicate beaks, The beak structure was dependent on which island they lived. The birds with the optimal beaks had a competitive advantage and survived to reporduce.

These birds were the fittest for their environment. Due to the islands isolation, he presumed the birds were derived from a single original species, which evolved over time to separate species depending on their habitat. This was not an “Ah Ha”

moment; rather it took him 28 years of study and consultation along with several publications before he published his seminal work. A rival naturalist was preparing a similar thesis for publication. They both presented their works in 1859. Darwin then published his completed theory “ Natural Selection; on the Origin of Species”. The other author had some minor differences. He was ignored, and is largely forgotten. The finches are now called Darwin’s finches.

So that is my reason for wanting to see the Galapagos. I offered this trip to my daughter many years ago, but she became engaged to a boy, got married, went to graduate school, got a Master’s in Divinity at Notre Dame University, became Director of Religious Education at Fenwick High School in the Chicago suburbs, and had two children. The trip was delayed. Following the COVID 19 pandemic thing finally came together and we took the trip over Easter Week 2023. It was fabulous.

Lunch with one of Darwin's Finches

PAVING THE WAY FOR PHYSICIANS

by Max Buetow, Cox Health President & CEO

Health care is absolutely a team effort, but physicians remain the cornerstone of our industry. Therefore, it is imperative that we leverage every available opportunity to ensure that the U.S. remains the top choice in the globally competitive arenas of physician training and recruitment. Unfortunately, the data on the physician shortage in the United States makes it clear: we are falling way behind the curve. Ensuring that we are able to continue meeting the health needs of our communities will require us to aggressively pursue both long and short-term strategies. Perhaps the most important is examining our visa waiver process to accommodate more physician talent.

Research performed by the Association of American Medical Colleges (AAMC) indicates the U.S. could see a shortfall of up to 124,000 physicians by 2034 (AAMC, 2023). In 2019, that number was 20,000; that’s a 620% increase in only 15 years. Take a second to let that sink in. According to the AAMC, the primary factor for this looming deficit is an increase in service demand due to population growth and aging. By 2034, the overall population is expected to increase by nearly 11%, with the 65+ and 75+ age groups projected to respectively rise by 42% and 74% (AAMC, 2023). In contrast, the U.S. Bureau of Labor Statistics predicts a mere 3% growth in the number of physicians by 2031 (Bureau of Labor Statistics, 2023). There are numerous factors we must address if we want to bolster our physician supply, many of which will take considerable time and effort to gain traction. Advancing technologies, developing robust care teams, and facilitating good work-life balance will go a long way to not only attract new entrants to the profession, but also extend the careers of existing ones. These strategies must be a part of our playbook, but they will not be able to produce meaningful results in the short-term. We need to explore more actionable opportunities to deliver near-term impact.

One promising avenue that can have an immediate effect on this trend is expanding access for non-U.S. international medical graduates (non-U.S. IMGs) to our health care systems. The Educational Commission for Foreign Medical Graduates reports, in 2023, 13.4% of first-year U.S. residency positions were filled by non-U.S. IMGs (ECFMG, 2023). Furthermore, the number of non-U.S. IMGs registering for the Match increased by 7% compared to the stagnant position of U.S. trained MDs and DOs and U.S. IMGs (ECFMG, 2023). These statistics gain significance when considering that, as of 2021, over 20% (more than 203,500) of physicians practicing in the U.S. are non-U.S. IMGs (AAMC, 2021). These trends highlight a growing supply of interested and qualified doctors, but they are not directly translating into an increase in our regional talent pool.

Unfortunately, there are barriers in the way of achieving this goal, primarily stemming from outdated legislation related to U.S. immigration and visa programs. Among the various layers of this complex issue, one particularly relevant aspect for the communities of Southwest Missouri is the J1 visa waiver process under the federal Conrad State 30 Program. The Conrad program allocates 30 visa waivers annually to non-U.S. IMGs willing to practice in designated medically underserved regions for three years. While the program aims to address areas of greatest need based on geography, population, and medical specialty, its fundamental flaw is that the severely rationed number of 30 annual slots falls significantly short of meeting the growing physician deficit.

Though precise figures are not readily available regarding the number of nonU.S. IMGs unable to acquire waivers and are therefore forced to leave the U.S. after completing residency, our local health care systems do have firsthand experience of the challenges posed by the Conrad program. Due to the extremely low waiver cap, CoxHealth puts forward an average of just 2 candidates per year — ideally, that number would be closer to 5-7. Even with this bare-bones annual ask, we successfully secure waivers only 70% of the time, resulting in unmet needs in short-handed specialties such as pulmonary critical care, endocrinology, cardiology, and general surgery. Given the high retention rates of our health systems and the long careers of our physicians spanning 25+ years, the compounding effect of these missed opportunities cannot be overlooked.

The solution to our problem is seemingly simple — create a more accommodating visa waiver process to pave the way for these highly skilled, US residency-trained physicians who want to become integral parts of our communities. There is precedence for this level of legislative reform in other regions, namely under the Delta Regional Authority (DRA). DRA’s program closely mirrors Conrad in that it provides J1 visa waivers to physicians who are willing to practice in health care shortage areas. One key difference is DRA does not set a cap on supplied waivers. Under such an arrangement, our communities could see upwards of 5-10 more doctors joining our health systems every year.

It is important that we continue to grow the supply side of the health care workforce equation. Expanding the Conrad program's restrictions could also serve as a catalyst for broader immigration and health care reform, including creating a more accessible pathway to U.S. medical training programs. We are already witnessing a positive trend of non-U.S. physicians aspiring to pursue residency training in the U.S. With a streamlined immigration policy, it is not difficult to envision heightened confidence and increased interest in U.S. health care careers.

Preserving robust health care services within our communities is essential for the region's vitality. We encourage you to join the conversation surrounding the reform of federal physician immigration policy.

For further information on this subject or to learn how you can support these efforts, please email Teresa.Coyan@coxhealth.com.

References

Association of American Medical Colleges. (2023). The Complexities of Physician Supply and Demand: Projections from 2019 to 2034.

Bureau of Labor Statistics. (2023). Physicians and Surgeons: Occupational Outlook Handbook.

Educational Commission for Foreign Medical Graduates. (2023). ECFMG News | Match Shows Strong

Gains for International Medical Graduates (IMGs).

National Resident Matching Program. (2023). 2023-Main-Match-Results-and-Data-Book-FINAL.pdf.

Association of American Medical Colleges. (2021). 1 in 5 U.S. physicians was born and educated abroad.

Who are they and what do they contribute?

RAYNAUD'S PHENOMENON

by David True, D.O.

As summer rolls around, my thoughts turn to Raynaud’s phenomenon. I know, you’re thinking that’s silly and that Raynaud’s bothers people in the winter when it’s cold. True, however, it also bothers people in the summer. Air conditioning and lighter clothing such as shorts and sandals often trigger episodes. I see a lot of referrals for possible Raynaud’s, and it is apparent there some misconceptions about the phenomenon. I thought it might be good to discuss prior to colder weather to allow counseling of patients prior to cold weather when they might suffer more serious complications.

Raynaud phenomenon (RP) is an exaggerated vascular response to cold temperature or emotional stress. The phenomenon is manifested clinically by sharply demarcated color changes of the skin of the digits due to abnormal vasoconstriction of digital arteries and cutaneous arterioles due to a local defect in normal vascular responses.

The microcirculation, composed of arterioles, venules, and capillaries, functions to provide nutrition to tissue, remove waste products, and regulate regional blood flow. Arterioles have vasomotor capacity to alter regional blood flow to tissues. The cutaneous microcirculation has arterioles and venules that form two plexuses in the dermis, a superficial one in the upper papillary dermis that provides nutritional blood flow to the tissue and a lower deep plexus that is in the dermal-subcutaneous junction. Numerous arteriovenous anastomoses, connect the superficial to the deep plexus and are concentrated in nonhairy glabrous skin of the fingers and toes, palmar surface of the hands and feet, ears, nose, and some nonglabrous skin sites.

RP is considered primary if these symptoms occur without an associated disorder. Secondary RP occurs in association with a related illness. Examples of associations include connective tissue diseases such as scleroderma, systemic lupus erythematosus, cryoglobulinemia, paraproteinemia, hypothyroidism, atherosclerosis, carpal tunnel syndrome, fibromyalgia, migraine, prior frost bite, vibrational injury, emotional stress, and medications such as sympathomimetic and chemotherapeutic drugs, nicotine, ergotamines and interferons.

Unlike secondary RP, patients with primary RP may exhibit reduced total digital blood flow via arteriovenous anastomoses with flow typically preserved in the nutritional capillaries. Therefore, patients with primary RP do not typically develop critical ischemia.

Primary RP usually starts between 15 and 30 years old, is more common in females, and may be familial. Although patients with primary RP are generally otherwise healthy, comorbid conditions that may aggravate attacks include hypertension, atherosclerosis, and diabetes mellitus.

Symptoms of RP occur in episodes rather than persistently, with the exception of severe cases with critical ischemia. A typical episode is characterized by the sudden onset of cold digits with sharply demarcated color changes of skin pallor, due to constricted blood flow, followed by cyanotic skin, consistent with tissue hypoxia. With rewarming and reperfusion there can be erythema. The presence of self-reported or witnessed blue and white color changes are generally required for establishing the diagnosis. The symptoms of RP result from ischemia and may include pins and needles sensation, numbness, clumsiness of the fingers, and pain in the affected digit(s). Signs and symptoms should reverse on rewarming or reduction of stress except in more severe cases where they can be more persistent and rarely lead to ulceration, tissue loss or gangrene.

Exposure to cold temperature triggers RP. This occurs during relative shifts from warmer to cooler temperatures. As a result, mild cold exposures such as air conditioning or the cold of the refrigerated food section of the grocery store may cause an attack. Although attacks occur locally in the fingers, a general body chill will also trigger an episode, even if the hands or feet areas are kept warm. An attack may also occur after stimulation of the sympathetic nervous system such as emotional stress or being startled.

Evaluation should consist of the following questions:

1. Are your digits unusually sensitive to cold?

2. Do your digits change color when exposed to cold?

3. If the fingers change color, are there associated symtoms?

4. Do the symptoms resolve with warming?

History should include age of onset of the skin color changes, the involved digits, degree of symmetry and severity of the attacks, and any history of digital tissue loss. Physical examination should evaluate for tissue loss (ulceration, gangrene) typically affecting the fingers or toes.

A compA complete physical exam should include a thorough musculoskeletal and cardiopulmonary evaluation and peripheral pulses should be assessed for evidence of proximal vessel disease. Attempts to induce an attack, such as with a cold-water challenge, are not recommended since the responses are inconsistent even in those with definite RP.

Patients should be asked about symptoms suggestive of a systemic rheumatic disease such as fever, joint or muscle pain, swallowing difficulty, significant gastroesophageal reflux and thickening of skin, sclerodactyly. The patient should be asked about chemical exposures, occupational or recreational cold exposure, history of frostbite, exposure to excessive vibration, repetitive hand trauma such as a carpenter or blacksmith, and history of carpal tunnel syndrome. A thorough evaluation of medication history

should be obtained such as current or prior chemotherapy, betablockers, or sympathomimetic drugs.

Patients with a suspicion of secondary RP should undergo additional testing guided by the history and physical examination. Testing could include complete blood count and differential, metabolic panel, urinalysis, antinuclear antibody testing by indirect immunofluorescence testing, thyroid-stimulating hormone, and C-reactive protein levels.

There are several conditions and disorders that can mimic Raynaud’s phenomenon:

• Excessive cold sensitivity is very common. These individuals report cold hands and feet when they are exposed to a cold environment, without sharply demarcated skin color changes. This may be a familial trait. Cold sensitivity and decreased skin blood flow following cold exposure occurs more commonly in females and in the older population.

• External compression of blood vessels such as from carrying a heavy item, can cause a transient numbness, pallor, and/ or coldness. This is not induced by cold or stress and is easily reversed once blood flow is restored.

• Peripheral neuropathy can cause cold intolerance with numbness and nonspecific skin color changes in the hands and feet. These patients will not have a sharply demarcated color change and may also have distal loss of sensation to pin prick, light touch, cold, and proprioception.

• Occlusive vascular disease can cause a cold limb and may be associated with secondary vasospasm. Unlike Raynaud’s, symptoms are often asymmetric, may be irreversible and nonresponsive to vasodilator therapy and require vascular imaging to identify the occlusive lesion.

• Acrocyanosis is a functional peripheral vascular disorder characterized by symmetrical painless and persistent blue discoloration of the hands or feet, often aggravated by cold exposure. Acrocyanosis can be differentiated from RP by the relative persistence of skin color changes, symmetry, and absence of pallor. Acrocyanosis is aggravated by cold exposure but is often associated with hyperhidrosis of hands and feet and rarely responds to vasodilator therapy.

• Pernio (chilblains) is an inflammatory cutaneous condition involving localized swelling and erythema caused by exposure to cold and damp conditions. It typically involves the feet and less so the hands, ears, and face. In pernio there are papules, plaques, and nodular lesions.

• Erythromelalgia is an episodic condition manifested by profound redness of the skin triggered by warm temperature and opposite of Raynaud’s, is improved with cold exposure.

Avoidance of episodes is the primary treatment. Counseling the patient on wearing gloves and a light sweater when an exposure is likely or while transitioning from one temperature to another is key. Warming of the hands with warm water, sitting on hands

or placing them under their arms if warm water is not available. Avoid hot water to treat episodes as that can lead to thermal injury, particularly if hands are numb.

Removal of medications that could exacerbate symptoms is important. Beta blockers can occasionally increase symptoms. Even OTC decongestants can induce episodes. All tobacco cessation is paramount as even oral tobacco can trigger attacks.

Calcium channel blockers are the mainstay of medication therapy. This can either be short acting as needed or daily extended release during persistent colder weather. This should be based upon comorbidities, baseline blood pressure and likely tolerance.

In summary, RP is an exaggerated vascular response to cold temperature or emotional stress manifested by sharply demarcated color changes of the skin of the digits. RP is more common among females, younger age groups, and related family members of patients with RP. Patients with RP are described as having either primary or secondary Raynaud’s based upon evidence of an associated disorder or exposure.

With both primary and secondary RP, a typical episode is characterized by the sudden onset of cold digits precipitated by exposure to cold, with sharply demarcated color changes of pallor followed by cyanosis. Hyperemia can occur with rewarming. In patients with darker skin, the cutaneous changes may be more visible on the palmar surface of the fingers.

Every patient with a presumptive diagnosis of RP should undergo a careful history and physical to look for clinical symptoms or signs indicative of a secondary disorder and indications of an exposure. Patients with atypical attacks should undergo vascular imaging to evaluate for other conditions.

The most common mimic of RP is excessive cold sensitivity. Mimics will not have the sharp demarcation of color change. Bluing of nailbeds is not indicative of significant vasospasm.

Treatment should focus on education and eliminating triggers. Calcium channel blockers are usually used for frequent symptoms. In those patients with indications of a possible associated condition, referral to rheumatology or a vascular specialist may be appropriate.

Courtesy of Fredrick M Wigley, MD. Graphic 66438 Version 9.0 © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

PACES POST: THE VALUE OF OUR MEDICAL SOCIETY

by Victor Pace, MD

The American Medical Association (AMA) often comes to mind when one thinks of a medical association. The AMA, founded in 1847, is America's largest national medical association. The Massachusetts Medical Society is the oldest continuously operating medical society in the United States.

In the borders of our great state of Missouri, we have the Missouri State Medical Association (MSMA) and several local medical societies, the most pertinent one to us being the Greene County Medical Society (GCMS).

GCMS was founded in 1874 as the Southwest Missouri Medical Society and, in 1938, recognized by MSMA as the Greene County Medical Society. Our mission statement, "Bringing physicians together to improve the health of our community," is simple but powerful.

I have been a GCMS member for almost twenty years, soon after relocating to Springfield, Missouri. While I no longer live in Southwest Missouri, I am still a member of our impressive medical society. I am in awe of how well this organization carries out its mission statement.

I am trying to understand why every local physician is not a GCMS member. I realize that while we physicians are often stretched thin, sometimes becoming a medical society member is the last thing on our minds. However, once non-member physicians learn of the benefits GCMS brings to their patients, they will stand in line to join our thriving group.

Within GCMS is the subcommittee Community Health Advisory Committee (CHAC). CHAC's vision is "to bridge health gaps in our community by enhancing partnerships within our local leaders." Springfield-Greene County Health Department, Jordan Valley Community Health Center, Mercy, and CoxHealth are some of the subcommittee members, to name a few. These organizations are strong supporters of GCMS. Our two central healthcare systems, Mercy and CoxHealth, are assisting in our membership drive as they see our members' impact on improving our community's health.

GCMS advocates for our local physicians and patients at the local, state, and national levels. Our society collaborates with MSMA and AMA to develop legislation for improving healthcare delivery, protecting medical practices, and impacting public health. Our GCMS members have held leadership roles within the MSMA, AMA, and even the World Medical Association (WMA).

GCMS, in collaboration with other local groups, has been instrumental in the developmental initiatives or support of the following: 1.

GCMS, an accredited Continuing Medical Education (CME) provider, sponsors several CME meetings and gatherings throughout the year. An intimate CME gathering was held in Moab, Utah in 2019. This summer, a groupis heading to Breckenridge, Colorado. On Wednesday, October 11, 2023, a GCMS CME event will be held at Highland Springs Country Club.

The GCMS Alliance (GCMSA), founded in 1924, "is an organization for physician spouses and friends of the Alliance dedicated to promoting health and health education in our community and providing support to our physician friends." The Alliance has led the way in distributing healthy lifestyle literature and educational DVDs to our school children. Leading the way, they also collaborate with the Alliances from the MSMA and AMA to develop opioid crisis materials. Our GCMSA members have held leadership roles within the MSMA and AMA Alliances.

GCMS and GCMSA also value balancing mind, body, and spirit. Past sponsored events have included Retired Physicians Luncheons, GCMS Date Night at B & B Boulangerie, GCMS Alliance Book Club, Social Hour at Char, and GCMS Social at The Ski Shack. Many more events have occurred, too numerous to list, and future events are in the pipeline.

Many physicians these days are isolated in their clinics. The days of physicians interacting in the doctors' lounges are from a bygone era. Medical societies have taken the place of the doctors'

lounge. Physicians yearn to interact with one another. By participating in GCMS and GCMSA events and becoming or staying members, we can put faces to our referrals. Physician gatherings allow us to talk shop, establish networks, mingle socially, and develop friendships. As a GCMS member, I have been blessed to create lifelong friendships with other GCMS members. I would not have had this opportunity without the Greene County Medical Society.

Ultimately, our goal as physicians is to optimize our medical care for our patients and community. We are equipped with many tools to assist in the care of our patients. Being or becoming a GCMS member should be one of our primary tools.

References

https://www.ama-assn.org/about#

https://www.massmed.org/About/History/#

https://www.msma.org/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9312445/

https://gcms.us/about-us/#

Bicycling in Breckenridge

GCMS Journal Co-Editors & GCMS President Dr. Sanjay Havaldar

Kristen Woods and Barb at the Lodge

Krystyna and Dr. Mike Clarke

ROCKY MOUNTAIN MEDICINE Breckenridge, Colorado

GCMS President Dr. Sanjay Havaldar & Dr. Jim Blaine

Sara and Barb Blaine in Frisco, Colorado

View of Breckenridge mountains from 3rd floor of the Residence Inn

Breckenridge hiking trail

Shawn Sando demonstrates how to cross the Blue River

Dr. Havaldar, Dr. Wilsey, and Dr. Le with Anna Le and GCMS Journal Junior Co-Editor Andrew Le.

Left..Dr. Blaine & daughter Sara Blaine at the Chuckwagon ride in Frisco, Colorado

Right..Dr. Havaldar at the Blue River

Jim and Lori Rogers with Shawn Sando being arrested in Frisco, Colorado

Shawn Sando and Dr. Vu Le at the Forvis sponsored Happy Hour at Mi Casa in Breckenridge

Jim Rogers and Minh-Thu Le on the Vail Pass Trail

Brightli President Shawn Sando presentation

GCMS Bikers lunch at Copper Mountain Ski Resort

Dr. Rogers presents on Cost Effective CRC

Dr. Shannon Woods lecturing on Arthritis and Running

Dr. Vu Le discusses the VA healthcare system

Zach Swartz, CFA, and Gretchen Cliburn, CFP, with FORVIS discuss Financial Planning for Physicians

Dr. Havaldar lectures on Colorectal Cancer Screening

YOUTH SUBSTANCE MISUSE - THE STAKES

ARE HIGHER THAN EVER BEFORE

by Kurt Larson of Larson & Miller Law

Our youth are uniquely vulnerable to potent marijuana and the risks associated with current-day substance misuse. The human brain continues to develop until we reach our early- to mid-twenties. It is during adolescence that the pre-frontal cortex further develops to enable us to appreciate risk, set priorities, formulate strategies, allocate attention, and control impulses. For this same age-group the outer mantle of the brain experiences a surge of development, helping youth to become more sophisticated at processing abstract information and understanding rules, laws, and codes of social conduct.

Meanwhile, the potency of drugs like today’s marijuana have increased. One study 1 suggests marijuana’s potency increased 300% since 1995. Given the pharmacological effects of current-day drugs like legally available “recreational” marijuana, the danger of death and/or lifetime addiction after first experimentation is greater than ever. This is not your daddy’s weed. More than ever before our youth need our help making smart decisions when confronted with the opportunity to experiment with drugs and alcohol.

A Smorgasbord of Dangerous Options

Cannabis is now medically and recreationally available in 37 U.S. states – arguably good for the economy, but also implicitly gives kids the impression it is safe, and its increased availability to them poses yet another serious threat to our youth. A recent study 2 from Columbia University finds that teens who use cannabis recreationally are two to four times as likely to develop psychiatric disorders such as depression and suicidality than those teens who do not use cannabis at all. It is evident that even casual cannabis use puts teens at greater risk for experiencing feelings of fear, panic, anxiety, irritability and sadness. During use, Marijuana also affects reaction time, coordination, and concentration. The resulting problem behaviors include impaired driving, poor grades, truancy, and trouble with the law – any of which can have long-term negative consequences that may keep youth from graduating high school and developing their full potential in adulthood.

And then there is the phenomenon of vaping, marketed to youth and perpetuated as a safe alternative to smoking cigarettes. The use of electronic cigarettes among adolescents remains a major public health concern given the exposure to harmful substances, plus potential association with cannabis and alcohol. Understanding vaping as it intersects with combustible cigarette use and other substances misuse informs our nicotine prevention efforts.

And last but certainly not least, Fentanyl. Known to be 50 times stronger than heroin, and 100 times stronger than morphine. This menace has quickly become the single deadliest drug threat our nation has ever encountered. It is everywhere, and readily available to youth through the internet. From large metropolitan areas to rural America, no community is safe from this drug. In 2021, 77% of teen drug overdose deaths were linked to Fentanyl.3 Prevention Education –

An Important Part of the Solution

Our youth and the adults that can positively influence them must be made aware of these frontline issues that pose a very real threat to their safety, and our youth must be given the tools to navigate the minefield. With the support and endorsement of the Greene County Medical Society, the nonprofit Safe and Sober (SNS) was formed in 2004 to examine how we can deliver engaging prevention education to this uniquely vulnerable population. Based on input from the medical, law enforcement, prevention education communities, parents, and students, we learned that if a meaningful difference was going to be made in our mission to prevent underage substance misuse, it had to start before the age of first experimentation (age 12 in Missouri) and it must include not only our youth, but also the adults who influence them.

Over the course of 20 years SNS has become a wildly successful and substantively important state-wide effort to prevent youth substance misuse. In its earliest years, Safe and Sober Prom Night was a one-night pledge made by 748 seniors in the five Springfield-area public high schools to remain alcohol free on prom night. Over time, the program has grown both in geographic breadth and in the substantive depth of our education model.

Today’s Safe and Sober is a year-long prevention effort to reach middle and high school age kids wherever we can find them: in school-wide assemblies, in small-group homerooms, and inside after-school youth organizations. At no cost to participating schools and organizations, we provide them with compelling videos outlining the inherent risks of experimentation, explain why they are uniquely vulnerable, and show them how they can avoid the fate so many young people experience who fall into the trap of substance misuse. We use peer-led education: real talk from real teens about strategies for navigating peer pressure and coping with the stress and anxiety of their world.

For educators, we provide ready-made lesson plans, discussion guides, and classroom activities to make it simple to deliver our prevention education content their way. And the student pledge is no longer a promise that ends at midnight on prom night (as

many of our little angels reported in the early days of our effort). The pledge has instead become a promise first made by students at the earliest ages before experimentation to remain substancefree as a lifestyle, and repeated every year thereafter. The pledge is important, because it treats them like the young adults they so desperately want to be by letting it be their choice. Because ultimately, it is their choice. At the same time, we empower them to make this commitment and mean it for so many good reasons, and create positive peer pressure.

There is a parental component to SNS as well. Despite what YouTube suggests, Parents remain important influencers in the lives of our kids. On these life-threatening issues, they need their parents to toe the line. Through our website, parents and grandparents are given resources they need to start the difficult conversations about substance use that must be started early, and frequently, with the young people in their lives. For the students who steer clear of drugs and alcohol, we have learned that having clear expectations, set by their parents and guardians, is one of the most important reasons these youth stay safe and sober. SNS has been embraced by schools throughout the country. As we enter our 20th year, we serve students at more than 500 participating Missouri middle and high schools annually, and in the last 3 years our program has been used by schools in 37 other states. By our last count, SNS prevention education has been made available to 1.3 million students since its inception.

Adaptation to a Post-COVID world

In the first decade of this prevention education effort, our primary focus at SNS was the threat of alcohol and drunk driving. Back then we knew alcohol killed more teens than all illicit drugs combined. And it was well-established that youth typically drank to get drunk, and peer pressure was the primary driver for first experimentation. Today, while those same motivators persist and alcohol remains one of the deadliest drugs to youth, the reasons youth drink and use drugs have become far more complicated, and are closely aligned with their mental health. More young people turn to these substances, not just for entertainment, but instead to cope with the pressures of life in our current environment.

This issue of the Journal of the GCMS rightfully draws alarming attention to the risks confronting our youth. The pandemic fundamentally altered our ways of life, and many adults and teens are having trouble adapting to the new normal. After nearly a decade of steady declines, impaired driving fatalities increased significantly in 2020, and have held steady since. At the same time, opioid and other drug-involved overdose deaths reached a record-high of nearly 100,000 deaths in 2020, and increased by another 8% to 107,000 in 2021, according to the latest data available from the Centers for Disease Control and Prevention 4. These statistics highlight the need for accurate harm-reduction education for adolescents 5

In order to continue our mission and stay relevant to our youth and the adults they encounter along the way, we recognize that SNS prevention education must evolve beyond our traditional model of school-based programs. Schools are in crisis and struggling just to deliver the promise of fundamental education. Yet the need for prevention education is greater than ever, so we are not letting up our mission to help them educate our youth. Some of the ways we are evolving to meet the needs of today’s youth include:

Expanding our audience beyond our traditional school-based model to include homeschool groups, afterschool youth programs like the YMCA and Boys & Girls Clubs, and other community organizations serving youth like Scouting.

Tailoring our content to the specific needs of these different audiences, and delivering our videos in modular format, allowing flexibility of use in large and small groups.

Partnering with juvenile justice agencies to reach high-risk youth in the criminal justice system.

· Collaborating with mental health agencies to address the root causes of substance misuse.

Increasing our content release frequency to sustain audience engagement throughout the year.

· Using new technology to measure our impact on youth attitudes and behaviors.

Every student that we reach represents a lifetime of potential that deserves the chance to develop unhindered by alcohol and drugs. That potential drives us in our vision to create a world where all youth are safe from the consequences of substance misuse, which in turns keeps all of us safer.

References

1 Chandra S, Radwan MM, Majumdar CG, Church JC, Freeman TP, ElSohly MA. New Trends in cannabis potency in USA and Europe during the last decade (2008-1997). Eur Arch Psychiatry Clin Neurosci 2019 Feb; 269 (8); 997

2 Sultan RS, Zhang AW, Olfson, M, et al. Nondisordered Cannabis Use Among US Adolescents, JAMA Netw Open 2023; 6 (5): e2311294.

3 Friedman J, Godvin M, Shover CL, Gone JP, Hansen H, Schriger DL. Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021. JAMA. 2022;327(14):1398–1400.

4https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/202205.htm

5Trends in Drug Overdose Deaths Among US Adolescents, JAMA 2022, supra.

MENTAL HEALTH 417

by Nancy Yoon, MD,. MPH

The Healthy Living Alliance of the Ozarks (HLA) has launched Mental Health 417, an online resource dedicated to improving mental health in the Ozarks. This tool was created in response to the mental health crisis that Springfield and Greene County are experiencing. According to the 2022 Community Health Needs Assessment, people in the Springfield Community (Greene, Christian, and Webster counties) experience poor mental health at a higher rate than people in the rest of Missouri and the United States. More than 24% of people in the Springfield Community experience depression, compared to 21% in Missouri and 18% in the U.S. The MentalHealth417.org website is a comprehensive and interactive resource hub for all of Greene County that includes:

• Overviews of common mental health disorders.

• Interactive mental health self-assessments

• A self-care toolbox with local ideas for managing stress and improving your mental wellbeing.

• Tips for starting conversations about mental health with friends, family, healthcare providers, etc.

• A treatment finder to help you get connected to professional mental health care.

No matter what stage of mental wellness a person is at, the hub can connect them with the resources they need. The hub also aims to normalize prioritizing mental health and reduce the stigma around seeking care. The goal of this initiative is to provide steps that people can take to halt the progression of the poor mental health before they reach crisis. If you or someone you know is experiencing a mental health crisis or have thoughts of suicide, call or text 988 to reach a trained crisis counselor who can help.

Suicide in Springfield

The rate of suicide in Springfield is higher than that of the region, state, and country, according to latest data from the

Ozarks Health Commission (ozarkshealthcommission.org). Every 5.5 days, someone in Springfield dies of suicide. It is the 7th leading cause of death in Springfield, killing more people than diabetes, kidney disease, and chronic liver disease in 2019. Additionally, the rate of deaths from suicide is 20% higher than the Missouri average and 60% higher than the U.S. average.

Physicians have higher age-standardized suicide rates, compared to the general population, including much higher rates for female physicians and moderately higher rates for male physicians.1 In addition, burnout now affects almost half of US physicians.2 This has also been exacerbated by the stresses of the COVID-19 pandemic. Physician burnout and distress have been associated with higher rates of alcohol use disorder and depression, increased risk for suicide, lower quality of life, reduced cognitive functioning, and poor quality of patient care.3

While burnout is the result of systemic and organizationallevel problems, taking proactive steps to identify and address physician distress can help to ensure the well-being of physicians, reduce the risk of suicide, and support patient care by protecting the health of the physician workforce. Warning signs of suicide can include increased substance use, feeling or expressing that there is no reason for living or purpose in life, changes in sleep patterns, expressions of hopelessness, withdrawal from friends, family and society, uncontrolled anger, engaging in risky activities, mood changes, talking or threatening to hurt or kill oneself, or talking or writing about death, dying or suicide.

It is essential for physicians to recognize the importance of self-care, model wellness behaviors, and encourage others to do the same. Steps to maintain one’s health include getting adequate sleep, eating nutritiously, exercising regularly, allowing time to recharge, learning to say “no” to requests that interfere with personal or relaxation time, learning to recognize signs of stress and burnout in yourself, and reaching out to trusted colleagues for assistance and support. If these self-care tips are not enough, it may be time to seek additional help.

Organizational leaders can foster a positive culture and decrease stigma related to talking about and seeking mental health care. They can encourage and model support for colleagues, support requests for time off and schedule flexibility, use appreciative inquiry to create a more positive work environment, and promote effective and healthy communications. The American Medical Association has several resources on identifying and supporting at-risk physicians for suicide, as well as promoting physician well-being and reducing burnout.4

Revive App

The 2022 Community Health Needs Assessment showed that the drug overdose mortality rate is more than 25% higher in Greene, Christian, and Webster counties than in the rest of the United States. According to the Centers for Disease Control and Prevention, opioids were involved in nearly 75% of drug overdose deaths in 2020 and a majority of those involved a synthetic opioid, primarily fentanyl. In response to this growing epidemic, Springfield-Greene County Health has launched the new mobile- and web-based app Revive. This app will provide resources and lifesaving guidance to people in both English and Spanish who use illicit substances, their loved ones, service providers and other people in the community who might encounter someone experiencing an overdose.

Revive allows people to find naloxone to carry with them and guides them through its proper use if the need arises. It walks the user through how to administer naloxone, conduct CPR and position the person so they can remain safe until emergency services arrive. Revive also provides information on recognizing the signs of an overdose, maps of community resources like drug disposal sites and treatment services and information for those who have experienced a drug overdose. The Health Department encourages everyone to download Revive and familiarize themselves with its features to help us

save lives, connect people with the resources they need to recover from addiction and lead longer, healthier and happier lives. Revive can be accessed and downloaded for free by going to Revive417.com or through the Apple and Google Play stores on your mobile device.

References

1 Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychi atry. 2004;161(12):2295–2302. doi:10.1176/appi. ajp.161.12.2295

2 Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014 [published correction appears in Mayo Clin Proc. 2016 Feb;91(2):276]. Mayo Clin Proc. 2015;90(12):1600–1613. doi:10.1016/j.mayocp.2015.08.023

3 West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071–1078. doi:10.1001/jama.296.9.1071

4 American Medical Association (2023, May 10). Preventing Physician Suicide. Physician Health. https://www.ama-assn. org/practice-management/physician-health/preventing-physician-suicide

Nancy Yoon MD,. MPH is the GCMS Community Health Advisory Committee Chair and Chief Medical Officer of the Greene County Health Department.

COX HEALTH FAMILY MEDICINE RESIDENCY CLASS

OF 2026

Jonathan Bingham I have been a Missourian for my entire life, being born and raised in Kansas City. I decided that I wanted a change in scenery and traveled to the University of Missouri – Columbia for my undergraduate education. I took a year gap between undergrad and medical school and worked at a local pharmaceutical company in Columbia, MO as an analytical chemist. Following this, I moved up to Kirksville, MO to attend medical school at A.T. Still University. During medical school, I took an additional year for a predoctoral fellowship to receive advanced training in Osteopathic Manipulative Medicine.

went on to attend the New York Institute of Technology College of Osteopathic Medicine at Arkansas State University.

During my time in medical school, in addition to my doctorate, I received a Master’s in Academic Medicine by spending a full year teaching preclinical medical students, taking courses on medical education development, and performing research. It was during this year that I fell in love with Family Medicine. I had enjoyed all of my specialty rotations, but what I was most excited about was sitting down to talk with a patient, answering any questions they have, and making a plan together. As I searched for a residency program where I could truly become the best physician I could be, CoxHealth became the clear choice. I am so blessed to be joining this team!

My wife and I have been married for two years and have one 3-year-old daughter who is the light of our life! My free time is primarily spent being bossed around by my daughter. Other than being her personal assistant, I enjoy fishing, grilling, working on cars, playing with my dog and watching/playing sports of all kinds.

Coming from a very underserved, urban area, I was able to see both sides of the coin from a young age. I was able to understand why people were unable to seek medical care, but I also saw the effects the lack of healthcare had on these same people. This, more than anything, drove me in my pursuit of becoming a family medicine physician. I knew this career would put me in the best position to help the most people who come from similar circumstances as myself. I feel that CoxHealth Family Medicine Residency, as a whole, is built to train physicians in a manner congruent with the skills I will need to accomplish my overall goal. My family and I could not be happier with our choice and cannot wait to join the Springfield community!

Hannah Boehler I was born in Little Rock, AR, and returned there for high school after spending eight years of my childhood in Yekaterinburg, Russia, as a missionary with my family. Growing up in another culture gave me a unique worldview, which was further widened as I continued doing missions in South America throughout high school. I attended Ouachita Baptist University, graduating with a Bachelor of Science degree in Chemistry and Biology, and a Bachelor of Arts degree in Spanish, with the goal of becoming a physician and serving in rural communities across the globe. Little did I know that upon meeting my husband, Gary, in my final year of college, I would discover a passion for serving the rural community in my own backyard here in the south. With this new mission in mind, I

Denim Bryson I was born and raised in Hot Springs, AR. I received my Bachelor’s degree at Ouachita Baptist University, where I met my husband, Spencer. I took two gap years and worked as an emergency room patient care tech in my hometown, and then in New Orleans. I then went to medical school at New York Institute of Technology College of Osteopathic Medicine in Jonesboro, AR. I chose Family Medicine for its broad scope and opportunity to develop long-term relationships with patients and their families.

From the moment I found CoxHealth FMR’s website, I fell in love. The blooper reel at the end of their welcome video showed me they were real people who embraced the fun in medicine. The faculty, staff, and residents are second to none, and I’m so excited to learn from them!

In my spare time, I enjoy reading, trying new restaurants, taking walks with my husband, and watching anything by Shonda Rhimes!

Erica Casey I am from the small town of Gassville, AR, which is near the better-known town of Mountain Home. I attended the University of Arkansas at Little Rock, where I couldn’t make up my mind what I wanted to study and ended up earning three degrees as a result. I studied biology, chemistry, and Spanish, along with a couple of study abroad adventures in Spain to improve my fluency for my future patients. I attended medical school at the University of Arkansas for Medical Sciences. Throughout my training, I was drawn to a little of everything and wanted to keep those bits of everything in my future career. More importantly, I was wholeheartedly all in for the patient-centered, relationship-driven field that is Family Medicine.

relationship-driven field that is Family Medicine. Along the way, I took courses to complete my Master of Public Health along with my MD. It’s paramount to understand families and even communities beyond the scope of medical sciences, and earning my MPH has helped me establish a default holistic approach that allows me to do just that.

Outside of medicine, you may find me curled up on the couch watching a K-drama with my two adopted fur babies, Abu and Tsuki. If you’re not a cat person, I bet they would change your mind! I also love cycling, exploring both musical and food genres with the love of my life, and I have recently started channeling my inner grandma and taken up knitting and crocheting.

I am so happy to train alongside the most supportive, welcoming colleagues I could imagine. Their mutual passion for lifestyle medicine, behavioral health, and practicing full-scope family medicine will no doubt provide me the toolkit to become the best, most compassionate family physician I can be.

before attending medical school at Liberty University College of Osteopathic Medicine. In my second year of school, my wife and I were blessed with our daughter, Goldie. I’d be remiss to not mention what an incredible wife and mother Katie is - I know I couldn’t have made it this far in my goals without her.

Family Medicine is a specialty I knew I wanted to enter long before medical school. This was, in part, because of the great relationship I had with my Family Physician growing up, as well as having role models like my mother, who worked for several years as a nurse and now Nurse Practitioner. I was instantly drawn to the diversity of care that Family Physicians are trained to deliver, and to a greater extent, I admired the life-long relationships that can form between them and their patients. Within Family Medicine, I am most interested in Obstetrics, Women’s Health, and Pediatrics. I’m excited to be completing my medical training at CoxHealth, not only because I know they have the faculty and resources to help me achieve my goals, but because of the incredible people I get to work with.

Shelbi Davis I was born and raised Midwesterner. I grew up in Sedalia, MO in a family of four, with an older brother who served in the Army. I attended the University of Missouri-Kansas City for my undergraduate studies, where I majored in Health Sciences with a strong focus on Social Determinants of Health and public health issues. During undergrad, I was able to work as an EMT and a home health aide. Kansas City offered me many amazing opportunities to volunteer and be a part of organizations to shape the health of underserved populations, such as the Veterans Community Project.

I chose Family Medicine due to the relationships you can build with your patients. I also enjoy that being a Family Medicine doctor involves considering the physical, social, emotional, and environmental factors that impact the patient’s health. I love that Family Medicine offers ongoing opportunities to see a variety of cases. My special interests include Street Medicine and Addiction Medicine. I chose CoxHealth for the strong, full-spectrum training and wonderful people I met during the interview season. Everyone was so welcoming and made it feel like home. I am thankful and excited to continue my journey at CoxHealth!

Outside of medicine, I enjoy spending time with family and friends, trying new places to eat, watching shows and hiking with my boyfriend, and cleaning/organizing!

I love being in the outdoors in my free time, and now, my wife and I get to share that with our daughter. Whether we’re hiking, strolling through the park, or spending time on Table Rock Lake, the time we spend together is always the greatest for me. I love caring for the people of southwest Missouri and serving and learning from this community!

Melissa Medley Growing up in the Springfield area, I attended the CoxHealth Medical Explorers program for high school students. Through this program, I developed a love for all aspects of the medical field, including global healthcare. I participated in multiple medical trips overseas, varying from El Salvador to Haiti to Iraq, throughout my high school and undergraduate time. I graduated from Evangel University in 2019 and continued my education by attending medical school at New York Institute of Technology College of Osteopathic Medicine in Jonesboro, Arkansas.

Mason Farris I was born and raised in Eldon, MO and attended College of the Ozarks, where I met my wife, Katie. After receiving my degree in Human and Molecular Biology, Katie and I moved to Lynchburg, VA, where I attended Liberty University as a graduate student studying Biomedical Science. At LU, I had the opportunity to teach and conduct research while receiving my master’s degree

During my time in medical school, I married the love of my life, Corbin Medley, and we now have two dogs who are spoiled rotten, named Luka and Finnigan. In my spare time, I enjoy spending time with family and friends, reading, and swimming. My husband and I are looking forward to being back in the area, especially for the Springfield cashew chicken, Pineapple Whip and our Nakato date nights. I decided to go into Family Medicine for a multitude of reasons; the main reason is my love of relationships with my patients. I love getting to know each person and being able to treat them holistically. Within the field, I believe the CoxHealth Family Medicine Residency creates a family-like environment that challenges the residents, as well as gives them the support and kindness necessary for success. I am very excited to practice as a resident physician at the hospital where I was born.

PACE’S POST

Haley Olsen I grew up about an hour east of Springfield in a tiny town of around 600 people. I played softball and basketball, worked for a catering company, entered art contests, and was big in FFA all through high school. I grew up showing quarter horses and dancing as well. I attended Drury University for three years in college where I got my degree in biochemistry, volunteered in Cox North’s ER, and was the university’s sports photographer and a campus tour guide. My fourth year overlapped my first year of medical school in Kansas City.

During medical school, I discovered that Family Medicine is one of my several passions – it is so well-rounded, patient-oriented, and the possibilities for growth and learning are endless! I can advocate for my patients, healthcare policy, women’s health, and so much more. I also love the application in international medicine. During my last year and a half of medical school, I have been able to serve patients in Guatemala (twice!) and in Kenya.

When looking for a residency, I wanted a program that could fulfill my broad-scope and in-depth training desires – international care, obstetrics, hospital medicine, osteopathic manipulation, procedures (honestly everything) – and would really value its residents and their individual strengths and wellness. I am thrilled and humbled to be back in Springfield for residency – I will be working in the same hospital where I was born! Life is wild sometimes.

In my free time, I will almost 100% of the time be with my pup, Ellie Mae (Eleanor), who I got during my first year of medical school. We love to hike and camp, run, bike, swim, and hammock. She’s my exploring adventure pal! I also enjoy cooking and baking, photography, drawing and painting, and plants. I find myself acquiring new hobbies as I go and look forward to expanding my experiences in Springfield. I am even more excited to grow professionally as a family physician with CoxHealth FMR.

Medicine are in women’s health, pediatrics, lifestyle medicine, osteopathic manipulative techniques, and chronic disease management.

I wanted to train at an unopposed residency that would equip me to practice full-scope Family Medicine. After my rotation with CoxHealth Family Medicine Residency, I knew it was the place I wanted to be. The faculty, residents, and staff functioned as a large family and I felt right at home. The welcome was warm and the education was of the highest quality. My husband and I are thrilled to be back in the Midwest, and I am excited to serve the patients in Springfield. In my free time, I’m usually spending time with my family, cooking, gardening, exercising, playing piano, or reading.

Tessa Tolen I am a born and raised Missourian, originally from northern Missouri. However, I’ve lived in Springfield, Missouri longer than anywhere else! I attended Missouri State University for my undergraduate degree in Anthropology, where I met my wonderful husband, Keith. I completed my medical education in Kirksville, MO at A.T. Still University.

I chose Family Medicine because it revolved around many of my passions, including advocacy, nutrition in medicine, preventative care, women's health and obstetrics, and lifestyle medicine. I love that Family Medicine allows me to be a physician for the entire family, from pediatrics to geriatrics. I aim to practice whole person, osteopathically-driven medicine, and I’m excited to begin serving the southern Missouri area.

I chose CoxHealth not only because of the excellent education and curriculum that mirrors many of my interests, but also because of the community I found in my time spent with them. The residents, attendings, and staff are all exemplary, and I am ecstatic to complete my residency training alongside them.

Cerena Stinogel I lived in many states growing up, but spent most of my childhood in Iowa, where I completed my undergraduate degree at the University of Northern Iowa. The following year I moved to the Kansas City area and completed a Master’s in Business Administration and scribed in the Emergency Department. I then attended Liberty University, where I completed a Masters in Biomedical Sciences and taught undergraduate Anatomy and Physiology labs. The favorite parts of my story come next. I married my best friend, Brett, and a year later, we welcomed our son into the world.

Family Medicine is the perfect fit for my personality and skills. I enjoy seeing whole generations of families and building long-lasting relationships with my patients. My specific interests in Family

When I am not in the clinic, I love being outdoors with Keith and our pup, Rhea. Our favorite activities are hiking, canoeing, and kayaking. I also enjoy all things that grow and have a huge houseplant collection. I love outdoor gardening as well, to supplement some of the produce for our family. I am an avid reader, and keep busy by sewing bibs and burp cloths for our local Newborns in Need.

Welcome to the Family Medicine Class of 2026!

Dermatology, Procedural

Eye Surgery/Ophthalmology

EYE SURGEONS OF SPRINGFIELD, INC.

C. BYRON FAULKNER, MD H

Comprehensive Cataract Ophthalmology

JUDD L. McNAUGHTON, MD H

Comprehensive Cataract Ophthalmology Diplomates, American Board of Ophthalmology

1330 E. Kingsley St. • Springfield, MO 65804

Phone 417-887-1965 • Fax 417-887-6499 417eyecare.com

Eye Surgery/Ophthalmology

MATTAX • NEU • PRATER

EYE CENTER

JAMES B. MATTAX, JR., MD, FACS H

American Board of Ophthalmology

LEO T. NEU III, MD, FACS H

American Board of Ophthalmology

KENNETH NEU, MD, FACS H

American Board of Ophthalmology

THOMAS PRATER, MD, FACS H

American Board of Ophthalmology

JACOB K. THOMAS, FACS, MD H

American Board of Ophthalmology

BENJAMIN P. HADEN, MD H

American Board of Ophthalmology

Family Medicine

LESTER E. COX

FAMILY MEDICINE RESIDENCY PROGRAM

FAMILY MEDICAL CARE CENTER

1423 N. Jefferson B 100 Springfield, MO 65802 (417) 269-8817

AmericAn BoArd of fAmily PrActice

Cameron Crymes, MD

Kristi Crymes, DO

Gabrielle Curtis, MD

Katie Davenport-Kabonic, DO

Kristen Glover, MD

Kyle Griffin, MD

Shelby Hahn, MD

Laura Isaacson, DO

Michael Kabonic, DO

Jessica Standeford, MD

Audrey Williams, DO

Brian Williams, MD

WOMAN’S CLINIC www.womansclinic.net

Leaders in Minimally Invasive Gynecology & Infertility

MICHAEL H. SWANN, MD H

AUTUMN COURTNEY, PA-C

PATSY DUGGAN, PA-C

WESLEY N. WORMINGTON, PA-C

3850 S. National Ave, Suite 705 Springfield, MO 65807

Phone: 417-888-0858 • Fax: 417-889-0476 www.swanndermatology.com

Direct Primary Care

ASCENT DIRECT PRIMARY CARE, LLC

MATTHEW GREEN, DO H

Family Medicine

www.ascentdpc.com

417-595-0956

413 N McCroskey, Ste 2 Nixa, MO 65714

MICHAEL S. ENGLEMAN, OD

MARLA C. SMITH, OD

MATTHEW T. SMITH, OD

1265 E. Primrose Springfield, MO 65804 417-886-3937 • 800-995-3180

DONALD P. KRATZ, MD, FACOG H American Board of Obstetrics and Gynecology

AMY LINN, FNP-BC American Academy of Family Nurse Practitioners

VANESSA MCCONNELL,

MERCY CLINIC UROLOGY (FREMONT)

ERIC P. GUILLIAMS, MD, FACS H

American Board of Urology

ROBERT D. JOHNSON, MD, FACS H

American Board of Urology

TYRUN K RICHARDSON, MD

American Board of Urology

MARK J. WALTERSKIRCHEN, MD, FACS

American Board of Urology

Phone 417-820-0300

Fax 417-882-9645

1965 S Fremont, Ste. 370 Springfield, MO 65804

Internal Medicine

ADULT MEDICINE & ENDOCRINOLOGY

JONBEN D. SVOBODA, MD, FACE, ECNU

American Board of Endocrinology

JAMES T. BONUCCHI, DO, ECNU, FACE

American Board of Endocrinology

NICOLA W. GATHAIYA, MD, ECNU, FACE, CCD

American Board of Internal Medicine

American Board of Endocrinology

STEPHEN M. REEDER, MD, FACP

American Board of Internal Medicine

ANA MARCELLA RIVAS MEJIA, MD, CCD

American Board of Internal Medicine

American Board of Endocrinology

JACQUELINE L. COOK, FNP-BC, CDCES, CCD

KELLEY R. JENKINS, FNP-C, CDCES

ALINA CUMMINS, PA-C

STACY GHOLZ, FNP-C

SHELLEY L. CARTER, DNP

JESSICA A. CROUCH, FNP-C

Phone (417) 269-4450

960 E. Walnut Lawn, Suite 201 Springfield, MO 65807

Nephrology

SPRINGFIELD NEPHROLOGY ASSOCIATES, INC.

1911 South National, Suite 301 Springfield, MO 65804

Phone 417-886-5000 • Fax 417-886-1100

www.springfieldnephrology.com

STEPHEN E. GARCIA, MD H

American Board of Internal Medicine

American Board of Nephrology

ETHAN T. HOERSCHGEN, MD

American Board of Internal Medicine

American Board of Nephrology

GISELLE D. KOHLER, MD H

American Board of Internal Medicine

American Board of Nephrology

DAVID L. SOMMERFIELD, MD

American Board of Internal Medicine

American Board of Nephrology

SUSAN A. WOODY, DO H

American Board of Internal Medicine

American Board of Nephrology

Neurosurgery

SPRINGFIELD

NEUROLOGICAL AND SPINE INSTITUTE

CoxHealth Jared Neuroscience

West Tower • 3801 S National, Ste 700

Springfield, MO 65807 • 417-885-3888

Neurosurgery:

H. MARK CRABTREE, MD, FACS

EDWIN J. CUNNINGHAM, MD

MAYUR JAYARAO, MD

J. CHARLES MACE, MD, FACS H

CHAD J. MORGAN, MD

MICHAEL L. MUMERT, MD

SALIM RAHMAN, MD, FACS

ANGELA SPURGEON, DO

ROBERT STRANG, MD

Interventional Neuroradiology

MICHAEL J. WORKMAN, MD

Physiatry:

TED A. LENNARD, MD

KELLY OWN, MD

Physician Assistants:

JOSHUA BARBIERI, PA-C

MARK BROWN, PA-C

ERIC CHAVEZ, PA-C

BLAKE MARTIN, PA-C

HEATHER TACKETT, PA-C

Nurse Practitioner:

EMILY CROUSE, NP-C

BILL HAMPTON, ANP-BC

ROZLYN MCTEER, FNP

BRANDON RUBLE, ACNP-AG

ALYSSA CHASTAIN, FNP

Obstetrics/Gynecology

COXHEALTH

PRIMROSE OB/GYN

MARCUS D. MCCORCLE, MD, FACOG

Diplomate, American Board of Obstetrics and Gynecology

THOMAS M. SHULTZ, MD, FACOG

Diplomate, American Board of Obstetrics and Gynecology

GREGORY S. STAMPS, MD, FACOG

Diplomate, American Board of Obstetrics and Gynecology

P. MICHAEL KIDDER, DO, FACOOG

Diplomate, American Osteopathic Board of Obstetrics & Gynecology

Phone 882-6900

1000 E. Primrose • Suite 270 Springfield, MO 65807

Obstetrics/Gynecology

SPRINGFIELD

OB/GYN, LLC

MATTHEW H. TING, MD, FACOG H

American Board of Obstetrics & Gynecology

909 E. Montclair, Suite 120

Springfield, MO 65807

Phone 417/882-4466 • Fax 417/890-5631

Oncology/Hematology

ONCOLOGYHEMATOLOGY

ASSOCIATES OF SPRINGFIELD, MD, P.C.

WILLIAM F. CUNNINGHAM, MD, FACP

American Board of Internal Medicine

American Board of Medical Oncology

JIANTAO DING, MD H

American Board of Internal Medicine

American Board of Hematology

American Board of Medical Oncology

ROBERT J. ELLIS, MD, FACP

American Board of Internal Medicine

American Board of Hematology

American Board of Medical Oncology

BROOKE GILLETT, DO

American Board of Internal Medicine

American Board of Medical Oncology

V. ROGER HOLDEN, MD, PhD

American Board of Hematology

American Board of Medical Oncology

DUSHYANT VERMA, MD, FACP

American Board of Internal Medicine

American Board of Hematology

American Board of Medical Oncology

Springfield Clinic

3850 S. National, Ste. 600

Springfield, Missouri 65807

Monett Clinic

802 US Hwy 60 Monett, Missouri 65708

Phone 882-4880

Fax 882-7843

Visit our website: www.ohaclinic.com

Rheumatology

417 RHEUMATOLOGY

Independent rheumatology care and infusion services

DAVID TRUE, DO, FACR H

Board Certified in Internal Medicine and Rheumatology by American Board of Internal Medicine

Phone 417-501-2644

Fax 877-540-0429

909 E. Republic Rd., Building D200 Springfield, MO 65807 www.417ra.com

Otolaryngology

MERCY CLINIC–EAR, NOSE & THROAT

BENJAMIN L. HODNETT, MD, PHD H

ERICH D. MERTENSMEYER, DO, FAOCOO

AARON R. MORRISON, MD

A. DANIEL PINHEIRO, MD, PhD, FACS H

RAJEEV MASSON, MD

MARK J. VAN ESS, DO, FAOCOO

Diplomates, American Board of Otolaryngology

SHELBY BRITT, PA

MELISSA COONS, FNP

TAHRA LOCK, NP

ELIZABETH (BETSY) MULLINGS, FNP

PAUL STRECKER, FNP

Audiology

JASON BOX, AuD, CCC-A

MAMIE JAYCOX, AuD, CCC-A

JENNIFER PLOCH, AUD

ALLISON WHITE, AUD, CCC-A

Phone 417-820-5750

Fax 417-820-5066

1229 E. Seminole, Ste. 520 Springfield, MO 65804

Plastic Surgery

MERCY CLINIC–FACIAL PLASTIC SURGERY

MATTHEW A. KIENSTRA, MD, FACS

American Board of Facial Plastic & Reconstructive Surgery

American Board of Otolaryngology

Phone 417-887-3223

1965 S. Fremont, Ste. 120 Springfield, MO 65804 facialplasticsurgeon.com

Psychiatry

JAMES E. BRIGHT, MD H Diplomate, American Board of Psychiatry & Neurology.

Practice Limited to: Adult Psychiatry

Phone 882-9002

1736 E. Sunshine, Ste. 400 Springfield, MO 65804

JUNE 20TH GCMS HAPPY HOUR

PRESENTED BY

A recent GCMS Happy Hour event sponsored by Forvis and Ol-

was held at the Ski Shack—a local store that sells all the toys needed for fun on the lake from ski equipment to boats. They also have a small wakeboarding cable park in the back to test your skills. Dr. Schaller got to check out their latest electric liftfoils.

lis/Akers/Arney

Ski Shack's wakeboarding cable park

Dr. Kent Schaller demonstrating the art of Wakeboarding.

Chad Turner (left) and Justin Coyan (right) from Ollis/Akers/Arney and Carlee Lynn (left) and Gretchen Cliburn (right) from Forvis

Dr. Jake Thomas ( Mattax Neu Prater) and his wife, Dr. Giselle Kohler (Mercy)