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Duke’s CIPHERS Project Studying Epigenetic Sperm Changes in Male Cannabis Users
- RESEARCH IN ACTION
By Bryan Luukinen and Samuel Cohen Nicholas School of the Environment at Duke University
The landscape of marijuana legalization and public opinion on marijuana use in the U.S. are shifting rapidly. An increasing number of states have legalized recreational marijuana use, with 11 states plus Washington D.C. currently allowing recreational use. Today, more Americans perceive marijuana to be safe, and an increasing percentage of adults now use marijuana. Over the past few decades, the concentration of THC in marijuana has significantly increased, making it more potent. Modern use methods such as vaping, dabbing, and the use of high-THC resins can offer THC concentrations upwards of 75%. Criminal justice reform and increased tax revenues are touted benefits of the regulatory shifts, but public health and medical practitioners still need to address the potential consequences of use by at-risk groups including adolescents and pregnant women. Around pregnancy, efforts to study the potential effects of marijuana have focused almost exclusively on women. Although the available science has some limitations and uncertainties, groups like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists advise women not use marijuana during pregnancy or while breastfeeding. Few resources have been devoted to studying potential preconception use among men. In the future, family physicians should expect questions about marijuana use around family planning and pregnancy to come up more and more often.
The Cannabis-Induced Potential Heritability of Epigenetic Revisions in Sperm (CIPHERS) Project at Duke University seeks to understand the impact of male marijuana use on the epigenetic profile of sperm, and male fertility and preconception health. Through research in humans and animals, our team works to understand how marijuana effects sperm, whether these effects are passed on to offspring, and whether abstaining from use might reverse these effects.
Nearly all of our cells carry the same genes, but cells in different parts of the body look different and do different things, in part because of epigenetics
Our findings are preliminary, but do seem to indicate that marijuana use may alter certain epigenetic marks in the sperm of those exposed. Our pilot study also found an association between marijuana use and lower sperm counts. Our most recent study identified a specific gene linked with autism that appears to undergo changes
in the sperm of men who use marijuana (the study does not draw a definitive link between autism and marijuana use, but does warrant further research).
In addition to the research, the CIPHERS outreach and education team works to share the findings and broader impacts with several key stakeholders, including medical providers, public health organizations, and community groups. We started this effort locally, and have heard from family physicians and OB GYNs that maternal marijuana use around pregnancy is a growing concern.
For some women, marijuana is seen as an effective treatment for symptoms around pregnancy such as nausea. Some do not believe that the practice is harmful for their baby’s health, while others may simply be unsure of where to look for advice. One study interviewed pregnant women who used marijuana and found that few reported receiving helpful information on the topic from their health care provider or social worker, and instead relied mainly on internet searches and anecdotal experience or advice from family or friends.
So what does all this mean for medical practitioners? Patients are looking for more information about marijuana use before, during, and after pregnancy, and family physicians can help.
We have created outreach materials for clinical settings that summarize our research findings and highlight considerations for parents who may be planning to start a family. You can find those materials, along with a whiteboard illustration video that describes our research, links to our research articles, and informative blog posts on our website: https://sites.duke.edu/ ciphers.
STATE PROGRAMS
Upstream USA Partnering with North Carolina to Reduce Unplanned Pregnancy
Upstream USA is a national nonprofit working to expand opportunity by reducing unplanned pregnancy in the U.S. Upstream partners with states to provide training and technical assistance to health centers to ensure all patients have equitable access to the birth control method of their choice.
Upstream provides patient-centered, evidence-based training and technical assistance to hospital systems, state and local health departments, Federally Qualified Health Centers (FQHCs), community agencies and more. The program works with the entire center, from administrative staff to nurses to physicians, to ensure a tailored and cohesive experience for the whole team. Its CME/CEU-eligible training is delivered in-person by experts in reproductive health
and is designed to equip staff and providers to provide best-in-class contraceptive care. After training ends, Upstream’s quality improvement team works on-site and at the elbow with health center staff to ensure they have the best practices, guidance, resources, and tools necessary to provide same-day access to all methods of birth control for all patients.
See ‘Upstream’ on next page Results from its early work and first statewide initiative in Delaware gives program leaders confidence in the strength of the model. Pre- and post-surveys show that knowledge of LARC methods and other indicators
increases after training, and providers report that they feel confident in their ability to talk with their patients about their options. Patient surveys conducted at Upstream-trained healthcare centers affirm that patients are in charge of choosing their own method, feel listened to by their healthcare providers, and don’t feel pressured to choose a specific method of birth control.
The project is working to achieve impact at scale across the United States. By 2024, its goal is to work with healthcare centers across four states, including North Carolina, that serve over one million women each year.
The NC Academy of Family Physicians has endorsed Upstream’s efforts in North Carolina and has a representative on Upstream’s State Advisory Committee: Dr. Jennifer Mullendore, Medical Director at Buncombe County Health and Human Services.
The program is excited to get started in North Carolina! To learn more about Upstream or schedule a meeting to talk about a potential partnership visit: https://upstream.org.
New State Law Requires Licensed Physicians to Report Certain Misconduct
The N.C. General Assembly recently passed House Bill 228, an Act to Modernize the N.C. Medical Board (NCMB). The Act includes several provisions that affect licensed medical professionals, including a new legal obligation to report certain misconduct by any individual licensed by NCMB. This new “duty to report” provision (N.C. Gen. Stat. §90-5.4) went into effect Oct. 1st, 2019, and obligates any individual licensed by NCMB to report:
1. Sexual misconduct involving a patient by a licensee. 2. Fraudulent prescribing, drug diversion, or theft of any controlled substances by a licensee.
Medical professionals need not have definitive evidence of misconduct to make a report. The law specifies that licensed medical professionals should submit a report if they “reasonably believe” that misconduct has occurred. Licensees who report suspected misconduct in good faith are granted civil immunity. NCMB has created a new online form to receive reports from healthcare professionals or institutions. The form may be used to report information required by statute, or to report any other concern the reporting individual believes NCMB should investigate. The online form can be accessed at www.ncmedboard.org/report. This page also includes FAQs and other information to help licensees understand their reporting obligations under the law.
PRACTICE TRANSFORMATION
Need an AHEC Practice Support Contact? Regional Contact Listing Helps Practices Engage
Any Family Medicine practice across North Carolina can engage with the NC AHEC program to access its practice support services. AHEC’s quality improvement coaches (QICs) are trained to work with practices to transform the way
NORTH CAROLINA AHEC REGIONAL PRACTICE SUPPORT CONTACTS
Northwest AHEC Greensboro AHEC Wake AHEC Area L AHEC
Eastern AHEC South East AHEC Southern Regional AHEC Charlotte AHEC Mountain AHEC SHANNON CAMBRA (252) 972-6958 shannon.cambra@arealahec.org LORA WRIGHT (919) 350-0472 lowright@wakeahec.org
ANGEL MOORE (252) 744-5221 moorean@ecu.edu SUZANNE LINEBERRY (336) 662-5810 suzannelineberry@conehealth.com CHRIS JONES (336) 713-7039 cjones@wakehealth.edu
JESSICA WILLIAMS (910) 667-9350 jessica.williams@seahec.net DONNA BOWEN (910) 678-0119 donna.bowen@sr-ahec.org ERIN CLOUTIER (704) 512-6052 erin.cloutier@carolinashealthcare.org LESLIE MCDOWELL (828) 771-4227 leslie.mcdowell@mahec.net CHRIS WEATHINGTON Director-Practice Support (919) 966-2401 chris_weathington@ncahec.net NC AHEC PROGRAM OFFICE PRACTICE SUPPORT TEAM DEBBIE GRAMMER Deputy Director (919) 966-0801 deborah_grammer@ncahec.net MONIQUE MACKEY QI Manager (919) 445-3501 monique.mackey@arealahec.org MARY MCCASKILL HIT Manager (910) 818-4371 mary_mccaskill@ncahec.net Stokes
Guilford Davidson
Randolph Forsyth Swain Haywood Macon Clay Cherokee Graham
Jackson Madison
Buncombe Henderson Yancey
McDowell
Rutherford Polk Avery
Burke
Cleveland Watauga
Caldwell Ashe Alleghany Wilkes Catawba Lincoln Gaston Surry Yadkin
Davie Rowan Iredell
Union Cabarrus
Stanly
Anson Richmond Rockingham
Lee
Harnett Cumberland
Bladen Columbus
Brunswick Moore
Hoke
Robeson
New Hanover Wake Franklin Warren
Nash Chatham Wilson Halifax Northampton
Hertford Gates Wayne
Lenoir Edgecombe
Pitt Greene
Jones Craven
Pamlico
Cartaret Beaufort Hyde Dare Tyrrell Martin Bertie Pender Onslow Duplin Sampson Johnston Caswell Person Orange M i tchell Me c k l e nb u r g Mo n tgom e r y Al a m a n c e D u r ha m G r a nv i l l e V a n c e Ale x a n der T ran s y l v ania S c o t l a n d W a sh i n g t o n C h o w a n P e r q u i m a n s P a sq u o tank Ca m d en C ur ri t uc k CAROL STANLEY Medicaid Transformarmation Manager (919) 966-0815 carol_stanley@ncahec.net
in which care is delivered and help them prepare for new payment models and incentive programs while focus
ing on patient-centered care– from electronic health records to Medicaid transformation. For complete contact information on each part of the state, download AHEC’s Practice Support contact listing at www.ncafp.com/ahec-support.
DPP Navigators Help Patients Locate Diabetes Prevention Programs The NC Division of Public Health, Community and Clinical Connections for Prevention and Health Branch hosts diabetesfreenc.com, a portal for CDC-recognized Diabetes Prevention Programs (DPPs) throughout North Carolina. DPPs are evidence-based year-long programs led by a trained lifestyle coach and provide a group learning environment. The lifestyle coach helps participants develop strategies for healthy eating and physical activity and connects participants with others working on similar goals to prevent type 2 diabetes. DPPs are offered to North Carolinians in both in-person and online formats with various start dates and times.
In conjunction with this, a new service is now being offered by the NC Division of Public Health called the DPP Navigator. DPP Navigators are available to locate DPPs and coordinate enrollment for participants throughout the state. DPP Navigators also receive and coordinate referrals from health care providers, practice referral coordinators and community-based organizations. DPP Navigators provide bi-directional feedback to referring providers and organizations to include participant enrollment and program completion status.
DPP Navigators are available to assist and receive referrals Monday through Friday from 7am to 7pm via phone 1.844.328.0021; Fax 1.866.336.2329; email dppreferral@dhhs.nc.gov; and NCCARE360.org.
Keep Updated on Recommendations on Lead Poisoning in Children
The July issue of the American Family Physician journal has a nice review article titled, Lead Poisoning in Children, by Dr. Laura Mayans. The NC Division of Public Health’s recommendations for follow-up testing for children with elevated blood lead levels differ, however, from those listed in the article. NCDP’s recommendations can be viewed online at https://nchealthyhomes.com/files/2018/06/2018-06RevisedFollowupScheduleforLead.pdf.
Also at nchealthyhomes.com/lead-poisoning are links to lead risk assessment questionnaires for children and pregnant women (high risk zip codes are listed on the back), educational materials, a list of lead-certified painters and contractors in North Carolina and more. Remember: test at age 2, as well as, at age 1! -- the risk of lead poisoning is highest at age 2. Physicians or practices with questions may contact Ann Chelminski, MD, MPH at ann.chelminski@dhhs. nc.gov or at 919-707-5861.
North Carolina’s Early Check Program Screens for Fragile X Syndrome
All babies born in North Carolina are screened for a set of 37 health conditions shortly after birth as part of the state’s standard testing protocol. North Carolina’s Early Check (http://earlycheck.org) program provides two additional tests for babies whose parents sign up for the complimentary service: spinal muscular atrophy and fragile X syndrome (FXS). Although FXS is a rare condition, it is the most common inherited intellectual and developmental disability. Children with FXS may have problems with attention, impulsive actions, and anxiety, but also have moderate to severe intellectual challenges and language problems. While there is no cure for FXS, early intervention, support services, and connecting with physicians who serve this population has shown promise. Learn more at Early Check and its optional, free testing at the program website earlycheck.org/what-isearly-check/conditions-tested.
