Amendment 2: Medical Marijuana

Many of us Floridians may be feeling quite disappointed by the recent midterm election. A crook has another 4 years leading our state and the medical marijuana Amendment 2 fell short of passing by a mere 2%. Many of us shake our heads in disbelief over both of these results.

On the Amendment 2 issue, many Floridians sadly have rejected this amendment. What a shame. A non-toxic, natural medicinal option for pain relief (and other ailments) was voted against, so patients are forced to the option of synthetic drugs.  One of the primary options for pain relief in the United States are opioid pain pills. This class of synthetic drugs are derived from the opium poppy and includes hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), fentanyl (Duragesic, Fentora), methadone, and codeine. Basically, opioid narcotics are pharmaceutical-grade heroin. Here is the chemical structure of oxycodone and heroin. Quite similar.

Opioid drugs have led to an epidemic of prescription painkiller abuse. Millions of prescriptions for opioids have been written. Many people obtain prescriptions when the medication really isn't needed or they obtain the medication on the street (or in their parent's medicine cabinet).  The abuse of these drugs leads to hundreds of thousands of emergency department visits each year. The abuse doesn't end with those who obtain a prescription when it is not needed. More than 12 million people reported using these drugs for nonmedical purposes or just to obtain the ‘high’ or euphoric feeling from the drugs. Opioids cause a physical dependence and can lead to addiction. After taking these drugs one may need to take a higher and higher dose until that euphoric feeling is achieved.  This can lead to a depressed function of the respiratory system, or slowed breathing, which can lead to death (overdose).  Interestingly, opioids have not even been proven to be effective for long-term, non-cancer pain management, yet are still so widely prescribed for this issue.

The death rates from prescription pain medication overdose are astounding.  The CDC reports that nearly 40 Americans die per day from overdose of painkillers, such as Vicodin and OxyContin. This equates to about 15,000 Americans each year. So where does Florida rank in these rates? Yep, you guessed it, Florida has one of the highest rates of pain medication prescriptions written and one of the highest death rates related to pain medication overdose.

So we’ve established that prescription drugs cause death by overdose in about 15,000 Americans each year, but how do recreational drugs measure up? The most common recreational drug, alcohol, kills around 50,000 people each year through alcohol poisoning. The second most common recreational drug, tobacco, is attributed to over 400,000 deaths annually. Comparatively, marijuana, the third most common recreational drug, is nontoxic and CANNOT cause death by overdose. In at least 10,000 years of marijuana use in humans, there have been ZERO documented deaths related to marijuana overdose.

Medical marijuana provides patients with a natural medicine that is much safer than the toxic, synthetic drugs discussed above. Yet, ending the prohibition against marijuana seems impossible in states such as Florida.

So what states have legalized the use of medical marijuana? Well, I researched this & found that it happens to be many more than I had initially realized! The following states all have laws allowing the use of marijuana for varying ailments. The year after the state name is when the law was passed.  Alaska (1998), Arizona (2011), California (1996), Colorado (2001), Connecticut (2012), District of Columbia (2010), Hawaii (2000), Maine (1999), Michigan (2008), Montana (2004), Nevada (2001),  New Jersey (2010), New Mexico (2007), Oregon (1998), Rhode Island (2006), Vermont (2004), Washington (1998). Some states had this passed into law in the late 1990’s and here in Florida we can’t get it passed in 2014? Wow. Florida is pretty far behind the curve.

These states had medical marijuana signed into law, but have not yet become operational: Delaware (2011), Illinois (2013), Maryland (2014), Massachusetts (2013), Minnesota (2014), New Hampshire (2013), New York (2014).

Cannabinoid (CBD) is the second major cannabinoid in marijuana, after tetrahydrocannabinol (THC). CBD specific medical marijuana has been found to have anti-inflammatory and pain-relieving properties, without the psychoactive effects. However, it has limited use and limited effectiveness has been reported with this type of therapy. Incidentally, CBD has shown great promise in inhibiting the growth of cancer cells in animals.  

States with CBD specific marijuana laws are: Florida, Iowa, Kentucky, Mississippi, Missouri, North Carolina, South Carolina, Tennessee, Utah, and Wisconsin.

So what types of ailments has marijuana been found, through research, to benefit? Marijuana is widely popular because of the effect of pain relief. In particular, neuropathic (nerve damage) pain is well controlled with marijuana use. Other ailments include nausea, glaucoma, movement disorders, seizures, Chron’s disease, and muscle spasms related to Multiple Sclerosis, paralysis, and other degenerative disorders. It is a powerful appetite stimulant (this is why people using it get the ‘munchies’) and patients with HIV, AIDS wasting syndrome, and dementia can all benefit from use of this drug. Can’t envision your dementia-suffering granny sitting around toking on a joint? Well, this is where edibles come in and where the trend in consumption has shifted over the years.

So while the obvious choice for safer medical treatment of chronic pain is medical marijuana, Floridians must continue to use synthetic heroin instead. Or they can suffer. I guess that’s another option.  Those with other medical ailments that would benefit from marijuana treatment must continue on with less effective, less safe alternative synthetic drugs. We can only hope that Floridians will get it someday and join the ranks of other states providing safer alternatives of drugs to treat chronic illness.

Dr. Donna Poma Fife DNP, ARNP

Disclaimer: This blog is meant for informational purposes only and does not constitute medical advice. If you or someone you know may be suffering with a chronic illness, your best bet to receive safe, natural treatment of your ailment may be to seek care outside of Florida.  For those in Florida who understand the benefit of medical marijuana, keep fighting.  We’ll get there someday. 

ADHD awareness week: Impulsivity

One of the most common symptoms for many kids with ADHD is impulsivity. This impulsive behavior leads kids to act before they think. We neurotypical (non-ADHD) people may evaluate a situation for social norm or potential danger and decide to not partake in an action that could be seen as socially unacceptable or dangerous. Those with ADHD who have impulsive characteristics will generally not self-regulate and decide against an unpleasant or potentially harmful situation. This impulsive behavior leads kids to spending extended amounts of time in trouble at home. They may end up in time-out or end up grounded. Of all the symptoms of ADHD, impulsivity is often the most difficult to control.

So what is impulsivity? This is described as behavior without adequate thought. The person with impulsive behavior may have a tendency to act with less forethought than others.  They may react to stimuli without regard to the consequences that could occur.

I recall a story a friend told me about her ADHD son. When he was about 7 or 8 years old and they were riding their bikes in their neighborhood. There was a vicious looking dog barking relentlessly at them from a backyard, behind a chain link fence. Her son got off of his bike and started walking towards the dog. The mom yelled “What are you doing?” In his innocent, sweet voice he said “I’m going to pet the dog.” My friend was in shock! She yelled to him to stop! “That dog might bite you! Get back here!” They had a discussion about the dangers of approaching a dog they don’t know. My friend said they had conversations like this many times in the past, as she always wanted to be sure he respected animals and their space. His impulsive behavior led him to nearly put himself in a potentially harmful situation.

Not only does impulsivity commonly occur in those with ADHD, but it is associated with other mental disorders, such as mania, substance abuse, and personality disorders as well.  The International Society for Research on Impulsivity (yes, there is actually a society dedicated to the research on this characteristic!) studies impulsive behavior that occurs with mental disorders, such as ADHD. This society has developed several rating scales as measurement tools to make research projects more meaningful.

One of the most commonly used tools is a questionnaire designed to assess the personality/behavioral construct of impulsiveness is the Barratt Impulsiveness Scale. There are 30 items on the scale that describe common impulsive and non-impulsive behaviors and preferences. These behaviors are rated as: Rarely/Never, Occasionally, Often, Almost Always/Always. This scale can be viewed at: http://www.impulsivity.org/pdf/BIS11English.pdf

Other scales include the Balloon Analogue Risk Task: http://www.impulsivity.org/measurement/BART

Cued Go No-Go Task: http://www.impulsivity.org/measurement/cued_Go_NoGo

Immediate and Delayed Memory Tasks: http://www.impulsivity.org/measurement/IMTDMT

Okay, enough about rating scales, as I’m sure that has bored many of you!

Impulsivity has for many years been linked to the neurotransmitter dopamine. Neurotransmitters are chemical substances that transmit nerve impulses across a synapse from one a neuron (nerve cell) to a “target” cell. They carry, boost, and modulate signals between neurons and other cells in the body. There have been over 100 neurotransmitters identified. Dopamine is a neurotransmitter that helps control the reward and pleasure centers of the brain. It allows us to see a reward and to take action to move towards the reward. Dopamine also plays a role in movement, sleep, mood, sustained attention, working memory, motivation, learning, and emotional responses.  

For years scientists have believed that one of the primary causes of ADHD is low dopamine levels, but recent research suggested that structural differences in the brain’s grey matter may play a significant role. Structural differences in the ADHD brain and non-ADHD brain include variations in the prefrontal cortex, the caudate nucleus and globus pallidus, and the cerebellum. Nerve pathways, in particular the basal-ganglia thalamocortical pathways have been found to have abnormalities in the ADHD brain. The research will likely continue on the link between chemical and structural differences in the ADHD brain. Regardless of the cause, the symptom of impulsivity can lead the ADHD person to take risky, dangerous actions.

So is impulsivity always considered bad or a negative characteristic? The answer is no. There are times when impulsive behavior is the right response to a particular situation. We may act of off a gut instinct in an impulsive manner. An impulsive action may lead us to seize a valuable opportunity. But high levels of impulsivity is where this characteristic can be maladaptive.

With proper treatment of medication and behavioral therapy, those with ADHD and this prominent symptom of impulsivity can find success in controlling some impulsive behaviors.

There may be those outliers with ADHD who don’t have symptoms such as impulsivity. They may have a little trouble focusing & managed to get doctor to put them on a stimulant medication so they can maintain a greater than 4.0 GPA in school.  I’ve heard colleagues speak of this issue in their practice. This information doesn’t really pertain to them. This pertains to the millions of individuals with ADHD who have presenting symptoms, such as impulsivity, that greatly affects their life on a daily basis. Hopefully, these individuals will receive the care they need to treat this symptom and the others associated with ADHD.  

Dr. Donna Poma Fife, DNP, ARNP

Disclaimer: This blog is meant for informational purposes only and does not constitute or substitute medical care. I speak of generalizations and do not speak to any particular individual with ADHD, so don't feel singled out if it does/doesn't apply to you!  If you think you or your child may have ADHD please see a healthcare provider, preferably a psychiatrist or a neurologist, as they are best equipped to make a proper diagnosis. 

ADHD Awareness: Getting the diagnosis

ADHD Awareness Month #ADHD #ADHDawareness #Seekahealthymind 

So my previous blog brought awareness to the symptoms of ADHD, but how does a person get diagnosed with the disorder? Well, I’m here to tell ya!

Making the diagnosis of ADD/ADHD:  

One of the most important steps in getting a proper diagnosis of ADHD is selection of a healthcare provider. Who can diagnose ADHD? Well, family doctors, pediatricians, psychiatrists, psychologists, and neurologists are all licensed to diagnose. However, when it comes to a neurodevelopmental disorder, such as ADHD, seeking evaluation by a psychiatrist and/or neurologist is often your best bet. These specialized healthcare providers are trained in diagnosing and treating this disorder, whereas many family doctors and pediatricians are not.

Diagnosing ADHD is done according to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders or DSM-V. This book provides diagnostic criteria for mental disorders.  The criteria for diagnosing according to the DSM is that the patient has to show six of nine symptoms of inattention and/or hyperactivity/impulsivity before the age of seven. I had listed those symptoms in my last blog, so refer back if you need to.  The symptoms should have persisted for at least 6 months, and must impair the person’s functioning in settings such as the home, school, and work.

 A clinical interview utilizing a standardized ADHD rating scale should be used in the diagnostic process. This scale rates the symptoms into classifications of inattention, impulsivity and hyperactivity.  The ADHD rating scale can be found at: http://www.fmpe.org/en/documents/appendix/appendix%201%20-%20adhd%20rating%20scale.pdf

There are common mistakes that occur in the diagnostic process. These mistakes may occur when seeking a diagnosis from a family or pediatric doctor. I’m not downing these types of providers, they are generally highly educated and experienced in general or pediatric practice. But many have limited knowledge in diagnosing and treating ADHD. Diagnosing is best accomplished by a neurologist or psychiatrist. Common mistakes include:

·         Length of time of an exam: A diagnosis of ADHD should not be done in a 15 minute office visit with a family/pediatric doctor. This is a complex disorder and a thorough evaluation is essential.

·         Diagnosing secondary symptoms as the primary problem. Many of those with ADHD have coexisting conditions of anxiety, depression, or other mood disorders. These may be secondary symptoms caused by the primary diagnosis of ADHD/ADD.

·         Academic success: Just because a person isn’t failing or doing poorly in school doesn’t mean they don’t have ADHD. Some kids with ADHD may do very well in school.

·         The child has a high IQ, therefore they can’t have ADHD. Many of those with ADHD have an average or higher than average IQ score.

Finding the right clinician is important. If I had listened to the first pediatrician who told me Nevia doesn’t have ADHD, we would have never received a proper diagnosis or treatment. This can really make a kid suffer unnecessarily. Of the three pediatricians Nevia has been to, none of them utilized the ADHD rating scale to evaluate for this diagnosis. She received a diagnosis of ADHD from doctor #2, and #3 carried on treatment after we switched providers for insurance purposes. While prescription of the medication to treat ADHD was not an issue, neither of the pediatricians referred us to a psychiatrist or psychologist for counseling or behavior therapy.

A friend of mine told me a story of a coworker who asked another coworker who has ADHD what symptoms she has with this disorder. She mentioned that she wants to get a prescription for ADHD because she heard it acts as an appetite suppressant. So this young lady went to her primary care doctor complaining of inattention & difficulty focusing. She even acted the part by staring out the window & losing her attention when the doctor was talking. After her 15 minute encounter with her primary care provider, she walked out of the office with a prescription for a Schedule II narcotic, Focalin. This medication is commonly prescribed to treat ADHD. It is a HIGHLY abused medication by those who don't actually have ADHD, but somehow managed to get diagnosed with it. A more socially acceptable form of drug abuse, I suppose.

Many of those with ADHD/ADD have coexisting learning disabilities, as well. While ADHD is not considered a learning disability, it is important to evaluate for learning disabilities in those diagnosed with ADHD. Some disabilities that may coexist include; dyslexia, dyscalculia, dysgraphia, dyspraxia, and executive functioning. By the way, I dislike the term ‘disability’. I really wish they would change the wording to Learning Differences. Those with learning disabilities have the capacity to learn. They just learn differently. Additionally, other screening tests may be conducted in those with ADHD to assess for coexisting conditions, such as anxiety, depression, and other mood disorders. This particular testing can take about 4 hours for a psychologist to complete. Yes, my daughter Nevia sat through FOUR hours of testing. Quite an accomplishment for an ADHDer!

So in some circumstances, getting a diagnosis of ADHD may be quite simple. However, it is a complex disorder with many variables and the potential for coexisting conditions. This is why a thorough evaluation by a licensed psychiatrist and/or psychologist is important.

Mental health does not receive the attention that it should. We have a tendency to undervalue the importance of a healthy mind. With ADHD Awareness Month, hopefully more focus will be shed on this mental disorder that over 15 million Americans have been diagnosed with and many others live with without a proper diagnosis.

Dr. Donna Poma Fife, DNP, ARNP

 Disclaimer: This blog is meant for informational purposes only and does not constitute or substitute medical care. If you think you or your child may have ADHD please see a healthcare provider, preferably a psychiatrist or a neurologist, as they are best equipped to make a proper diagnosis.

ADHD Awareness month

Welcome to October! At this time of the year, the kids are back in their routine of school, autumn is well under way, and we may be enjoying the cooler weather that is coming our way. In addition to the changing colors of leaves, shorter, cooler days, and pumpkin lattes, October also brings ADHD awareness month. Those individuals living with ADHD or living with a child with ADHD, are well aware of this disorder on a daily basis. But with a month dedicated to ADHD, hopefully many more will gain awareness of this disorder that affects more than 15 million Americans.

The terminology Attention Deficit Hyperactivity Disorder (ADHD) and Attention Deficit Disorder (ADD) are often used interchangeably. So you may see either of these recognized variations of the name and abbreviation being used. Either way, it is the same disorder, just with varying symptomatology.

ADHD is one of the most common neurodevelopmental disorders of childhood. The causes and risk factors for this disorder are unknown. Research points in the direction of genetics, brain injury, environmental exposure to toxins such as lead, alcohol/tobacco use during pregnancy, premature delivery, and low birth weight as possible causes/risk factors. But more research needs to be done.

A common misconception is that other factors, such as high intake of sugar, watching too much TV, poor parenting, and lower socioeconomic status contribute as causes to this disorder, but these factors have NOT been supported by research.  While they may not contribute to the diagnosis of ADHD, limiting sugar intake and TV time are good choices for everyone!

The CDC lists that as of 2011, approximately 11% of kids age 4-17 have been diagnosed with ADHD. This number continues to rise. Another common misconception is that ADHD occurs more commonly in boys than in girls. However, girls hold the same risk for the disorder, but are often not given the proper diagnosis like their male counterparts. The average age at diagnosis of ADHD is 7 years of age. However, many parents notice symptoms of the disorder well before the child’s 7^th birthday.

 This disorder affects adults as well. Many adults with ADD/ADHD have never received a proper diagnosis of the disorder. While ADD has been recognized in the medical community for many years, those with ADD in generations before the 1980s didn’t usually receive this diagnosis. They may have been labeled as bad kids, lacking discipline, unintelligent, lazy, or defiant. Imagine what these labels do to the self-esteem of a person. Think about how the self-esteem of the individual could have been supported, rather than diminished, if a proper diagnosis was made early on in life.  

Adults with ADD may have trouble with organization and remembering appointments and important events. They may have trouble completing the tasks to get out of the house in the morning, often making themselves and/or their kids late for work/school. They often have a history of difficulty in school during childhood & adolescence, and they may have a history of issues with employment and sustaining relationships.  Thankfully, healthcare providers are more aware of the disorder and the prevalence in adults, and with proper diagnosis and treatment, adults with ADD can find success and lead a productive, organized life.

So what are the symptoms of ADHD/ADD?

 Many may think that lack of focus and/or distractibility are what constitute a diagnosis. However, these symptoms are only the tip of the iceberg. Adults and children with ADHD/ADD generally have many of the following symptoms:

·         Trouble paying attention

·         Makes careless mistakes

·         Seems to not listen when being directly spoken to

·         Has trouble following instructions and finishing tasks

·         Trouble planning and organizing work/activities

·         Trouble completing and/or turning in homework

·         Avoid tasks, in particular those that require sustained mental effort

·         Loses things often

·         Becomes easily distracted, misses details, frequently switches from one activity to another

·         Forgetful, forgetful, forgetful

·         Fidgets and can’t seem to sit still

·         Gets up and moves around when they are expected to stay seated

·         Is often ‘on the go’ or acts as if ‘driven by a motor’

·         Talks too much or blurts out answers

·         Can’t wait his/her turn

·         Interrupts or intrudes on others’ conversations

Wow, that’s quite a list! Now some may read this and say “well I have trouble paying attention and am forgetful, perhaps I have ADD”. Well what human doesn’t fit some of these descriptors? Most all of us can think of times that we were sitting in class and started daydreaming or thinking of a plethora of other things we wish we were doing. I’m forgetful at times. I lose things at times. That doesn’t necessarily constitute an ADD diagnosis. Individuals with ADD/ADHD live with many of these symptoms, often to a VERY high degree, and deal with these on a daily basis.  While some individuals may outgrow the symptoms of ADHD, for many the symptoms are lifelong.

As a parent of a child with ADHD, I have a great passion for learning about this complex disorder.  In honor of ADHD awareness month, I hope to pass on some of the education that I have gained through my endless reading about this disorder and my life experiences gained with a child with ADHD!

Dr. Donna Poma Fife, DNP, ARNP

Disclaimer: This blog is meant for informational purposes only and does not constitute or substitute medical care. If you think you or your child may have ADHD please see a healthcare provider, preferably a psychiatrist or a neurologist, as they are best equipped to make a proper diagnosis. 

Giving thanks: Part 2

No, it's not Thanksgiving yet, I'm giving thanks as a part of the 'what are you thankful for?' challenge. This challenge encourages participants to post 3 things they are thankful for over 5 days. With so many things to be thankful for, I am having fun with this!

I am thankful for my mother-in-law, Peggy, also known as Mema. She is an energetic, kind, loving person who always puts others before herself. She has the biggest heart of anyone I know and she is always there to help others when needed. I couldn't ask for a better mother-in-law! Dank Dank was a wonderful father-in-law as well. They made a great team! Miss you Dank Dank!

I am thankful for my rescue mutts, Bella and Coco. They are my fur babies! They have filled our home with love, companionship, and lots and lots of dog hair! Our house would be so empty without them!

I am thankful for my career. Taking care of others is my purpose in life. I have had the pleasure of caring for many people in my 20+ years in the medical profession. Every patient I have cared for has been special in one way or another. I couldn't imagine doing anything else!

So, there you go, 3 more things that I am thankful for! 

Giving Thanks: part 1

So I was challenged by Valerie Morrow to list 3 things a day for 5 days of what I am thankful for. This should be easy, as I have a lot to be thankful for and think about this quite often! Saying it with words alone may not evoke the feeling and emotion that I have behind this, so I'll say it with pictures as well!

1. I am thankful for my husband and kids, who keep me laughing with their unending humor, keep me busy with their unending laundry, and keep my heart filled with all the love they give me.

2. I am thankful for my siblings. We may not all be geographically close, but it's great knowing I have them on my side! (not pictured, my sis Joann)

3. I am thankful for my 'framily', the friends who I call family. They are the people who have proved that you don't have to be blood related to be family. Life long friends are hard to find. Glad I found mine!

ALS Ice Bucket Challenge

                                              In Loving memory of Dank Dank 

ALS #IceBucketChallenge

With social media, it doesn’t take long for a video, trend, or challenge to go ‘viral’. One of the latest challenges to take on a viral status is the ALS Ice Bucket Challenge.

Many of you may be wondering what ALS even stands for. Our family knows all too well what these three letters mean. ALS or amyotrophic lateral sclerosis, more commonly known as Lou Gehrig’s disease, is diagnosed in about 5,600 Americans each year. My father-in-law, Thomas Fife (affectionately known as Dank Dank to the grandkids), was one of the victims of this disease. First diagnosed in a baseball player named Lou Gehrig in 1939, ALS is a progressive neurodegenerative disease that affects the nerve cells in the brain and spinal cord. This neurodegenerative process causes progressive loss of voluntary muscle control, leaving the person with the inability to eat, speak, walk, and eventually breathe. The individual eventually becomes totally paralyzed. There are no effective treatments for this disease. Those diagnosed with ALS live an average of only 2-5 years from the time of diagnosis. ALS is 100% fatal.  

So what is the ALS Ice Bucket Challenge? This challenge surfaced a few weeks ago, started by former Boston College baseball player Pete Frates. The challenge quickly spread across the country. Celebrities, politicians, athletes, and common men and women, have taken part in the challenge to have a bucket of ice water dumped over his/her head. When they complete the challenge, they are to challenge others to do the same or make a donation to fight ALS (or a charity of their choice) within 24 hours. Apparently, those individuals who completed the challenge end up making a donation as well. The ALS Association reports donations to various chapters of the organization totaling $4 million between July 29 & August 12 as a result of this challenge. Last year at the same time donations totaled about $1.12 million. Not only is the ALS association thanking the public for the monetary donations, but also for the visibility the disease has gained since the inception of this challenge.

It is great to live in a time when we can see something such as the Ice Bucket Challenge bring so much awareness to a disease and lead to so many generous donations to organizations committed to fighting ALS. Social media is a huge part of our life today. Those of us who peruse Facebook, Twitter, or Instagram view pictures of friends, kids, spiritual sayings, political bashing, recipes, and even pictures of what a friend had for lunch. We are uplifted, angered, or given new information to discuss with friends. We are given reminders of friend’s birthdays and flooded with well wishes when we post how sick we feel. We use social media for so much today. Some negative, some positive. I love to see when our use of social media can have such a profound positive force in our lives and in this world. The #IceBucketChallenge makes me appreciate it so much more.

To learn more about ALS and to make a donation, visit: http://www.alsa.org/ Go ahead. I #IceBucketChallenge you!

 Dr. Donna Poma Fife DNP, ARNP

Disclaimer: Author has no affiliation to the ALS association. It’s just an issue near and dear to my heart. 

Here is our ALS #IceBucketChallenge!  Nevia wasn't home to join in on the fun. It's hard to get us all in the same place at one time! In the video, you will see that our dog Coco thinks we are nuts!

https://www.youtube.com/watch?v=QwqtGPQley0&feature=youtu.be