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                    [post_content] => In July of 2014, Governor Charlie Baker signed a bill into law protecting the civil rights of transgender individuals in Massachusetts. Supported by a broad coalition of business, community, and civic groups, this Transgender Anti-Discrimination law ensures equal rights of transgender individuals in public spaces, including parks, restaurants, and public transportation. It also guarantees access to public restrooms, enabling individuals to use restrooms in accordance with their gender-identify.
What’s this week’s Ballot Question 3?
Ballot Question 3 asks: “Do you approve of a law summarized below, which was approved by the House of Representatives and the Senate on July 7, 2016?”

After a summary of the law, voters are guided: “A YES VOTE would keep in place the current law, which prohibits discrimination on the basis of gender identity in places of public accommodation. A NO VOTE would repeal this provision of the public accommodation law.”

That is, a YES vote keeps the existing law in place, continuing to protect transgender rights across the state.
What the Current Law Protects
Taking intimate photographs of people without consent and sexual assault are crimes, and violators are prosecuted under existing criminal law. The Transgender Anti-discrimination Law protects transgender individuals from acts of discrimination and social exclusion. It does not change criminal law. The anti-discrimination law states that a person’s gender identity cannot be used for an “improper purpose” and a person must assert a “consistent and uniform” gender-related identity if questioned in court.
The Opposition
Opponents of the anti-discrimination law include Keep MA Safe, funded primarily by the Massachusetts Family Institute, gathered 50,000 resident signatures to place the Transgender Anti-Discrimination Law on the 2018 ballot with the goal of repealing it. The passage of the 2014 law had immediately sparked opposition among some, based on fear that the law would allow sexual predators, posing as transgender women, to enter women’s restrooms to engage in criminal behavior. Opponents of the law also suggested that civilians who report suspicious gender-based behavior (such as questioning a person’s intent for entering a bathroom) risked being arrested and fined up to $50,000.

Neither of these hypothetical concerns has come to pass.

In fact existing laws do not allow male sex offenders to enter a women’s restroom or locker room. It also does not penalize citizens from reporting criminal behavior. Chapter 151B Section 5 of Massachusetts General Laws: Individuals and organizations can only be arrested or fined if found to have participated in the “discrimination or restriction” of a person based on gender identify. Contrary to 'No on 3’’s campaign ads, fines of $50,000 many only incur when multiple acts of discrimination occur over a seven-year period.
The Nondiscrimination Law Promotes Health and Wellbeing
A study by the Williams Institute on Sexual Orientation and Gender Identity Law and Public Policy at the UCLA School of Law found that laws protecting transgender rights have had no effect on the number of bathroom-related crimes in the state of Massachusetts. In fact, they found that safety and privacy violations decreased in areas with stricter implementation of the nondiscrimination law. The researchers also found bathroom-related violations to be extremely rare, providing evidence that many of the opposition’s arguments are based on hypothetical outcomes rather than quantifiable data.

A 2015 report by the National Center for Transgender Equality found that 40% of transgender respondents expressed experiencing psychological distress (depression, stress, and anxiety) in the past month. Suicide attempts by transgender persons is 9 times higher than the national average. Before anti-discrimination legislation passed in North Carolina in 2016, 60% of transgender respondents reported avoiding public restrooms in fear of confrontations, 32% limited what they ate or drank so they didn’t have to use a bathroom, and 8% suffered from bladder-related infections as a result of bathroom avoidance.
What’s in Store for the Future
A June 2018 poll found that 49% of respondents were in favor of keeping the law, as oppose to 37% who reported in favor of repealing it. The margins are slim. This is especially concerning given the recent memo from the Department of Health and Human Services seeking to change Title IX’s legal definition of sex, which currently bans gender discrimination in schools that receive federal funding. This HHS change would create binary definitions of gender (male or female) based on an individual’s biological sex, as assigned at birth. It would eradicate the ability of 1.4 million transgender Americans to self-identify their gender.

Massachusetts is a leading state for policies concerning freedoms and equality. We were the first in the nation to recognize marriage equality. What message will we be sending to the rest for the nation if we repeal this law?

Your vote matters. So on November 6th, get out and vote YES on question 3!

Opportunities to volunteer with the Yes on 3 campaign can be found here.

Feature image from Freedom for All Massachusetts Coalition
                    [post_title] => Vote Yes on 3
                    [post_excerpt] => Erin Polka urges a YES vote on Massachusetts Ballot Question 3, to uphold a state non-discrimination law and protect the the civil rights of transgender individuals. 
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                    [post_content] => Think about where you work or another place you gather regularly with others. Do you have a sense of what the norms are, how you should behave, and how people react? You don’t shout commands to actors in a theater, for example. Yet it’s fine to yell at players at a sports event. Yes, for silence and anti-social behavior in a library. No, for never speaking with your colleagues at work. Okay to eat with your hands at a pizza shop. Not so much at a French restaurant.

What is this sense of “the way we do things around here”? It’s culture. It’s the usually unexpressed assumptions, values, and beliefs of people within an organization. It can manifest in myriad ways. Aviation provides some heart-stopping examples of why culture is important to understand, measure, and change. In the 1980s, the reporting culture around near misses (crashes that almost happened) was in its infancy. The attitude of “nobody knows, so let’s keep it secret” was common. Yet just last year a crash of five full-sized airplanes was averted. One factor in avoiding that disaster may have been that air traffic controllers now work in a culture where speaking up about errors is encouraged.
But as anyone interested in transforming organizations will tell you, changing a culture is difficult. Organizations comprise many levels and micro cultures.

 
But as anyone interested in transforming organizations will tell you, changing a culture is difficult. Organizations comprise many levels and micro cultures. Setting up structures and processes that support change requires consistency, institutional commitment, local champions, effective channeling of resources,  constant communication, and more. The list is long. And these potential difficulties are frequently compounded by everyone’s tendency to defer to the status quo.

An ever increasing part of my career nevertheless focuses on changing cultures. Why? First, my area of choice needs help. I work with nursing homes, particularly those in the Veterans Health Administration (VA) system. The VA Community Living Centers (as nursing homes are known there) yearly serve over 40,000 veterans, many of whom are among the system’s most vulnerable. I detailed in a previous post the reasons nursing homes deserve attention from all of us. The residents who live there—the future you and me—deserve the best care and living environment society can provide. Yet the staff working closely with older adults are often underpaid and overworked. And despite years of effort to change the culture of care, change has been slow. For those of us who love a challenge, it’s a good area to choose.
But there’s another reason I’m increasingly drawn in this direction: our work focuses on the positive.

 
But there’s another reason I’m increasingly drawn in this direction: our work focuses on the positive. If a nursing home is trying to improve prevention of pressure injuries (a.k.a. bed sores), for example, frontline staff can gather for a quick huddle and focus their attention on instances when (a) someone was at risk for developing a bed sore but (b) did not develop one. In these huddles, everyone can have a voice—and it’s easier to speak up when the focus is positive. From the positive examples, staff can learn from what’s already working, then devise an action plan to test small changes they can monitor, repeating this huddle-discuss-plan-observe process in an ongoing cycle. We call this “learning from the bright spots.” It helps change the culture by creating high-functioning, relationship-based teams ready to tackle all kinds of quality, safety, morale, and other challenges.

The consultants with whom we work have achieved miraculous changes in nursing home cultures across the nation for decades. But for the first time, with support from VA’s central leadership, we are tackling change in a large, integrated healthcare system.

Sometimes you don’t want to change the way things are done around here, like eating pizza with your hands. But sometimes you need to. Nursing homes need change. There are some terrific, shining examples of what’s possible. But we need to raise the level of all. I believe changes in systems, to the benefit of everyone, is possible.

Feature image: Jeffrey Smith, Senior Dance 1. Jeff Smith/Staff Photographer, used under CC BY-ND 2.0. Used for illustrative purposes only.
                    [post_title] => The Way We Do Things Around Here
                    [post_excerpt] => Cultural change in nursing homes requires consistency, institutional commitment, local champions, and focusing on the positive.
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                    [post_content] => Though the surgeon general recommends more people carry naloxone to enable opioid overdose reversals, economists in a recent study argue that greater access increases crime and incentivizes drug use. They allege naloxone allows people who survive an overdose after receiving naloxone to go on to commit more “opioid-related” crimes. They claim the cost of reversing overdoses is burdensome, arguing some people may need to be reversed again. They correlate changing naloxone laws with increasing rates of opioid use and suggest naloxone increases such use by “providing a safety net.” They argue that naloxone presents a moral hazard, an insurance policy guarding opioid users from the consequences of their actions. Yet no credible evidence exists that providing naloxone increases compensatory substance use, and economic arguments do not tell human stories.

While on call this past year in Central Appalachia, an area heavily affected by opioid use and overdose, we heard from a pregnant patient with opioid addiction. She had overdosed the night before. Thankfully, she was with people who had naloxone—they used two kits to get her breathing again. She went on to enter substance use treatment and deliver a healthy baby. Without naloxone, she would have died; she would not have gone on to parent a wanted child. For anyone with an un-medicated chronic illness, a relapse or worsening of symptoms is common. Unlike other diseases, in addiction, relapse can be deadly. What compelling economic argument is there that people deserve to die from relapse How many reversals do these economists consider too many?
Four North Carolinians die every day from overdose—because of poverty, pain, and lack of access to treatment and health care overall.

 
Working in a harm reduction program in Western North Carolina, we distribute naloxone to people who use drugs. In the last year we noticed a dramatic increase in the number of naloxone kits requested, and reversals reported—188 fatal overdoses were prevented through peer reversals, in the first half of 2018 in one county, alone. We know that people who use drugs and access harm reduction services are five times more likely to enter treatment than people who don’t. Part of the reason is that harm reduction—which includes the provision of naloxone—offers a judgment-free space for stigmatized opioid users to get what they need, and to be heard. Unfortunately, the high demand for substance use treatment is not currently met in North Carolina or throughout the South, where opioid use disorders rates are higher and access to treatment is lower than elsewhere in the country. Four North Carolinians die every day from overdose— because of poverty, pain, and lack of access to treatment and health care overall. Naloxone is a life-saving solution to a structural overdose problem.

We do not consider the likelihood of a future property crime before offering naloxone, safe injecting equipment, or treatment. We do think about people overdosing and dying. Substance users deserve to live. We have at our disposal an overdose reversal medication that enables survival. It is immoral not to provide and use it.

Feature image: VCU CNS, Narcan_Product_Image_2, used under CC BY-NC 2.0
                    [post_title] => Is There a Risk to Naloxone?
                    [post_excerpt] => Naloxone is a life-saving intervention used to reverse drug overdose, but critics argue that it increases crime and promotes drug use. Ostrach and colleagues disagree, arguing that withholding it is immoral.
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                    [post_content] => In the Willa Cather novel, Death Comes for the Archbishop, the protagonist lives a long life, with death arriving peacefully. In contrast, for many persons who experience homelessness, life is short and death is not gentle.

We—a team of researchers from Boston University School of Public Health, Boston Health Care for the Homeless Program, and the US Department of Veterans’ Affairs—are conducting a longitudinal study of homeless people and the health advantages that may accrue from a mobile phone and health-related text messaging intervention. While our study is not yet completed, we have seen death and adversity come too often to our participants. To date, our sample of sixty-four has experienced at least five incarcerations, five deaths, one stroke, and one attempted suicide.

The research term, “lost to follow-up,” does not adequately describe what our team feels when we lose a participant to illness, incarceration, or death. When we learn that someone has passed or has been incarcerated, we can’t help but vicariously feel their suffering. When we sit down with a participant to complete a survey and she shares with us the hardships she’s faced that day, our natural reflex as human beings is to lend a hand. But since we are public health researchers—not clinicians or friends—we must remain objective and focus on the larger solutions related to our research question, not individual solutions for the human being sitting in front of us. This tension between humanity and research can be a source of secondary traumatic stress, a phenomenon in which individuals who care for persons exposed to trauma themselves feel the toll of that trauma. Secondary traumatic stress has been documented in various areas of health care, including social research.
A recent study at the Boston Health Care for the Homeless Program found that all-cause mortality in Boston was three times greater among the unsheltered homeless than the sheltered homeless, and nearly ten times greater than the non-homeless.

 
We are not the first or only study to encounter conspicuous adversity and mortality among people experiencing homelessness. Larger research studies have documented the substantial burden of illness and high death rates in this population. A recent study at the Boston Health Care for the Homeless Program found that all-cause mortality in Boston was three times greater among the unsheltered homeless than the sheltered homeless, and nearly ten times greater than the non-homeless. The most common natural causes of death were cancer, heart disease, alcohol-use disorder, and chronic liver disease, all health problems with well-established methods for prevention and treatment. Additionally, life expectancy for some homeless populations is shorter by 8 to 13 years compared to non-homeless populations.

Our research continues, but with an underlying urgency to collect data while our subjects are still able to provide it, and swiftly use our results to contribute to knowledge, interventions, and solutions that address the needs of homeless populations.

For every challenge that comes from our research, there is something to celebrate. Some of the people participating in our study have shared their excitement at receiving a first mobile phone, or being able to join our study after we developed Spanish consent and interview materials. Moreover, we have been inspired by the resilience many of our participants exhibit in spite of debilitating illness, housing instability, or precarious relationships. One participant, in spite of chronic illness and abuse, reported in our survey that he “tr[ies] to have a sense of humor and laugh…to take away the pain.” Another participant shared that his study mobile phone helped him secure health insurance and housing for himself and a friend. Moments like these counter the emotional toll of working with Boston’s homeless population, reenergize our team, and leave us better equipped to put forth evidence-based solutions that promote stability, health, and finally—like Cather’s protagonist—peace, for the homeless.

Feature image: kargig, Homeless in Köln, used under CC BY-NC-SA 2.0 for illustrative purposes only. 
                    [post_title] => Death Comes for the Homeless
                    [post_excerpt] => For many persons who experience homelessness, life is short and death is not gentle.
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                    [post_content] => What were you doing on International Whore’s Day (June 2)? If you are a sex worker or a sex worker advocate, you may have been protesting the new anti-sex trafficking legislation President Trump signed in April. The new law (HR 1865) led to an immediate shut-down of the websites sex workers use to solicit and vet clients, negotiate payment, and share information about predators. Backpage.com was seized by the federal government. Craigslist killed their personal ads. EventBrite stopped promoting events with explicit sexual content. Many others followed.

The new law is an amalgam of two bills: House Bill 1865 (also known as the Allow States and Victims to Fight Online Sex Trafficking Act of 2017 or FOSTA) and Senate Bill 1693 (the Stop Enabling Sex Traffickers Act or SESTA). The long names, numbers and acronyms get confusing quickly. The new law is the House version, FOSTA, but many activists and the media refer to it as SESTA or SESTA/FOSTA. This naming ambiguity is just the first layer of semantic obfuscation.

Most of the language of the new legislation focuses exclusively on sexual trafficking of others. The goal is to eliminate traffickers’ online ability to lure vulnerable children and adults into a web of false promises and then sell them to perpetrators of rape and abuse. HR 1865 amends the Communication Act of 1934 to specify that websites are not protected from legal action when they “unlawfully promote and facilitate prostitution” and “facilitate traffickers in advertising the sale of unlawful sex acts with sex trafficking victims.” It also criminalizes operation of interactive internet services to “promote or facilitate the prostitution of another person.”

The problem is that the law conflates voluntary sex work with coerced prostitution (i.e., trafficking). As a result, it targets all online sex forums as trafficking venues that serve no positive purpose.
Prior to the internet, sex workers met clients on the streets and in bars, and often worked under the control of pimps or other third parties who controlled them and took their money. Online platforms allowed many to work autonomously, make decisions from a safe distance about which clients to meet, and collect their negotiated fees electronically without the risk of being robbed or cheated.

 
Prior to the internet, sex workers met clients on the streets and in bars, and often worked under the control of pimps or other third parties who controlled them and took their money. Online platforms allowed many to work autonomously, make decisions from a safe distance about which clients to meet, and collect their negotiated fees electronically without the risk of being robbed or cheated.

Sex workers marched in June to protest SESTA/FOSTA as one more federal law ostensibly created to protect individuals from exploitation and violence that is, instead, doing harm. The Department of Justice defines human trafficking as “modern-day slavery,” involving victims who are “exploited for commercial sex in numerous contexts, including street prostitution, illicit massage parlors, cantinas, brothels, escort services, and online advertising.” Sex workers argue that their chosen profession is the antithesis of trafficking.

Sex workers and anti-trafficking advocates are often at odds as many of the latter see all selling of sex as a form of exploitation that must be abolished. But the SESTA/FOSTA protests have taken a twist. While some anti-trafficking activists heralded the internet crackdown, others (including trafficking survivors) have allied with sex workers to decry the new law, claiming that internet advertisements are critical for tracking and rescuing trafficking victims and providing evidence to prosecute perpetrators.

Exchanging sex for money is illegal in the United States, with the exception of some counties in Nevada. For this reason, sex workers have been forced to operate in the shadows of the internet and other unregulated spaces alongside perpetrators of human bondage and sexual assault. The 2018 International Whores’ Day protests made it clear that HR 1865 pushes sex workers and trafficking victims into even darker corners without the protection provided by the internet.

Feature image:  juno mac, SW_PARLIAMENT_PROTEST_080318_046, (detail). Sex workers demonstrate outside a parliamentary debate in London on the 4th July 2018, to protest discussion of a UK version of FOSTA (A US law that criminalizes the advertising of sex work on the internet) and to draw attention to their campaign to fully decriminalize sex work, used under CC BY-NC-ND 2.0

 
                    [post_title] => It's Dangerous to Confuse Sex Work and Trafficking
                    [post_excerpt] => A new law designed to thwart online sex trafficking shuts down sites like Backpage.com and Craigslist personal ads. Sex workers use these sites to solicit and vet clients and share information about predators and say the legislation increases the dangers they face. 

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                    [post_content] => Boston’s streets are full of the evidence of the ongoing opioid epidemic, which is killing Americans at an alarming rate. Drug-use-associated litter is a problem that poses minor public health risks but stokes significant community anxieties. While many cities have established needle exchanges or safer needle disposal programs, these services are underutilized because of the stigma associated with substance use disorders, and some have recently closed, facing political and financial pressures.

In 2015, Boston established a Mobile Sharps Collection Team to respond to discarded needle pick-up requests throughout the city. These crowdsourced requests leverage the existing non-emergency 311 infrastructure by allowing Boston residents to request a needle pick-up through a website, Twitter or, most commonly, the Bos:311 mobile app. Notably, Boston has made the data from this program publicly available.
These crowdsourced and publicly available data shine a bright light on the role of citizen scientists in building healthy communities.

 
As Boston-based clinicians and researchers caring for patients with substance use disorders and interested in publicly available data, we wondered: could the data from discarded needles provide an opportunity to address the underlying epidemic? More specifically, could examining temporal and spatial trends in discarded needles throughout the city help us develop community responses to the opioid-use and overdose epidemics? Our initial findings were published last month in the American Journal of Public Health. We highlight the rising number of reported needles in Boston, up from 600 needle pick-up requests in 2015 to well over 2,000 in 2017. We identify discarded needle hot spots clustered in the South End and Roxbury neighborhoods, with several outlying hotspots in the North End, Allston-Brighton and the South Boston-Dorchester border. Using additional geospatial methods like buffering analysis, where we calculate discarded needles within a set distance from points of interest, we also found an association between sites of high social stress (hospitals, homeless shelters, safe needle disposal sites, methadone clinics) and areas with a high density of publicly discarded needles.

These crowdsourced and publicly available data shine a bright light on the role of citizen scientists in building healthy communities. By reporting discarded needles, Boston community members call attention to the immediate public health risks of needlestick injuries, while the resulting data can be used to target services for individuals with substance use disorders more effectively. People who inject drugs face significant stigma. They also lack safe places to use and reliable access to harm reduction services including needle exchange and naloxone to reverse overdose.

There are at least two hundred municipal 311 programs in the United States and a number of international cities have followed. The crowd-sourced data generated by these programs provide a precise accounting of public concerns; however, few cities are reporting their data publicly. So far, only Boston, Seattle, and San Francisco are collecting discarded needle data. We hope that our work highlights the value in public reporting of drug-related litter. By uniting community members, researchers, and public health advocates we hope to catalyze an increase in targeted harm reduction services including syringe exchange, overdose prevention sites, and access to medications to treat opioid addiction.

Map created in ArcGIS by John F. Pearson, MD. Sources: MassGIS, OpenStreetMap.org, BOS:311
                    [post_title] => Crowdsourcing the Opioid Epidemic
                    [post_excerpt] => In 2015, Boston established a Mobile Sharps Collection Team to respond to discarded needle pick-up requests throughout the city. Data from discarded needle locations could provide an opportunity to address the underlying epidemic. 
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                    [post_content] => In July, 15,000 people living with HIV, activists, researchers, policymakers, and donors gathered in Amsterdam for the 22nd International AIDS Conference.  This year’s theme—Breaking Barriers, Building Bridges—focused the world’s attention on sex workers and other marginalized populations disproportionately affected by HIV.

Amsterdam was deliberately chosen to host the 2018 conference because of its high-profile red-light district and the legal status of sex work in the Netherlands. Sex workers were front-and-center in press conferences, panel discussions, and awards ceremonies. They even raucously interrupted President Clinton’s key note address to protest US policies and demand that the 2020 AIDS meeting not be held, as planned, in San Francisco. The US government, they argued, has a long history of violating the human rights of people who sell sex, implementing oppressive laws, and making it difficult for sex workers to protect themselves from HIV and violence.

The Prohibition on the Promotion and Advocacy of the Legalization or Practice of Prostitution or Sex Trafficking embedded in the President’s Emergency Plan for AIDS Relief (PEPFAR) is a particularly egregious example. The Anti-Prostitution Pledge requires organizations receiving US funding to certify that they will not “promote or advocate the legalization or practice of prostitution or sex trafficking.” They must have an explicit policy against sex work and trafficking and agree to not use private funds to support sex workers. It has been derided by many, but its restrictions have gradually loosened over the years. Simultaneously, PEPFAR has committed to promoting the health and wellbeing of sex workers through its focus on key populations. Here’s a brief overview of the current situation and how we arrived here.
Since 2003, PEPFAR has invested $70 billion dollars and has changed the course of the HIV pandemic. It is an enduring positive legacy of George W. Bush’s presidency.

 
Since 2003, PEPFAR has invested $70 billion dollars and has changed the course of the HIV pandemic. It is an enduring positive legacy of George W. Bush’s presidency. At the same time, Bush’s conservative values also limited PEPFAR programming for many years by pushing abstinence over condoms as a primary form of prevention, and prohibiting needle exchange. Eradicating prostitution is a core goal of the PEPFAR legislation. Forcing countries and public health organizations to comply with the anti-prostitution pledge was one means to that end.

The grip of the Anti-Prostitution Pledge has been the most enduring, but it too has gradually loosened. In 2013 the Supreme Court ruled the Pledge violates freedom of speech. A later win in New York went further, ruling that US organizations and their foreign implementers are protected by the First Amendment. Despite these successful challenges, all organizations receiving PEPFAR funding are still required to certify compliance. And foreign organizations receiving funding directly from the US government are bound by its restrictions.

If you are confused, it’s with good reason. In a direct contradiction of the Anti-Prostitution Pledge, PEPFAR is channeling millions of dollars to programs that support sex workers. Simply type “PEPFAR key populations” into your search engine to find information about the many programs for sex workers the US government supports.  PEPFAR’s declaration that it “stands firmly and unequivocally with and for key populations” is based on detailed ethical framework “ensuring human rights and leaving no one behind.”

I’m not complaining. I have worked with PEPFAR-supported programs focused on the health and human rights of people who sell sex in Ghana and elsewhere. These collaborations have sometimes allowed me to forget that the Anti-Prostitution Pledge is also part of the PEPFAR ethos. I led a PEPFAR-funded study that had an express goal of helping USAID and Ghana’s government better understand the vulnerabilities and needs of adolescents and adults engaging in sex work. The Anti-Prostitution Pledge rarely came up. But we cannot dismiss the Pledge as an unimportant policy relic.

For now, evidence seems to be winning the tug of war with ideology. But we can’t afford to be complacent.

Feature image: Michael Coghlan, Where the 'Ladies' Sit (detail), used under CC BY-SA 2.0
                    [post_title] => What’s Up with PEPFAR’s Anti-Prostitution Pledge?
                    [post_excerpt] => The US government has committed millions of dollars to HIV prevention for sex workers, a major departure from the Anti-Prostitution Pledge. 
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                    [post_date] => 2018-08-30 05:30:48
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                    [post_content] => Legislation authorizing medical cannabis in 31 states over the past 22 years has transformed the marijuana infrastructure in the United States, enabling widespread access. Many now regard cannabis as no different, or even safer than, alcohol or tobacco. The alternative wellness community embraces cannabis as a therapeutic aid, fostering public perception of positive health benefits. Medical cannabis can be home grown or purchased at dispensaries via a physician recommendation in a wide variety of forms, to be smoked, vaped, or ingested in tinctures and edibles.

With this shift toward cultural acceptance, it is important to keep in mind that cannabis has addictive potential and may exacerbate mental health problems, particularly among adolescents and emerging adults. Portable vape pens are a popular form of cannabis use among youth due to convenience and discretion. Vaping may lead to more frequent use and misuse compared to smoking. Our research indicates that 18 to 30-year-old medical cannabis users are motivated to use cannabis out of boredom and show more problematic cannabis use than middle-aged and older adults.
Our research indicates that 18 to 30-year-old medical cannabis users are motivated to use cannabis out of boredom and show more problematic cannabis use than middle-aged and older adults.

 
The two main chemical compounds in the cannabis plant are tetrahydrocannabinol (THC) and cannabidiol (CBD), both of which affect the naturally occurring cannabinoid system in the brain and body. Unlike THC, CBD does not cause intoxication or cognitive deficits, and has low potential for misuse. Emerging scientific evidence indicates that THC and CBD can be used to treat certain physical problems. Likewise, individuals are increasingly using cannabis to manage psychological conditions, such as anxiety, depression, stress, insomnia, trauma, attention-deficit hyperactivity disorder, and psychosis.

Research consistently shows however that cannabis is not a viable treatment for depression. While CBD may help with psychosis, social anxiety, and sleep, THC is known to exacerbate psychosis, increase anxiety and impair sleep quality, especially if the individual relies on cannabis to sleep. Trauma survivors and veterans with PTSD, who use cannabis to cope with anxiety, nightmares, and insomnia may develop cannabis addiction and avoid dealing with their underlying issues. While some researchers promote cannabis as a less harmful substitute for opioids in treating chronic pain, Canadian physicians recommend against medical cannabis for all conditions except severe refractory pain when all other options are exhausted.
Although I have patients who claim cannabis works better than psychiatric medications, it should not be regarded as a first-line treatment for any mental health condition because of the potential for misuse and dosing inaccuracy.

 
Although I have patients who claim cannabis works better than psychiatric medications, it should not be regarded as a first-line treatment for any mental health condition because of the potential for misuse and dosing inaccuracy. If psychotherapy and medications fail, low doses of cannabis could be considered in consultation with one’s doctor, depending on symptoms and case history. Because CBD is thought to offset the negative effects of THC, medical cannabis patients should consider using cannabis that contains elevated levels of CBD. Clinical outcomes often depend on cannabis dose and strain-type, as well as a person’s neurochemistry.

Due to federal prohibition, cannabis research is still in its infancy. The expanding cannabis industry and its messaging have outpaced the ability of scientists to conduct and disseminate research. Public health initiatives driven by cannabis regulatory science could address misinformation being given by dispensary staff and the online cannabis community. Evidence-based recommendations for safe and effective therapeutic uses of cannabis are critically needed in the mental health arena.

Feature image design by Daniel Paduano
                    [post_title] => At a Crossroads: Medical Cannabis and Mental Health
                    [post_excerpt] => Cultural acceptance of marijuana is increasing, but cannabis has addictive potential and may exacerbate mental health problems, particularly among adolescents and emerging adults.
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                    [post_content] => Suppose you are in the United States on a student visa and want to enroll in a Marketplace plan. Or maybe you are on an H1-B work visa and want to enroll your newborn in WIC. Sure, why not? Well, do you want to stay? Then, not so fast. The Trump administration is pushing for a revision of the “public charge” rules, which could force non-citizens living here legally to choose between popular benefits and their future immigration status.
What is the Public Charge Rule?
For over 100 years, public charge regulation has played a role in who is allowed to legally immigrate into and remain in the United States as a permanent resident. The roots of this type of regulation stretch back to colonial times when "colonists were especially reluctant to…welcome…impoverished foreigners." These rules provide a legal basis to discriminate against those in need, creating a disincentive for immigration by those who would rely upon public support.

For nearly two decades, “non-cash benefits,” like tax credits (e.g., Earned Income Tax Credit) and in-kind benefits (e.g., health insurance, nutrition support) have been excluded from such determinations. For example, “lawfully present” immigrants must generally wait five years before being eligible for Medicaid, but many can apply for coverage and get financial help in the Marketplace. (Oh, except if you here under Deferred Action for Childhood Arrivals, then you cannot participate in the Marketplace at all.) The complex patchwork of qualifying statuses for various programs is already a barrier to participation since many do not know that they are eligible.
The Leak
A draft proposal modifying the public charge rules leaked in March, broadening them to include those receiving “almost any form of welfare or public benefit, even popular tax deductions.” This would expand the scope of public charge determinations from about 3% of non-citizens to 47% under the draft rule. Benefits used by dependents, even those who are citizens, could factor in. Also, the current standard of being "primarily dependent" on government support for considering one to be a public charge would change to receiving nearly “any government assistance,” excluding only those receiving very low value of benefits (i.e., less than $1 per day for a single person). These changes could easily be framed as conserving resources for citizens and permanent residents, which is objectively defensible at face value. But this rationale ignores the larger context and apparent motives behind these changes.
How Would These Changes Affect Families?
Nearly 15% of the 27.5 million uninsured are ineligible for ACA coverage due to their own immigration status (e.g., undocumented, DACA). However, there are another 10 million children who are citizens with non-citizen parents. These children are not only at risk for separation if their parents are forced to leave, but this could also have the (un)intended consequence of discouraging parents from signing their children up for programs like WIC and Medicaid.

There was a “chilling effect” of being in a mixed status household on Medicaid coverage prior to the 2016 election, likely deepening to a freeze with the anti-immigrant stance of this administration. In a country where Latinxs are already disproportionately more likely to be uninsured, a further disincentive to participation in widely used programs would make climbing the economic ladder even more difficult.

The republic sits at an ethical crossroads. From remarks by then-candidate Trump about Mexican “rapists” to tweets about “infestation” by MS-13 and a reprehensible family separation policy, this administration continues its anti-immigrant assault. This change to the public charge rules would represent an insidious new low in how we treat immigrants in America. We should push the administration and Congress to enact comprehensive immigration reform rather than using regulation to institutionalize and further widen economic and health disparities between immigrants, particularly those in the United States legally, and their neighbors.

Feature image: jordi.martorell, Statue of Liberty? (detail), used under CC BY-NC-ND 2.0
                    [post_title] => Public Charge Regulation and Institutionalizing Immigrant Poverty
                    [post_excerpt] => The Trump administration's revision of public charge rules could force non-citizens living here legally to choose between benefits and their future immigration status.
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                    [post_content] => The United States has the highest drug prices in the world and it's not even close. For millions in the country, the cost of prescription drugs is an ever-growing barrier to proper disease treatment. This is most often the case for minority groups, who have long experienced disproportionally adverse health access and outcomes. But high drug prices alone do not explain the inequity we see. Though cost is a major factor, Colon, et al. found that disparities are not simply a function of socioeconomic status—the story is more complicated.
Minorities Face Many Barriers to Prescription Medicines
Costs
White Americans are, on average, much wealthier than Black and Hispanic Americans. The median net worth of White households in 2016 was 9.7 times higher than African-American households and 8.3 times higher than Hispanic households. Wealth disparities result in negative health consequences. Among insured adults with diabetes, Tseng, et al, found race and ethnicity to be a significant predictor of medication underuse—patients underusing their medication in order to prolong supply—due to cost. (Medication underuse is a somewhat common cost saving strategy, per the CDC.) The authors attribute this to lower incomes and higher out-of-pocket drug costs. Although study participants all had health insurance, disparities persisted.

Lack of Insurance
Affording medications is even harder for those without coverage. Though the Affordable Care Act (ACA) reduced the number of uninsured Americans, over 28 million remain without insurance. More than half (55%) of uninsured Americans under the age of 65 are people of color. For those with no insurance, paying retail prices for medications is often financially impossible.

Implicit Racial Bias in Prescribing Practice
Race can have an implicit effect on the prescribing practices of providers. For example, one study showed that White children treated at pediatric emergency departments inappropriately received antibiotics for respiratory infections more often than Black or Hispanic children, indicating that prescribing patterns can vary depending on the race of the patient. Terrell, et al., found that in their sample, ethnic and racial minorities were prescribed analgesics at a lower rate compared to White patients when discharged from the emergency department.
Practical Policy Pursuits
Here are four policy options for addressing racial disparities in access to prescription medication:

Continue to Expand Medicaid

One in five people of color have access to prescription drugs through Medicaid. Virginia recently expanded Medicaid (becoming the thirty-third state to do so). Medicaid expansion is on the November 2018 ballot in Utah and Idaho (Atkeson and Jones write more about the Idaho intiative here) while supporters in Nebraska are collecting signatures to get it on the ballot. A Maine state court has ruled that Governor LePage must submit the paperwork to expand.

Promote the ACA and an Essential Benefits Package

The ACA has played a key role in increasing health insurance among low-income people of color. Prescription drugs are one of ten essential health benefits the ACA requires insurers to cover. Interventions to increase coverage are needed, particularly in regard to medications. Research shows that promoting coverage gains through increased advertising is effective.

Reduce Implicit Bias in Prescribing  

Parity in prescribing practices is possible. New research shows that reducing stigmatizing language in electronic health records can reduce implicit bias in physicians-in-training, influencing their attitudes about both patients and prescribing behavior.

Value-based  Formularies to Reduce Costs

Pharmacy cost reduction is critical. One method for cutting costs is to use value-based formularies (VBFs), which guide prescription decisions based on cost-effectiveness. Simply, if there’s a drug with similar efficacy that costs less, that drug can be placed on an insurer’s formulary in favor of a competitor.

For example, Express Scripts, the nation’s largest pharmacy benefit manager, cut Amgen’s Repatha (evolocumab) in favor of Sanofi and Regeneron’s Praluent (alirocumab), which is used for preventing cardiovascular disease, because of the latter’s willingness to lower the price to match valuation done by the Institute for Clinical and Economic Review (ICER).

The multidimensional nature of health disparities and pharmaceutical law, policy, and practice requires multiple, synergistic approaches like those mentioned here, as a means to promote equitable access to necessary and effective medications for minorities.

Feature image: Thomas Hawk, Prescriptions (detail), used under CC BY-NC 2.0
                    [post_title] => Racial Disparities, Prescription Medications, and Promoting Equity
                    [post_excerpt] => For millions in the US, drug prices are an ever-growing barrier. Here are four policy options for addressing racial disparities in access to prescription medication.
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