There are currently four medical marijuana dispensaries open in Massachusetts — in Salem, Brockton, Northampton and Ayer. But patients aren’t able to buy the full 10 ounces every 60 days that is allowed by state law because most of the marijuana grown by these facilities is not passing state testing standards, which dispensaries say are too strict and not realistic. Now the state is proposing a fix.
Revised draft testing standards released Friday by the Department of Public Health (DPH) propose changing the amount of marijuana — and in turn possible contaminants — regulators expect heavy users to consume.
The current assumption is up to 1 ounce a day. That’s a lot of marijuana — in the range of 40 joints, depending on the size. If you smoke 40 joints a day you’re much more likely to inhale a dangerous amount of lead, mercury or arsenic than if you smoke 12 to 15 joints a day, which is what the state would assume (using a very rough ounce to joint translation) under the new proposed standards.
To be more precise, the state’s revised standards are based on the assumption that patients would inhale or ingest 0.35 ounces a day, or 10 grams.
“The department is shifting away from a worst case risk assessment style approach and more to a pharmaceutical industry based approach,” said Marc Nascarella, director of the environmental toxicology program at DPH.
The revisions include allowing generally higher amounts of arsenic, cadmium, lead and mercury, but with more specific guidelines for recommended use. More lead is allowed, for example, in marijuana products a patient eats or drinks than in pot used for smoking, vaping and creams.
New labels would have to say how much of the product is safe for daily use and in what form — by inhalation, ingestion or topical.
“With this new pharmaceutical approach, we’re able to specify the amount of exposure and the intended use,” Nascarella said, “similar to what you’d see on a bottle of Tylenol.”
Here’s a DPH summary of the proposed before and after:
Nascarella says the state is comfortable making these adjustments because it now has some information now about how much patients are consuming and in what form.
The medical marijuana industry says it is encouraged by the revisions and is pleased the Baker administration will take comments before making the changes final.
“While the new standards appear to be a step in the right direction, there is still work to be done and we look forward to engaging with DPH during this comment period and beyond to provide additional research that may help to address any remaining areas of concern,” Commonwealth Dispensary Association executive director Kevin Gilnack said.
But a group that represents patients using marijuana says the revisions don’t go far enough.
If allowed levels for arsenic and hydrocarbons used to extract marijuana aren’t increased before these changes take effect, “marijuana flower and marijuana concentrates will no longer be accessible through dispensaries,” said Nichole Snow, executive director of the Massachusetts Patient Advocacy Alliance. Snow argues that slightly higher levels of arsenic and hydrocarbons in regulated marijuana would be safer than what’s sold on the street.
Snow and Gilnack plan to file comments on the state’s proposed changes, which are scheduled to become final on March 31, 2016.
Dispensary owners and patients who use marijuana for medical care are anxious to resolve the question of what’s safe for use and adjust testing rules. The medical marijuana industry is growing rapidly in Massachusetts. The state cleared a fourth dispensary to open in Ayer on Nov. 6. A fifth store, in Brookline, is expected to begin sales before the end of the year and there may be a sixth dispensary in January. The number of patients registering for the program and total sales are both rising rapidly.
By Rebecca Sananes
For healthy eating fans, it was the All-Star Game. Pick your preferred diet — vegan, paleo, Mediterranean, you name it — and the scientist, clinician or academic behind it was at the table in Boston this week. Think Dean Ornish, S. Boyd Eaton and T. Colin Campbell.More From CommonHealth:
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They all gathered at the Finding Common Ground Conference, convened by the nonprofit Oldways, to hammer out a consensus on healthy eating — an antidote to what can seem like endless flip-flops on dietary research. And amazingly enough, they did.
What they found was that despite all the food fights, the prevailing theories of nutrition and healthy eating actually have more in common than you’d think. (Though it’s a bit more complex than Michael Pollan’s classic, “Eat food. Not too much. Mostly plants.”)
After two days of presentations on the latest research, debates over ethics and attempts to differentiate between nit-picky nuance and important distinctions, Harvard’s Walter Willett sums up the consensus like this in a press release: “The foods that define a healthy diet include abundant fruits, vegetables, nuts, whole grains, legumes and minimal amounts of refined starch, sugar and red meat, especially keeping processed red meat intake low.”
So there you have it. But for a more granular look, here’s my take on the 11 principles these top scientists and nutritionists agreed should be the guiding principles when thinking about what and how we eat:
1. Yes to the federal guidelines
From the consensus statement:
The Scientists of Oldways Common Ground lend strong, collective support to the food-based recommendations of the 2015 Dietary Guidelines Advisory Committee, and to the DGAC’s endorsement of healthy food patterns such as the Mediterranean Diet, Vegetarian Diet and Healthy American Diet.
The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meats; and low in sugar-sweetened foods and drinks and refined grains.
Additional strong evidence shows that it is not necessary to eliminate food groups or conform to a single dietary pattern to achieve healthy dietary patterns. Rather, individuals can combine foods in a variety of flexible ways to achieve healthy dietary patterns, and these strategies should be tailored to meet the individual’s health needs, dietary preferences and cultural traditions. Current research also strongly demonstrates that regular physical activity promotes health and reduces chronic disease risk.
The Dietary Guidelines Advisory Committee is a group of scientists handpicked by the government to create a report detailing nutritional and dietary guidelines. Every five years, their report is reviewed by the USDA and the Department of Human Health Services before being voted on by Congress and implemented as the American Dietary guideline — the public policy informing public school lunches, military food and food industry regulations. The official vetted guidelines are due out by the end of the year.
Along with endorsing that committee’s report, the Oldways Common Ground Committee also backed Mediterranean and vegetarian diets.
2. We have to think about the planet when we eat
Form the consensus:
We emphatically support the inclusion of sustainability in the 2015 DGAC report, and affirm the appropriateness and importance of this imperative in the Dietary Guidelines for Americans because food insecurity cannot be solved without sustainable food systems. Inattention to sustainability is willful disregard for the quality and quantity of food available to the next generation, i.e., our own children.
Background: The DGAC recommended to Congress, for the first time, that nutritional policy should take into account environmental impact.
Harvard professor Frank Hu, who sits on the DGAC and attended the conference, says: “I believe this issue will not go away, so even though those recommendations were not included in the 2015 Dietary Guidelines, hopefully, our work will plant seeds for future recommendations.”
“We can’t completely separate human health from the health of our planet,” he said.
3. Keep politics out of our food policy
The Scientists of Oldways Common Ground lend strong, collective support to the overall process, as well as the overall product, of the 2015 DGAC. We express confidence in their approach to the weight of evidence. We support a transparent process where the evidence-based report of the scientists is translated directly into policy without political manipulation.
One thing the scientists could agree on is that politics should not trump good food policy. When the DGAC’s nutrition report is vetted and voted on by Congress, science sometimes takes a backseat to lobbyists from particular food sectors.
4. The yum factor
Food can and should be:
• Good for human health
• Good for the planet (sustainability; ecosystem conservation; biodiversity)
• And simply…good – unapologetically delicious.
This is good news for food lovers and health nuts alike. Dean Ornish, a clinical professor of medicine at the University of California of San Francisco who researches vegan and vegetarian diets, wants to change the trope that plant-based food is rabbit food.
“What Steve Jobs did to make Apple aspirational — he wasn’t showing how much RAM was in his computer,” Ornish said. “He’d have John Lennon or Gandhi saying ‘Think Different.’ I’d love to see an ‘Eat Different’ type campaign.”
5. Let’s be clear
We express strong concern for the high level of apparent confusion prevailing, and propagated among the public about what constitutes a healthy eating pattern. Despite uncertainty about some details, much of this confusion is unnecessary, and at odds with the understanding of experts and the weight of evidence. We affirm that experts with diverse perspectives and priorities can find common ground.
Translation: We might bicker about whether to drink wine, cut out eggs, or whether bacon is the devil – but we agree on some basic tenets: more fruits and vegetables and less processed food.
6. The fundamental things apply
Fundamentals and current understanding do NOT change every time a new study makes headlines. The Oldways Common Ground Scientists emphasize the importance of basing understanding of diet and health on the weight of evidence, including ALL relevant research methods. Biology (adaptation, evolution, plausibility) is a relevant source of evidence. Heritage (cultural traditions) are an additional, relevant source of real-world information on long-term feasibility and health effects of diet.
The newest fad diet… is the oldest one. For the first time, paleos and vegans agreed at the conference that nutrition should come from the paradigm of human diets that have existed for millennia. Anecdotal evidence — albeit long term — is an acceptable measure of what works, as well as lab experiments, attendees said. This was the basis of the Mediterranean diet, which originally looked at good mortality rates in Greece during the 1960s and prompted experiments to test this diet. Trust your elders, was the message; what they ate is probably what nutritionists think you should keep eating. (Or as Michael Pollan puts it: “Don’t eat anything your great-great-great grandmother wouldn’t recognize as food.”)
7. If it bleeds (or involves butter or bacon), it leads
Representations of new diet studies to the public should be made in the context of the prevailing consensus. New evidence should be added to what was known before, not substitute for it sequentially. Accurate reporting is the responsibility of both scientists and the media.
In other words, just because a new study comes out every week, doesn’t mean it’s turning the whole world on its head. Studies come out all the time, that doesn’t mean the basic pillars of eating well change with it. Scientists are asking everyone to remain calm when a new study tells you butter is killing you and remember that it’s more about the big picture.
8. Bring in the subs
To make recommendations for dietary changes meaningful, we strongly endorse the general principal of specifying practical dietary substitutions – a “compared to what” approach. e.g, Instead of simply saying, “Drink less soda,” for instance, say “Drink water instead of soda.” What we consume and what we don’t consume instead, both contribute to health outcomes.
My reaction: “Finally!” Who is sick of being told what you can’t do? (Me!) These scientists are saying they will work to put more emphasis on what works than what doesn’t. More emphasis should be put on the importance of the nutrients you are putting in your body versus what you should cut out.
9. Food stamps, too
Oldways Common Ground Scientists recommend that education programming, policy, and legislation in support of these goals be implemented widely and in a timely manner, with regular monitoring and evaluation. For example, in the U.S., we urge compliance with 7 USC Sec. 5341, which calls for the Dietary Guidelines for Americans to “be promoted by each Federal agency in carrying out any Federal food, nutrition, or health program” – including food assistance programs.
10. Knowledge is power
We support the cultivation of widespread “food literacy” and believe that individuals benefit from becoming knowledgeable about the origins of their food, the conditions under which it is produced, and its impact on their health and the health of the planet. A knowledge of and respect for food traditions and the cultural context of food – health through heritage – is also beneficial, and can be a powerful motivator for better eating, as well as a means of imparting crucial life skills (e.g., cooking).
11. Locavores and composters
Oldways Common Ground Scientists agree that food systems (production, manufacture, food waste, etc.) should align with priorities for human and planetary health while supporting social responsibility/justice and animal welfare. Diverse, localized/regionalized solutions, that reflect site-specific priorities and capabilities are more resilient and democratic. Each of us has a role to play in ensuring a healthy and sustainable global food supply.
Scientists are agreeing that they are friends to the regional farms and ecosystems in the places people live. If you can find food that’s been grown in your area and represents what grows naturally – you’ve done something right, they say.
Overall – the scientists did seem to agree on more than you’d think. My own takeaways: One size does not fit all for healthy diets, and people should not experience whiplash every time a new study comes out. A few basic tenets cover the bases: eat whole foods, preferably grown locally and — my favorite — enjoy it.
The Realities of Work for Individuals with Disabilities: Impact of Age, Education, and Work Experience
By Dr. David Scales
The elderly woman had been normal all day, my colleague told me, tolerating it well when a tube was placed in her bladder to measure her urine. But that evening, she was found wandering the hospital halls yelling in Italian, carrying her urine bag under her arm thinking it was her purse, traumatized that hospital staff were trying to take it away.
Another night in the hospital, a female Sri Lankan colleague saw an elderly man who was convinced she was a Nazi soldier. Reassurances and even a plea from the doctor: “how could I be a Nazi? I have brown skin!” could not persuade him otherwise. The next day the patient was back to normal, incredulous when told about what transpired the night before.
An 80-year-old man — I’ll call him Bill — came to our emergency room after a fall. He seemed fine and his tests were negative, but his family wanted him admitted over night for observation. That evening, he began shouting out, repeatedly wanting to get up and walk to the bathroom (forgetting he had just gone). Our calming efforts only riled him up more.
This erratic nighttime behavior is called “sundowning.” Staff in hospitals and nursing homes always worry what will happen as twilight approaches. As the sun sets, many elderly patients can change drastically: They can become extremely confused, agitated, not know where they are, and even hallucinate. In other words, they exhibit signs of delirium, a confused state that can lead them to do things they otherwise wouldn’t.
Thankfully, not every elderly patient sundowns, but when one does, it can be emotionally traumatizing for everyone. To be confused or hallucinate, or to see a relative acting out in irrational ways is frightening and destabilizing. Yet, sundowning seems to be extremely common. So, what is it? Why do people sundown? And what can you do to minimize the risk of sundowning in yourself or a close friend or relative?
Experts agree that confusion and agitation are more common in the evening and at night. But there is surprisingly little scientific consensus on what sundowning actually is.
The debate is in how much sundowning and delirium are related. Some experts think they’re the same thing, others separate but related entities.
It’s hard to study sundowning without a clear definition and diagnostic criteria. Experts can’t even be sure how often it happens. A recent review found a rate of anywhere from 2.4 percent to 66 percent.
Dr. Eyal Kimchi, a neurologist at Massachusetts General Hospital who studies delirium (and a friend of mine from medical school), says we are still in the early stages of understanding sundowning. “There are probably many types of delirium — delirium after operations, delirium in the intensive care unit, delirium tremens associated with alcohol withdrawal — and some we haven’t separated out yet. Sundowning may be another one of them.”
We do know a few things, though. Elderly people with memory problems are the most likely to sundown, especially those with bad Alzheimer’s dementia. We know prevention works much better than treatment. Patients in hospitals and nursing homes are particularly prone to becoming agitated in the evening.
But being prone to sundowning isn’t enough — something has to tip the balance, like not being able to see or hear well. Other environmental factors can do it too, like being thrust into unfamiliar hospitals with bright fluorescent lights, having sticky heart monitors on your chest and alarm bells going off at all hours of the night.
Dr. Sharon K. Inouye, Harvard professor and Director of the Aging Brain Center at Hebrew SeniorLife, also pointed to a dizzying array of barely-pronounceable biological factors thought to contribute including “disruptions in circadian rhythms, nadirs in cortisol, stress hormones, sympathomimetic neurotransmitters, melatonin, or fluctuating cytokines.”
If syllable count is any measure, this is as complicated as it gets.
Which is why experts like Inouye and her colleagues developed a series of interventions to address the various factors that contribute to delirium, called Hospital Elder Life Program (HELP). (CommonHealth covered aspects of the program earlier this year)
Many hospitals have similar friendly-sounding protocols. Beth Israel here in Boston uses GRACE (Global Risk Assessment and Care plan for Elders). And there’s NICHE (Nurses Improving Care for Healthsystem Elders), a nursing protocol found in hospitals around the country. While they haven’t been studied specifically for sundowing, they are often used in hospitals to help prevent it.
All of these protocols are similar, and consist of various ways to keep patients oriented, for instance, keeping hearing aids and glasses within reach, getting patients out of bed, making sure they stay hydrated and well fed, avoiding medications that cause confusion, managing pain and reducing noise to allow patients to sleep.
It sounds simple and obvious, but these factors are so interrelated that changing one has only a tiny effect. Its power is in the package. HELP is now being used by more than 200 hospitals nationwide and abroad.
Still, it’s an uphill battle convincing hospitals to invest in more staff to implement these protocols. “It’s the best thing for the patient and for maintaining quality,” Dr. Hollis Day, currently at University of Pittsburgh Medical Center but incoming Chief of Geriatrics at Boston Medical Center, told me. “Its hard to pay for something that doesn’t happen.”
But this is changing. Accountable care organizations are more common, so hospitals will get penalized if patients stay in the hospital too long. “The financial implications of increased length of stay is one thing motivating hospitals to try to prevent delirium more systematically,” Kimchi said.
Implementing delirium precautions isn’t easy. It requires a change in mindset away from medications to behavioral interventions. “Doctors can’t always order therapeutic sleep protocols at night or reorientation activities three times a day,” Inouye said. “Giving a sleeping pill is so much quicker than a back rub, herbal tea and soothing music, but much more hazardous.”
While hospitals are changing, friends and families can get engaged in the effort as well. So what can you do to help prevent sundowning?
Ask what protocols the hospital has in place to detect and minimize sundowning or delirium. There’s no data on which is the best, but the important thing is checking that a hospital or nursing home is working to prevent and detect sundowning and delirium.
A “Sense” Of Security
Bring hearing aids, eyeglasses, or dentures to the hospital. This helps keeps patients involved in what’s going on, not to mention able to eat. But keep track of them – these items can get lost in the hustle and bustle, and can be expensive to replace.
Make sure the doctors and nurses know what normal behavior is for you or your relative. Is your relative usually sharp as a tack? Or is it normal for them not to know what day it is? This helps the medical team recognize sudden changes.
Help patients stay informed on world events or maintain hobbies like crosswords or knitting. Pictures of loved ones or other familiar objects can make the hospital seem less foreign. These steps help keep people oriented and calmer.
Work with doctors, nurses and physical therapists to understand how your family member can stay active. Encourage them to take care of themselves by showering or brushing their teeth, or walk with them around the room – if that is ok with the hospital staff.
Dr. Deborah Rosenbloom, assistant professor at UMass College of Nursing researches family involvement in caring for patients with delirium. She acknowledges that many people cannot stay with their relatives all day — they might live hours away or need to work. In those cases, Dr. Rosenbloom suggests phoning the medical team at admission and then checking in daily.
In Bill’s case, we tried bed alarms, which made things worse. We tried dimming lights and minimizing noise so he could sleep. His bed was near the nurses’ station but we still worried he might jump out of bed and fall before someone could catch him.
At 11pm one recent night, we called his family and discussed two options – sedate him with medications to keep him from hurting himself — a last resort which might worsen the problem — or send him home. All the crucial tests were negative so we agreed that the safest thing, despite the late hour, was for him to go back home to familiar people and a familiar environment. I never heard from him again, but I hoped the familiarity helped him feel settled.
David Scales, M.D., Ph.D. is a third year resident in internal medicine at Cambridge Health Alliance.
As a member of the Legislative and External Relations Office in the Law Library of Congress, I have the exciting opportunity to plan public events that celebrate law related observances such as Law Day and Constitution Day. I also have the pleasure of coordinating program visits for legal professionals and students from all over the world who want to learn about the Law Library of Congress.
On Friday, November 13, I organized a program for participants of the 12th Annual Appellate Judges Education Institute Summit (AJEI). The group included federal and state appellate judges and lawyers from across the United States. This pic of week shows the participants with Rare Book Curator, Nathan Dorn and Senior Legal Information Analyst, Jim Martin who provided a display of rare books and manuscripts from the Library’s past exhibition, Magna Carta: Muse and Mentor.