maria ramas

5 February 2019
NH HB 481 Testimony
Marie-Elizabeth Ramas, MD, FAAFP
On Behalf of the New Hampshire Academy of Family Physicians (NH AFP) I speak in opposition of HB
481. As a family physician who currently practices at Lamprey Health Care in Nashua, the
commercialization of marijuana would adversely affect the health and safety of our most vulnerable
population, children. While, the Academy supports research and decriminalization of marijuana,
legalizing a drug with known long term affects on a person’s cognitive capacity and abilities to think
objectively fundamentally opposes my responsibility to “do no harm” towards my patients.
Below, I have some key points that have already been highlighted on the floor. However, I submit my
expertise from a scientific perspective in order to bring objective and personal experience to this matter.
As such, I would like to offer additional commentary on the opinions presented to the commission
I appreciate the commission’s thorough assessment on the pros and cons of the legalization and
commercialization of marijuana in our state, and as he said “this is a big leap”. We have already taken
steps to both medicalize and decriminalize marijuana. What this bill is asking for is to completely allow
free market into an industry that is young and lack evidence to support its benefits.
As a family physician who delivers babies and cares for the continuum of the life spectrum, cradle to
grave, I see first hand the effects of marijuana on school performance, relationship isolation and on
intrauterine exposure to marijuana as children proceed in grade school and beyond. There has been
repeated commentary that this bill addresses the adult use of marijuana. I also want to point out that
the same people who underlined that marijuana use should be for adults admitted that youth inevitably
are exposed to it. As a physician scientist, it is my obligation to first “do no harm”. How can I be sure
that I am living up to the standards of my profession when allowing early exposure, whether in the
womb or environmentally, to marijuana can lead to permanent and irreversible damage to the delicate
and impressionable development of a child’s brain?
I heard someone say, “is the prohibition of marijuana worth ruining peoples’ lives [who benefit from it]”.
I submit to the committee that indeed the passing of this bill in its current form would indeed ruin the
lives of our most vulnerable, our children. And it is our duty as responsible citizens to protect the most
I have heard several correlations between alcohol and marijuana, using the legalization and
commercialization of alcohol as an example of how to proceed with marijuana. As a physician scientist,
this is far from truth! With alcohol, although harmful, I can tell you the mechanism of action on the
body. We can test and measure alcohol content in a practically universal fashion. As a physician, I
cannot even legally study the uses, harms and benefits of marijuana. Furthermore, its distribution is not
regulated as alcohol. How am I supposed given objective recommendations to the consumer, my
patient, so that she may make an informed decision? Furthermore, how would a police officer be able to
objectively screen for DUI without objective data and standardization?

one of my physician colleagues, quoted equivocal evidence on the harmful influence of marijuana by the
American Academy of Pediatricians. I would like to also point out that my pediatric colleagues also note
overwhelming evidence that early exposure to THC and its counterparts leads to decreased school
performance, increased depression, and increase cognitive delay.
I can tell you that being a family physician who worked in a rural town of 3500 people in in the crux of
legalization of marijuana within one of California’s largest geographical counties, I witnessed all of these
effects. From the babies I delivered whose parents consumed and used marijuana, to the increased
rates of depression and cognitive-behavioral problems in school, to the increase ER presentations (that I
would cover) and the lung disease, abdominal problems in adults. I saw it all.
I continue to hear the terms “decriminalization” and “legalization” as interchangeable. They are not.
Decriminalization is imperative, as someone pointed out that although people of color have essentially
the same rates of use of illicit drugs as Caucasians, People of color disproportionately imprisoned for
possession and related causes. Decriminalization addresses this issue, and NH has already taken the
needed steps regarding this matter. Legalization gives a carte blanche to the manufacturing,
distribution and selling in addition to possession of the drug. Should we be so quick to take this step,
when we as a state may not have the necessary infrastructure to provide oversight, education and
responsible distribution of this substance? I respectfully caution the committee to take deliberate and
intentional steps in this process, so as to avoid unintended consequences that we will not be able to
take back! Should we be so quick to allow a “something is better than nothing” approach in this matter.
Lastly, there has been multiple commentary regarding the opportunity to gain tax revenue by
commercializing marijuana. How much tax revenue is a good enough reason to bargain the health and
longevity of our future? I was in these chambers more than 20 years ago as a young child advocating
against the commercialization of tobacco in the state and I seem to hear the very same verbiage today
as big Tobacco.
I urge the committee to assess and consider wisely this bill that leaves all the liberties of how our state
rolls out the distribution of marijuana without any provisions towards the education and protection of
our most impressionable.

Thank you.
1. Full commercialization of a drug will yield the affects of targeting youth, much like the tobacco
2. Early exposure to marijuana has shown to reduce brain development and IQ in impressionable
In another recent study on twins, those who used marijuana showed a significant
decline in general knowledge and in verbal ability (equivalent to 4 IQ points)
between the preteen years and early adulthood, but no predictable difference
was found between twins when one used marijuana and the other didn't. This
suggests that the IQ decline in marijuana users may be caused by something
other than marijuana, such as shared familial factors (e.g., genetics, family

environment). 6  NIDA’s Adolescent Brain Cognitive Development (ABCD) study, a
major longitudinal study, is tracking a large sample of young Americans from
late childhood to early adulthood to help clarify how and to what extent
marijuana and other substances, alone and in combination, affect adolescent
brain development. Read more about the ABCD study on our Longitudinal Study
of Adolescent Brain and Cognitive Development (ABCD Study)
3. Newborns exposed to marijuana in the womb demonstrate signs of withdrawl at time of
delivery and have increase correlation with poor school performance
4. As it is currently illegal to do research on the medical efficacy and uses of marijuana, it is
irresponsible to allow the selling of substances that known negative risks to one’s as well as
inability to standardize the potency of the products available to consumers. With that, we do
know that the potency of marijuana compared to that of the earlier generations is much higher.
5. This bill leaves a carte blanche for complete commercialization without the necessary
precautions and educational resources needed to appropriately inform those about the risks
and benefits.

As a family physician who continues to deliver babies and as mother myself, i submit that we cannot
condone this bill without seriously considering the unintended consequences that can adversely affect
our most vulnerable.


Madame Chairperson,

Thank you very much for the opportunity to speak with you in opposition to House Bill 509, the
“Graduate Physician Bill”.

I am a practicing Family Medicine physician resident in my third and final year of training at the NH
Dartmouth Family Medicine Residency here in Concord, New Hampshire. I am also a sitting board
member and resident representative to the New Hampshire Academy of Family Physicians. As a current
resident, Canadian, and International Medical Graduate (having attended medical school outside of
North America) I believe that I do have a unique perspective to this topic and believe that the passage of
HB 509 would put patients at risk.

1. Residency training is a process that is required of physicians because it works. As a recent
medical school graduate myself, I was woefully un-prepared for the rigor, standards, and
decision-making that is required of me in the care of vulnerable patients and populations. Under
the watchful eye of incredible attending physicians who are trained to teach, I have learned the
skills necessary to be able to provide cost-effective, safe and appropriate care to my patients.
Skills I am beginning to feel prepared to bring out into my own independent practice in just a
few months.
2. Supervisory roles within primary care are complex. Requesting that a Primary Care Physician
provide thorough and safe monitoring to graduate physicians is likely impossible in practice.
Primary Care Physicians are often overworked and limited in their time. Every moment that I am
involved in patient care I have the benefit of having one, two, or sometimes three physicians
who have dedicated their time away from patients to supervise my care directly, discuss
appropriate treatment, and monitor patient progress. It is only through this vigorous monitoring
and discussion that I am able to learn to provide care in the most cost-effective, safe, and
appropriate way possible.
3. The “Match” process into residency is extremely rigorous; for a purpose. Patients deserve to be
treated by those who have the moral, ethical and intellectual strength that the Match demands.
The Match process has existed in this country for over 60 years, and provides us with a vetting
process which ensures that the physicians who gain residency positions and are able to practice
clinical medicine are those with the highest academic, ethical and behavioural standards. I know
many physicians who have applied multiple times to residency programs across the country and
have been repeatedly denied; this is often for the best.
4. Rural populations require appropriate solutions. As a member of a residency that has a rural
health clinic I am able to see that the health needs of an rural community are remarkably
complex and require measured health considerations. These populations are already at a high-
risk of adverse health outcomes and to put their care in the hands of gradate physicians would
place them at likely higher risk. Particularly in a state which is so affected by the opioid epidemic
it is crucial that healthcare providers receive quality training in how to manage these patients
and their complex needs. While in medical school I received one 1 hour lecture on opioid

medications during my pharmacology course. Not once did we discuss the dangers of
prescribing or the potential harms of these medications. It was during my residency training in
which the complexities of opiate prescribing became understood and I was able to seek out the
resources and teaching that would allow me to manage these patients appropriately and
monitor my own prescribing practices. Without this residency training inappropriate narcotic
prescriptions are likely to harm patients and further worsen this epidemic which has already
claimed far too many lives.

I am a family physician. I will choose to work in rural areas because I believe that these populations have
medical needs that are complex and require the absolute best care possible. In my experience the bill
put forth puts patients at risk of inappropriate tests and harmful treatments. Rural communities have
complex needs and HB 509 is not the answer. Improved funding in rural areas, load-repayment
programs and programs which support residency-trained physicians in rural practice helps to ensure
that all people in the State of New Hampshire receive the quality healthcare that they deserve. Please
do not put the health of rural populations at risk by voting for this bill.

Thank you,

Philip Baker, MD
Resident Physician – PGY-3
NH Dartmouth Family Medicine Residency

Opioid Prescribing In NH 2016/Pertaining to Physicians (likely Nursing Boards will refer to similar)

Current Board of Medicine Emergency rules: (sunsets May 4, 2016)

Acute pain ~ must advise patient of risk, where to dispose of, that they may be victims of criminalization, impairment

Chronic: ~ risks as above (addiction, od and death, physical dependence, physical side effects, tolerance and crime victimization), risk assessment by using a screening tool; treatment plan, tx agreement, appropriate consultations, follow up, review, tox screening,

Read More....

Opioid Prescribing for Physicians - New Hampshire Laws and Rules 2016





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