Oklahoma DO October 2013 by Oklahoma Osteopathic Association

The Journal of the Oklahoma Osteopathic Association

OKLAHOMA D.O. October 2013 May/June 2013

Volume 78, No. 4

• 2014 Winter CME Program

• Opioid Prescribing Guidelines for Oklahoma Emergency Departments & Urgent Care Clinics

• OOA Awards Nomination Form

Oklahoma D.O. | October 2013

PAGE 1

Oklahoma D.O.

In this Issue:

JOIN THE REGION’S BEST PHYSICIANS CALL PLICO TODAY AT 405.815.4800 OR VISIT OUR WEBSITE

Oklahoma D.O. PAGE 2

AT PLICO - OK.COM

Oklahoma D.O. | October 2013

The Journal of the Oklahoma Osteopathic Association

OKLAHOMA

May/June 2012 May/June 2013 October 2013

January 2012

OOA Officers: Bret S. Langerman, DO, President (South Central District) Michael K. Cooper, DO, FACOFP, President-Elect (Northeastern District) C. Michael Ogle, DO, Vice President (Northwest District) Layne E. Subera, DO, FACOFP, Past President (Tulsa District) OOA Trustees: Kenneth E. Calabrese, DO, FACOI (Tulsa District) Dale Derby, DO (Tulsa District) Melissa A. Gastorf, DO (Southeastern District) Timothy J. Moser, DO, FACOFP (South Central District) Gabriel M. Pitman, DO (South Central District) Christopher A. Shearer, DO, FACOI (Northwest District) Kayse M. Shrum, DO, FACOP (Tulsa District) Ronald S. Stevens, DO (Eastern District) OOA Central Office Staff: Lynette C. McLain, Executive Director Lany Milner, Director of Operations and Education Matt Harney, MBA, Advocacy and Legislative Director Marie Kadavy, Director of Communications and Membership Lydia Cheshewalla, Administrative Assistant

The Oklahoma D.O. is published monthly from the Oklahoma Osteopathic Association Central Office: 4848 N. Lincoln Blvd., Oklahoma City, OK 73105-3335. Lany Milner, Graphic Designer and Associate Editor

For more information: 405.528.4848 or 800.522.8379 Fax: 405.528.6102 E-mail: ooa@okosteo.org

Oklahoma D.O. | October 2013

“The Future Looks Bright” provided by Bret S. Langerman, DO, 2013-2014 President

2014 Winter CME Seminar Program

Winter CME Seminar Registration Form

Center for Rural Health provided by Jeff Hackler, JD, MBA

“OSU-CHS Student Update” provided by Trace Heavener, OMS-II

“Rules & Laws to Know to Help Stay Out of Jeopardy” provided by Angela Wall, PMP Educator

“AOOA Update” provided by Vicki Stevens, 2013-2014 AOOA President

“Protecting Yourself Against Lawsuits” provided by Jennifer Smith, Insurica

Legislative Update provided by Matt Harney, MBA

What DO’s Need To Know

Opioid Prescribing Guidelines for Oklahoma Emergency Departments & Urgent Care Clinics

40 “Clin-IQ Project Clinical Question: What Are the Appropriate Treatments of Proctalgia Fugax and Chronic Poctalgia and Are These Treatment Modalities Founded on Solid Evidence?” provided by St. Anthony Family Medicine Residency 42

“Sleep Apnea Wake-Up Call” provided by the American Osteopathic Association

“Preventing Drug Overdoses in Oklahoma” provided by Lyle Kelsey, executive director, Oklahoma Medical Board

OEFOM Update provided by Robin R. Dyer, DO, 2013-2014 OEFOM President

October Birthdays

Bureau News & Announcements

OOA Awards Nomination Form

Classifieds & Calendar of Events

PAGE 3

The OOA Website is located at www.okosteo.org

Volume 78, No. 4

Lynette C. McLain, Editor Lany Milner, Associate Editor

Oklahoma D.O.

Copy deadline is the 10th of the month preceding publication. Advertising copy deadline is the 15th of the month preceding publication.

D.O.

BRET S. LANGERMAN, DO President 2013 – 2014 oklahoma osteopathic association the future looks bright!

Oklahoma D.O. PAGE 4

As summer comes to an end I hope that you and your families have had an enjoyable and safe season. If your homes are anything like mine, this means it’s back to school for the kids and back to all of the extracurricular activities which makes for very busy times. It has also been quite busy at the OOA central office. We have hired some new staff with outstanding talents, some of whom you may have met at the summer CME Seminar in August. The newest additions to the osteopathic team are Marie Kadavy, Director of Communications and Membership; Matt Harney, Legislative and Advocacy Director and Lydia Cheshewalla, Administrative Assistant. The OOA staff is currently in the process of updating the association database so we can provide you, our members, with the most up to date and efficient association possible. We continue to advocate on your behalf and look for ways to expand and stream line our services for you. We feel these changes will help us accomplish just that. With the start of the new school year comes a new class of osteopathic medical students at OSU College of Osteopathic Medicine (OSU-COM). On behalf of the OOA, I had the opportunity to participate in the white coat ceremony in Tulsa where we welcomed 115 new students to the osteopathic family. As they were donned with their new white coats, it was quite inspirational to see the enthusiasm they showed to be involved with osteopathic medicine. In conjunction to orientation week, the OOA held the annual mentor/mentee dinner at the Downtown DoubleTree Hotel in Tulsa. This program paired each new student with a practicing D.O. to act as their mentor during their first year of training. Each student received a Littmann Stethoscope, courtesy of the OOA and the OEFOM. If you are not aware of this program, I would like to invite you to participate in this rewarding program, which

I believe shows just one of the many values of being a D.O. I would like to congratulate Kayse M. Shrum, DO, Provost and Dean of the OSU College of Osteopathic Medicine, for her success in what looks to be an exceptional entering class. On the legislative front, things have certainly not been quiet at the Oklahoma State Capital. You may recall that recently the Oklahoma Supreme Court struck down the 2009 tort reform legislation. This action led Governor Mary Fallin to convene a special session of the legislature to renew lawsuit reform. The legislature moved swiftly to pass some 23 bills that were signed by Governor Fallin. I applaud the legislature and Governor Fallin for their hard work on an issue that so affects what we do as physicians. These bills primarily repeat the initial tort reform language. The OOA was active and present during the special session to lobby for our interests as physicians. A special thank you to our lobbyists Mr. Gary Bastin and Mr. Mark Snyder. I would also like to thank Dr. Layne Subera, Immediate Past President of the OOA, for speaking on behalf of Osteopathic Physicans in this matter. The OOA along with the OSMA and the Patient’s First Coalition have worked tirelessly to prevent the advancement of scope of practice for paraprofessionals. Currently in Oklahoma, patients must be referred to physical therapists by a physician. Legislation was introduced previously to give direct patient access to physical therapists without the oversight by a physician. This was opposed by the OOA and currently lies dormant though Rep. Arthur Hulbert, a physical therapist, called for an interim study to further evaluate this issue. I would like to thank Dr. Tim Moser for his testimony to the House Public Health Committee on our behalf. We will continue to watch this legislation closely and lobby for the protection of our practice rights. Have a safe fall season !!

Oklahoma D.O. | October 2013

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3/28/11 11:05 AM

Winter CME Seminar Program

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Friday – January 31, 2014

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Oklahoma D.O. PAGE 6

Hard Rock Hotel & Casino Catoosa, OK Melinda R. Allen, DO, FACOI, program chair

Approval Requested for 19 Category 1A Credits from the AOA. Approval Requested for 19 Prescribed Credits from the AAFP.

12:00 – 6:00 pm

Registration-Sequoyah Foyer

2:00 – 6:00 pm

Exhibits Open

*12:00 – 3:00 pm “AOA CO*RE REMS Program” www.osteopathic.org/inside-aoa/development/ continuing-medical-education/Pages/core- rems-programs.aspx *3:00 – 4:00 pm “Who Needs a Pap Smear? Age Appropriate Screening for Women” Derek R. Holmes, DO (obstetrics & gynecology, Ponca City, OK) http://womenshealth.gov/publications/our-publica tions/fact-sheet/pap-test.cfm *4:00 – 5:00 pm “Update on PSA and Testosterone” Paul G. Hagood, MD (certified urologist, Tulsa, OK) www.cancer.gov/cancertopics/factsheet/detection/ PSA *5:00 – 6:00 pm “When Platelets Fall” Kevin P. Hubbard, DO, FACOI (certified internist & hematologist/oncologist & palliative medicine, Kansas City, MO) www.mayoclinic.com/health/thrombocytopenia/ DS00691 6:00 –7:00 pm

OOA Past Presidents’ & District Presidents’ Meeting

6:00 – 7:00 pm

OOA New Physicians Meeting

7:00-8:00 pm

AOA House of Delegates Meeting

Saturday – February 1, 2014 7:00 am

Registration-Sequoyah Foyer

7:00 am

Continental Breakfast

8:00 – 9:30 am

Bureau on CME Meeting

8:00 am – Noon

Exhibits Open

*8:00 – 9:00 am “Endocrinology Lab Data: Practical Advice for the Busy Clinician" Curtis E. Harris, MD, MS, JD, FCLM (certified endocrinology, Ada, OK) www.ncbi.nlm.nih.gov/pmc/articles/PMC2605414/

Oklahoma D.O. | October 2013

*9:00 – 10:00 am “Hypercoagulability” *10:00 – 11:00 am “Atrial Fibrillation” Kevin P. Hubbard, DO, FACOI (certified internist & Sandeep Chopra, MD, FACC, FASE (certified hematologist/oncologist & palliative medicine, internal medicine Oklahoma City, OK) Kansas City, MO) www.nhlbi.nih.gov/health/health-topics/topics/af/ www.clevelandclinicmeded.com/medicalpubs/dis easemanagement/hematology-oncology/ *11:00 am – Noon “Labs: The Unique, The Unusual, and The Relatively hypercoagulable-states/ Unknown” Melinda R. Allen, DO, FACOI (certified internal *10:00 – 11:00 am “Platelets, What To Ask Before You Transfuse” medicine, Blackwell, OK) Walter E. Kelley, DO (certified pathology, www.healthsystem.virginia.edu/pub/medlabs/lmup Oklahoma City, OK) date www.cpmc.org/learning/documents/bloodtrans-ws. html *Websites indicate Needs Assessment for each lecture. *11:00 am – Noon “How Do You Like My Genes? New Biomarkers in Oncology” Kevin P. Hubbard, DO, FACOI (certified internist & hematologist/oncologist & palliative medicine, Kansas City, MO) http://www.medscape.com/viewarticle/808930 *Noon – 2:00 pm “OOA Luncheon: “Lung Nodules” Daniel A. Nader, DO, FCCP, FACP (certified internal medicine & pulmonary disease, Tulsa, OK) http://my.clevelandclinic.org/disorders/pulmonary_ nodules/hic_pulmonary_nodules.aspx *2:00 – 3:00 pm “Creating a Winning Team using the PMP” g a Proper Prescribing Lecture – bin Prescri Sign-In Required for Credit Properre - Sign - dInit! Lectu ed for cre ir u Angela Wall (PMP Educator, Oklahoma City, OK) q Re www.ok.gov/obndd/Prescription_Monitoring_ Program/ *3:00 – 5:00 pm “Risk Management and the LAB: Friend or Foe?” gement a Risk Management Course – ana Risk Mre - Sign - Init! Sign-In Required for Credit Lectu ed for cred ir u Req MaryAnn Digman, RN, MSHA (Senior Clinical Risk Consultant, Mesilla Park, NM) www.medpro.com 5:00 – 6:30 pm

Mentor Mentee Reception Hosted by Bret S. Langerman, DO, OOA President & First Lady DeLaine Langerman

7:00 am

Registration & Continental Breakfast

*9:00 – 10:00 am “Discovering Disease through Urine” Kenneth E. Calabrese, DO, FACOI (certified internal medicine & nephrology, Tulsa, OK) www.ncbi.nlm.nih.gov/pubmedhealth/PMH0010405/ Oklahoma D.O. | October 2013

• Visit www.HardRockCasinoTulsa.com Click Online Reservations located on the left side of the page then click Group Reservation at the top of the page then enter the Attendee Code: OOAJANUARY1014 • Group attendees may use the URL below: https://reservations.ihotelier.com/crs/g_login. cfm?hotelID=13572. Type in the Attendee Code: OOAJANUARY1014

Hard Rock Hotel & Casino Features: Hard Rock Store; Variety of dining options including Toby Keith’s “I Love This Bar & Grill”; Vegas style buffet; bistro-style grills; & 24-hour casino with 2,300 slot machines.

All Hard Rock Hotel Rooms Include: iPod docking stations; refrigerators; complimentary wired & wireless high-speed internet; complimentary airport transportation; complimentary covered & uncovered self-parking; complimentary fitness center; and complimentary USA Today.

Room Rate: $134 a night Cut-off date: January 10, 2014

PAGE 7

*8:00 – 9:00 am “New & Old Markers on Rheumatology” Debbie A. Gladd, DO (certified internal medicine, Tulsa, OK) www.rheumatologynews.com/single-view/new-mark ers-criteria-promote-earlier-intervention-in-juvenile-l upus/cb4ceb477ccfca8f30053272dd373606.html

For Room Reservations:

• Individuals may call toll free number: 1-800- 760-6700 Don’t forget to mention: OOA 2014 to receive the special group rate

Oklahoma D.O.

Sunday – February 2, 2014

Room Reservations Information:

The OOA Winter CME Seminar “The ABC’s of the LAB’s: What’s New, What’s Hot & What’s Not” On or Before 1/24/14 After 1/24/14 q *DO Member Registration $340 $365 q DO Registration for Saturday afternoon “Proper Prescribing” & “Risk Management” Courses only (3 Credit Hours) $180 $205 q*Retired DO Member Registration $80 $105 q*DO Nonmember Registration $840 $865 q Nonmember Saturday Only Registration $680 $705 q *MD/Non-Physician Clinician Registration $340 $365 q Student, Intern, Resident, Spouse, Guest Registration $0 $0 Mail Registration Form & Payment to: OOA, 4848 North Lincoln Boulevard, Oklahoma City, OK 73105-3335 or Fax to 405.528.6102. DO Name (please print): ________________________________________________________________________________ Guest/Professional/Guest: _______________________________________________________________________________ Resident/Intern: _______________________________________________________________________________________ Student: _____________________________________________________________________________________________ q OMS-I q OMS-II q OMS-III q OMS-IV

Payment:

q Check Enclosed

q VISA/MASTERCARD

q DISCOVER

q AMERICAN EXPRESS

Credit Card No.: _________________________________________________________________ Card Exp. Date: ________ Signature: ____________________________________________________________________________________________ Name (as it appears on card - please print): _________________________________________________________________

Oklahoma D.O. PAGE 8

Billing Address: ________________________________________________________________________________________ City: ________________________________________________ State: _____________ Zip: ________________________ Office Telephone: (_______)_____________________________ E-Mail address: ___________________________________ Please indicate: q Printed syllabus OR q DVD syllabus PLEASE NOTE: requested print syllabus cannot be guaranteed after January 6, 2014 *Includes: Proper Prescribing Course, 2 Continental Breakfasts, Saturday Luncheon, & Evening Reception. Requests for Refunds Must Be Received Before January 24, 2014 and a $25 Service Fee Will Be Charged. Oklahoma D.O. | October 2013

Oklahoma D.O. PAGE 9

Oklahoma D.O. | October 2013

CENTER FOR RURAL HEALTH Provided by: Jeff Hackler, JD, MBA, Assistant to the Dean for Rural Service Programs Every year there are a number of policy issues that have the potential to dramatically impact rural health. This year, two federal policies could have a devastating impact on rural health in Oklahoma if they are allowed to proceed without opposition. One policy would significantly threaten the vast majority of critical access hospitals in the state, and the other policy would end the teaching health center program that funds a number of primary care residency programs in Oklahoma. Critical Access Hospital Threat A critical access hospital (CAH) is a hospital that meets specified conditions of participation to receive cost-based reimbursement for its Medicare patients rather than being reimbursed under the Prospective Payment System (PPS). Cost-based reimbursement in most cases is equal to 101% of a CAH’s reasonable costs in providing inpatient and outpatient services. Among the conditions of participation for a CAH are the requirements that the hospital be small (25 inpatient beds or fewer) and have an average length of stay of less than 96 hours.1 The hospital must also be located in a rural area and at least 35 miles from the nearest hospital by primary road. Prior to 1996, a state could waive the location requirements (rural or distance) for a CAH by designating it as a “necessary provider” of health care services for a community.2

In August 2013, the Office of the Inspector General (OIG) issued a report indicating that approximately two-thirds of the nation’s CAHs would not meet the location requirements if they were required to re-enroll in Medicare.3 The report indicates that the Centers for Medicare and Medicaid Services (CMS) could save more than $500 billion if it required all CAHs to recertify. The OIG presented its report to CMS along with a series of recommendations. One of these recommendations was to “seek legislative authority to remove [Necessary Provider] CAHs’ permanent exemption from the distance requirement, thus allowing CMS to reassess these CAHs.” CMS has indicated that it agrees with this recommendation from the OIG. The National Organization of State Offices of Rural Health (NOSORH) submitted a Freedom of Information Act request to the OIG to determine what CAHs the OIG had identified as being vulnerable to losing their CAH status based on the OIG’s recommendations. The OIG information provided to NOSORH indicates 28 of Oklahoma’s 34 CAHs would be at risk of losing their designation, representing more than 80% of our state’s CAHs (see Figures 1 and 2). Nationally, the State of Oklahoma ranks among the top 15 states for the number of CAHs, so this proposal would hit Oklahoma disproportionately hard.4

Oklahoma D.O. PAGE 10

Figure 1.

Oklahoma D.O. | October 2013

Figure 2. Hospitals That Could Lose ‘Critical Access’ Status by U.S. Congressional District

Community

Hospital

District

Representative

Markwayne Mullin

Coalgate

Mary Hurley Hospital

Markwayne Mullin

Holdenville

Holdenville General Hospital

Markwayne Mullin

Madill

INTEGRIS Marshall County Medical Center

Markwayne Mullin

Nowata

Jane Phillips Nowata Health Center

Markwayne Mullin

Okemah

Creek Nation Community Hospital

Markwayne Mullin

Tishomingo

Mercy Hospital Tishomingo

Markwayne Mullin

Anadarko

Physician’s Hospital in Anadarka

Frank Lucas

Buffalo

Harper County Community Hospital

Frank Lucas

Cheyenne

Roger Mills Memorial Hospital

Frank Lucas

Cleveland

Cleveland Area Hospital

Frank Lucas

Cordell

Cordell Memorial Hospital

Frank Lucas

Drumright

Drumright Regional Hospital

Frank Lucas

Fairfax

Fairfax Community Hospital

Frank Lucas

Guthrie

Mercy Hospital Logan County

Frank Lucas

Kingfisher

Kingfisher Regional Hospital

Frank Lucas

Mangum

Quartz Mountain Medical Center

Frank Lucas

Pawhuska

Pawhuska Hospital

Frank Lucas

Prague

Prague Community Hospital

Frank Lucas

Sapulpa

St. John Sapulpa

Frank Lucas

Seiling

Seiling Community Hospital

Frank Lucas

Stroud

Stroud Regional Medical Center

Frank Lucas

Weatherford

Weatherford Regional Hospital

Frank Lucas

Healdton

Healdton Mercy Hospital

Tom Cole

Marietta

Mercy Health Love County

Tom Cole

Sulphur

Arbuckle Memorial Hospital

Tom Cole

Waurika

Jefferson County Hospital

Tom Cole article continues on page 12...

Oklahoma D.O. | October 2013

PAGE 11

Atoka County Medical Center

Oklahoma D.O.

Atoka

Figure 3.

Oklahoma D.O. PAGE 12

To explain how significant the CAH designation is to a hospital, consider these numbers. In Oklahoma, a hospital that converts to CAH status experiences a median net change in profitability of $291,470 in the first year following conversion.5 Even after conversion, the average total margin for a CAH in Oklahoma is still negative.6 Without the CAH designation, it is difficult to understand how most Oklahoma CAHs would survive. Considering that hospitals are often one of the largest employers in a rural community, the impact is not solely on health, but also on the local economy. Sunset of the Teaching Health Center Program Another federal policy that will have a disproportionate impact on Oklahoma is the scheduled sunset of the Teaching Health Center (THC) Graduate Medical Education (GME) program. The THC GME program was created as part of the Patient Protection and Affordable Care Act that was signed into law in 2010.7 Under the program, the Health Resources and Services Administration (HRSA) at the United States Department of Health and Human Services was authorized to develop a five-year initiative for training primary care residents and dentists in community-based ambulatory patient care settings. As such, funding to support the residency programs would flow from HRSA instead of CMS. The THC GME program differs significantly from a traditional residency program in that the THC GME program is not

based in a teaching hospital; rather, the THC GME program is based in a community-based clinic that has responsibility for the administrative and financial management of the residency (residents still complete traditional rotations in hospitals).8 The community-based clinic administering the residency program must primarily serve rural and/or underserved populations. The premise of the THC GME program is that the United States needs more primary care physicians, and training them in clinics with a focus on community-based care for rural and/or underserved populations will increase the likelihood that the physicians will return to practice in those settings. Osteopathic residency programs, in particular, have benefited from the THC GME program. The osteopathic professionâ&#x20AC;&#x2122;s commitment to primary care is one reason its programs have participated at such a high rate in the THC GME program. Another reason is the American Osteopathic Associationâ&#x20AC;&#x2122;s ability to accredit new THC GME programs very quickly. The Osteopathic Medical Education Consortium of Oklahoma (OMECO), which is affiliated with the Oklahoma State University (OSU) Center for Health Sciences (CHS), acted very quickly to take advantage of the THC GME program. In fiscal year 2012, more than half of all HRSA funding to establish new THC GME programs went to programs that are part of OMECO.9 OMECO and community-based clinics in Joplin, Tahlequah, Talihina, and Tulsa operate a total of six THC GME programs with a capacity for 72 residents. Oklahoma D.O. | October 2013

Figure 3 illustrates the location and size of the OMECO THC GME programs relative to their national peers. When authorized, the THC GME program was scheduled to sunset in September 2015. This sunset date remains in effect, but the looming end of funding is causing problems already. Most of the THC GME programs are three-year residency programs (i.e., family medicine, internal medicine, and pediatrics). Residents who began three-year residencies in July 2013 will graduate in June 2016, nine months after funding for the program will end. The OMECO programs have committed to graduating their current residents after funding ends, but most of the programs have indicated that they will not continue to recruit residents into the program after this academic year because of the funding instability. As a result, a program that would be a pipeline for producing an average of 22 primary care physicians per year for rural and/or underserved areas in Oklahoma and the surrounding region is already beginning to dry up. It is imperative to the health of Oklahoma’s underserved residents that they have access to primary care services. If Congress would re-authorize funding for the THC GME program beyond 2015, OMECO’s funded programs could continue to make progress in producing physicians for a region that is in dire need of them. Combine this threat with the potential closure of many rural hospitals under the OIG’s recommendations and there is a tremendous need to fight for access to health care in our rural communities. OK

References: 1 What Are Critical Access Hospitals (CAH)? Health Resources and Services Administration. Retrieved from http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/critical.html. Critical Access Hospital: Rural Health Fact Sheet Series. Centers for Medicare and Medicaid Services. Retrieved from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/critaccesshospfctsht.pdf. 2

Most Critical Access Hospitals Would Not Meet the Location Requirements If Required to Re-Enroll in Medicare. Office of the Inspector General. http://oig.hhs.gov/oei/reports/oei-05-12-00080.pdf. 3

Number of CAHs per State. Flex Monitoring Team. Retrieved from http://www.flexmonitoring.org/cahlistRA.cgi. June 2013. 4

RN Lawler, GA Doeksen, and V Schott. Impact of Conversion to Critical Access Hospital Status for Oklahoma’s Rural Hospitals. The Journal of Rural Health. 2003. 5

Statewide Financial Performance of CAHs: Oklahoma. Flex Monitoring Team. Retrieved from http://www.flexmonitoring.org/documents/ Finance/2011/StGraph_OK2011.pdf. 2009. 6

Teaching Health Center Graduate Medical Education (THCGME). Health Resources and Services Administration. Retrieved from http://bhpr. hrsa.gov/grants/teachinghealthcenters/. 7

Patient Protection and Affordable Care Act, Section 5508. Retrieved from http://bhpr.hrsa.gov/grants/teachinghealthcenters/section5508.html. 8

Teaching Health Center GME Payments. Health Resources and Services Administration. Retrieved from http://bhpr.hrsa.gov/grants/teachinghealthcenters/payments.html. 9

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Oklahoma D.O.

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Oklahoma D.O. | October 2013

Trace Heavener, OMS-II Student Government Association President 2013 – 2014

OSU-CHS STUDENT UPDATE Only a few weeks into classes, many student organizations are already in full swing with welcoming a cadre of new students, community events, and national conferences. For example, the Student Osteopathic Rural Medicine (StORM) club hosted the 12th Annual Rural Health Fair at the Coweta Fall Festival in Coweta, Oklahoma. Also, the Student Osteopathic Medical Association (SOMA), along with the Oklahoma Osteopathic Association (OOA) and Oklahoma Educational Foundation for Osteopathic Medicine (OEFOM), presented anatomy atlases and stethoscopes to the incoming OMS-I class at a mentor/mentee dinner. SOMA has also created a Facebook page for their annual Scrub Run, which can be found by searching the term ‘scrub run’ in the Facebook search bar. Finally, OSU-COM sent close to a dozen student representatives to conferences held in conjunction with Osteopathic Medical Conference and Exposition (OMED) this fall.

PAGE 15

Oklahoma D.O. | October 2013

Many OSU-COM students, residents and faculty recently attended an event at the OSU Medical Center to thank the Oklahoma House of Representatives Speaker T.W. Shannon, and other members of the legislature, for state funding of the teaching hospital in Tulsa. The OSU Medical Center hosted a similar event earlier in the summer for Governor Mary Fallin. The students, residents and faculty would also like to thank the readers of this journal for their letters and calls of support to their legislative representatives for this cause. Osteopathic physicians in Oklahoma play a key role in shaping governmental decision making to support OSU-COM and the OSU Medical Center. We are very grateful for your efforts.

Oklahoma D.O.

OSU-COM offers a Stress Management Program to OMS-I students during their first semester of medical school. This program takes place during the noon hour once per week and is not mandatory. However, attendees report extremely high evaluations of the helpfulness in juggling the complexities of medical school. Further, the student government provides lunch for attendees several times throughout the semester. The program is taught by OMS-II students who have received extensive training and support in the curriculum. This program has been held as a national model and duplicated at several other medical schools throughout the country.

The Student Ambassador program allows current OMS-I and OMS-II students a means of expressing their enthusiasm for the osteopathic profession in general and OSU-COM in particular. Student Ambassadors lead campus tours for prospective students, attend recruiting events throughout the state and represent OSU-COM school to the community. The Student Ambassador Directors received such an abundance of applications that they were not able to accommodate all the student interest. There are about 80 total Student Ambassadors who will ‘take call’ two weeks this school year to serve as needed.

Oklahoma D.O. PAGE 16

0 KEEP CALM AND FOLLOW THE RULES RULES & LAWS TO KNOW TO HELP STAY OUT OF JEOPARDY BY: ANGELA WALL, PMP EDUCATOR

Oklahoma D.O. | October 2013

With the many rules and laws that Health Care Professionals (HCPs) must know in their scope of practice, a few more added to the list may not be happily accepted. Unfortunately, the rules and laws that HCPs may not know, could be the ones that put their professional name and practice in jeopardy. As an HCP who prescribes, distributes, dispenses and administers a controlled dangerous substance (CDS), one must not only be registered with the DEA, but first and foremost be registered with the Oklahoma Bureau of Narcotics (OBN) [Title 63 O.S. §§ 2-302(A) & 2-303; OAC 475:10-1-9(a) & 10-1-10(a, c)]. For HCPs to register with OBN, go to www.OK.gov/obndd, click on “Renew-New Registration” and follow the directions. Once registration has been completed, the certificate of registration will be good for three years and always expires on October 31st. A renewal reminder will be mailed out every August to the address on file. If there has been a change of business address, the HCP must notify OBN within fourteen calendar days of that change to update their account (OAC 475:10-1-21). If registration is not obtained or renewed, and CDS is prescribed, distributed or administered, the HCP will be in violation of the Uniform Controlled Dangerous Substances Act and subject to penalties [OAC 475: 10-1-9(c)]. OBN registrants must maintain records and inventories for all CDS that has been prescribed, distributed, administered and stored (Title 63 O.S. § 2-307). These records, as well as the establishment of the registrant, may be inspected by the OBN Director as well as his agents (Title 63 O.S. § 2-502(A); OAC 475:10-1-16] as far back as a two years prior to the inspection date (OAC 475:25-1-7). If there is theft or significant loss of any CDS, all registrants must notify OBN upon discovery of the theft or loss (Title 63 O.S. § 2-326). Notification to OBN for theft and loss will not only account for discrepancies in reports and inventories for the registrant, but also make OBN aware of any potential Prescription Drug Diversion. Prescription Drug Diversion is the deviation from legitimate use of prescription drugs for illegal purposes by obtaining, using and/or selling. As an OBN registrant, HCPs are required by law to guard against diversion (OAC 475:20-1-8b). Failure to do so can cause the HCP’s registration to be denied, suspended or revoked by the Director of OBN (Title 63 O.S. § 2-304). To help guard against diversion, OBN created the computerized prescription monitoring program (PMP). The PMP has “Real Time” reporting benefits in which HCPs must report all CDS within 5 minutes of being dispensed (Title 63 O.S. § 2-309C; OAC 475:451-5). Only dispensing HCPs must report to the PMP and by definition of this reporting system, dispensing means that the CDS is handed to the patient for purpose of medicating outside of the office/facility.

The PMP may only be used to run reports on those with whom the HCP has a doctor-patient relationship. If any other reports have been ran on the PMP using the HCPs DEA number, whether given permission or not (this includes sub-accounts created by the HCP to use the PMP), it will result in a misdemeanor, fine and loss of access to the PMP. HCPs also may not run reports on employees or family members unless a doctor-patient relationship has been created. Other violations regarding family members are that a HCP may not distribute, dispense, sell, give, prescribe, or administer any CDS for the practitioner’s personal use, or for an immediate family member. This does not include family members outside the second degree of consanguinity or affinity. It also does not apply to medical emergencies when a medical doctor is not available to respond to the emergency [OAC 475:30-1-3 (d)]. When it comes to prescribing CDS there are other rules and laws that OBN registrants must follow. CDS may only be prescribed for a legitimate medical purpose and that medical purpose must be within the HCPs scope of practice. [OAC 475:30-1-39(a)]. Prescriptions may not be issued for the dispensing of a CDS listed in any schedule to a drug dependent person for the sole purpose of continuing his/her dependence on the drug (does not apply to a properly licensed and registered narcotic treatment program) [OAC 475:30-1-3(c)]. Also, for those patients who need Pseudoephedrine, always check the Meth registry in the PMP before prescribing, even to those under the age of 18. Minors may not be able to buy Pseudoephedrine without a parent or guardian, but they could still be listed in the Meth registry. When writing a prescription for a CDS, it must be written on a single prescription form, and no other prescriptions (controlled or noncontrolled) shall be written on the same form [OAC 475:30-1-4(3)]. Due to the fact that many prescription pads are stolen for CDS diversion, report any lost or stolen prescription blanks to OBN including registration certificates, DEA forms, prescription blanks or other materials used in connection with CDS [OAC 475:20-1-8(a)]. Listed above are just a few of the basic rules and laws that OBN registrants need to know about registering, recording, entering, reporting, dispensing and prescribing. For the entire list of rules under code 475, visit the Oklahoma Secretary of State Online Oklahoma Administrative Code and Register (www.oar.state.ok.us). For the entire list of laws under Title 63 of the Oklahoma State Statutes, visit the Oklahoma State Courts Network (www.OSCN.net). Links to these sites are also at www.OK.gov/ obndd located on left side of screen under “Rules and Regulations”. These rules and laws are put in to place for OBN registrants in order to maintain effective controls against CDS diversion. Knowing the rules will also help protect Health Care Professionals from being in violation of state or federal laws or regulations that pertain to CDS. Don’t be in jeopardy – know the rules and laws. OK

Oklahoma D.O. | October 2013

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All OBN registrants, whether dispensing or prescribing, have access to the PMP. For HCPs to register for the PMP, go to www.OK.gov/obndd, click on “Register for PMP” and follow the directions. Along with access to the PMP, HCPs need to understand that the information collected for the PMP is confidential and is not open to the public (Title 63 O.S. § 2-309D). Therefore, HCPs may neither give copies of reports to the

Oklahoma D.O.

The dispensing information can be reported manually through the PMP or with an electronic device that is compatible to that used by OBN to receive the information by the PMP (Title 63 O.S. § 2-309C; OAC 475:45-1-3). By all dispensers accurately reporting information into the system, HCPs who use the system can receive patient-specific reports along with their own prescribing reports. These reports can help prevent abuse of prescription drugs and guard against those using them illegally. Failure to enter the information accurately and on time, may result in administrative action against the registration of the dispensing practitioner, including, but not limited to, fines not to exceed $2,000 per violation [Title 63 O.S. §2-309C; OAC 475:45-1-6].

patients nor may they put the reports in the patient’s medical file. The report may be discussed with the patient and noted in the file that it was ran/discussed, but afterwards it must be shredded. Any unauthorized disclosure of information shall be a misdemeanor and lead to administrative action against the practitioner (Title 63 O.S. § 2-309D).

Vicki L. Stevens President 2013 â&#x20AC;&#x201C; 2014 Advocates For the oklahoma osteopathic association Greetings from your Advocates. It is hard to believe my year is almost half over. Our efforts are beginning to bear fruit.

701132 Tulsa, Oklahoma 74137. They can also be paid online through the OOA membership portal at www.okosteo.org.

I wish to thank our National President, Nancy Granowicz and the AAOA staff, for their assistance in helping us prepare for OMED and our AAOA House of Delegates meeting.

Membership is critical. Having gone away from the above system caused a decrease in membership and fellowship. Please help us restore the AOOA by making sure your dues are paid. Restoring relationships are now more important than ever. If you have questions, concerns, ideas, or suggestions, please feel free to call me at (918) 781-2319. Donna Cannon, President-Elect/Membership Chair, has a new and exciting logo for our membership drive. Please visit: www. Advocates4okosteo.com for more information. Speaking of the website, your feedback about it is requested. Please check it often for information and announcements and remember to participate with us on our Facebook page. For technical questions or if you would like to advertise on our web page please contact Apryl Pritchett at apryl.pritchett@yahoo.com.

We have 9-registered AOOA Delegates, 2-registered SAA Delegates and 2-registered IRAA Delegates. I would also like to add that our Maghin Abernathy has been asked to serve as the Liaison to the National IRAA (2013-2014). The AOOA is fortunate to be able support these Delegates with stipends. This makes AOOA one of the largest Delegations in the AAOA House of Delegates. Politically this bodes well for us in the future.

Oklahoma D.O. PAGE 18

We are looking forward to the 2014 OOA Winter CME Seminar at the Hard Rock Hotel & Casino in Catoosa, Oklahoma, January 31-February 2, 2014. Please join the AOOA on Saturday from 10:30 am-12:00 pm for fellowship and activities. Flo Conklin will once again be donating her talent and skills to the AOOA during the jewelry making program. RETURN TO A BETTER SYSTEM - By the time this letter appears in the Oklahoma DO magazine, the OOA physician dues statements will have been sent. Please note the AOOA dues invoice will also be included in these mailers. (Kudos to Lynette McLain, and the OOA for allowing us to return to this system). Please make sure that your spouse and their staff are aware and make the appropriate payment. AOOA dues can be paid in multiple ways. One can simply tack on the extra $50 payment to the OOA physician dues. All forms of payment are excepted. Dues can be paid by sending the invoice to the OOA central office or to the AOOA at PO Box

I am going to take the President's privilege at this time to salute our SAA and IRAA Chapter Leaders Joy Vedros, Allison Johnson and Maghin Abernathy. Having spoken with other State Presidents it is my opinion, that without a doubt, we have the best student advocacy organizations. Please realize that your dues, used to support advocacy at this level, is returned a hundred fold. OMED - At the time of this writing OMED Convention is quickly approaching. I am looking forward to the OMED Convention and the AAOA House of Delegates. I am also looking forward to the fellowship and relaxation of the Post Convention trip in Tucson. I hope to see many of you there. Yours in Osteopathic Advocacy, Vicki Stevens, President AOOA

Oklahoma D.O. | October 2013

Oklahoma D.O. PAGE 19

Oklahoma D.O. | October 2013

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Oklahoma D.O. PAGE 20

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Oklahoma D.O. | October 2013

PROTECTING YOURSELF

AGAINST LAWSUITS BY: JENNIFER SMITH, INSURICA

In this issue, I will briefly describe some of the various executive professional liability exposures common to physicians and modern health care organizations. As a physician and owner of a medical practice, your professional liability exposures are extensive. Without a proper risk management program in place, your private practice could be left with unaddressed financial exposures. Of course, most physicians are familiar with Medical Professional Liability Insurance (MPLI) and its necessity in covering alleged negligence, but there are other professional liability insurance coverages that cover a physician’s exposures as a business owner. Exposures such as: Directors’ & Officers and Entity Liability, Employment Practices Liability, Cyber Security, and Crime and Fiduciary Liability. These professional exposures are not covered by a Medical Professional Liability Insurance policy but can be just as financially devastating to a health care practice.

Oklahoma D.O. | October 2013

Finally, many physicians sit as board members of for-profit or not-for-profit boards outside their organization. These outside board directorships can be a useful extension of activities and community involvement, but they also create complicated liability issues and unintended risks for the organizations and individuals who serve. This creates an often-overlooked exposure that should not be underestimated. The personal assets of insured persons who hold authorized outside directorships may be at risk in the event of a lawsuit against the board—particularly if the outside organization does not purchase D&O Liability insurance to help protect them. While all the risks associated with owning and managing a private practice may seem overwhelming, there are many insurance professionals available to assist in diagnosing your risk and offering a proper insurance treatment plan. Over the course of the next several Oklahoma DO Journals I will dive deeper into each one of these various professional liability policies and offer greater detail as to claims scenarios, exposures, and coverage options. Reference: www.chubb.com

PAGE 21

Regarding benefit errors and omissions, fiduciaries and other employees who manage and give advice regarding benefit plans may be held personally liable for these actions. Although many employee-related allegations arise out of compensation issues, the financial impact of poor administration or advice surrounding benefit plans increases the odds of litigation. Likewise, changes in employee benefit offerings increase fiduciary

Whether you are a large or small private practice, it’s likely your practice may be particularly vulnerable to crime exposures. Many health care organizations have the misguided belief that “no one would steal from us.” Sadly, this plays straight into the hands of a “trusted” employee with opportunity and motivation. In fact, an employee is a perpetrator in 2 of 3 cases, a manager in 1 of 3 cases, and an owner or executive in 1 of 8 cases of fraud. Your practice may be particularly at risk to the impact of long-term fraud if employees are multitasking due to an environment of expense constraint.

Oklahoma D.O.

As an owner of a private practice, the physician is also an employer, and employment-related issues are one of the leading causes of litigation against health care organizations. Although it is best to have human resource professionals handle all employment issues, the reality is that many people are involved in supervising, hiring, firing, etc. Many employment-related claims arise from the actions of employees who are not human resource professionals. The most common claims from employees are allegations of wrongful termination, failure to hire or promote, discrimination (age, gender, race, religion and national origin), evaluation, discipline, interviewing, references and sexual harassment. While Oklahoma is an “at-will” state which offers an employer many options in the hiring and termination of employees, employment-related lawsuits still arise and the cost to defend these claims can be substantial.

liability exposure from unhappy employees. Further, if officers of your organization also serve as fiduciaries of your benefit plan, be cautious of participants alleging poorly made decisions regarding the plan administration.

LEGISLATIVE

REPORT

Physicians Urge Legislators to Support Lawsuit Reform On September 5th, dozens of physicians from across the state attended a press conference at the state capitol urging lawmakers to support lawsuit reform. Layne E. Subera, DO, spoke on behalf of OOA President Dr. Bret Langerman encouraging the legislature to renew bipartisan lawsuit reform bills passed in 2009 that were struck down by the Oklahoma Supreme Court in June. The bills “were common sense reforms that provided rightful protections for our physicians. As Oklahoma already faces a significant physician shortage, we sincerely need your help in establishing a safer practice environment,” said Dr. Subera. The special session was called by Gov. Mary Fallin to address the 2009 lawsuit reform measures struck down by the Oklahoma Supreme Court. The legislature passed 23 bills all related to tort reform. An outline of the bills is included later in this report. 19 bills had emergency clauses enacted and will be effective immediately upon the Governor’s signature. The four bills that did not pass with an emergency clause are effective on December 8, 2013. All bills except SB 1 are primarily repeat language from HB 1603 in 2009 that was struck down by the Oklahoma Supreme Court. These measures were struck down as they were combined into one bill, violating the single-subject rule. The essence of SB 1 has twice been struck down by the Oklahoma Supreme Court for creating two classes of plaintiffs. Modified language was inserted into the iteration passed during special session. A total of 43 bills and 4 resolutions were filed during special session. Below are the subjects of the bills that were passed by the legislature and signed by the Governor:

SB1

Oklahoma D.O. PAGE 22

Passed 51-36

SB2

Affidavit of Merit* Restores certificate of merit requirement for filing of a professional negligence lawsuit, but broadens this requirement to all negligence cases where expert witness testimony is required. In an effort to eliminate the “financial burden" on potential plaintiffs, the bill now does away with the $40 filing fee for indigency exceptions. The affidavit would need to state that a plaintiff had consulted with experts who reviewed the facts of the claim and that a reasonable interpretation of the facts would support the plaintiff’s side. Critics note obtaining an expert’s opinion would likely be extremely expensive, therefore the financial burden limiting access to the courts remains.

Dismissal* Specifies a time that a case can be dismissed without the leave of the court from before trial begins, to before the final pretrial. After the pretrial hearing, it may only be dismissed by agreement of the parties or by the court. In either case, unless otherwise stated in the notice of dismissal, the dismissal will be without prejudice.

Passed 75-9

*No emergency clause

SB4 Passed 91-0

SB6

Recovery of Medicaid Payments Establishes a formula for the recovery of medical payments by the Oklahoma Health Care Authority for the care of a Medicaid recipient when the beneficiary receives a related liability settlement or judgment.

Expert Testimony* Conforms with federal rules of evidence on expert witnesses in civil litigation cases. Adds that facts or data that are otherwise inadmissible shall not be disclosed to the jury by the proponent of the opinion or inference unless the court determines that their probative value in assisting the jury to evaluate the expert’s opinion substantially outweighs their prejudicial effect.

SB7

Passed 82-0

Good Faith UCC* States that if a company breaches the “good faith” obligation with another company in the Uniform Commercial Code, the breach will not be cause for a separate tort case but will remain a contract action.

Passed 76-8

Oklahoma D.O. | October 2013

SB10

Passed 93-0

SB11

Emergency Powers of the Governor Current law allows the Governor to assume regulatory control over essential resources of the state during a declared state of emergency. The measure excludes a volunteer health practitioner from being considered an “emergency management worker” during a declared emergency. The use of volunteer health practitioners during a state of emergency is governed by the Uniform Emergency Volunteer Health Practitioners Act. The measure amends the definition of “resources”, as it relates to the Emergency Operations Plan used in a declared state of emergency, to exclude “health manpower.”

Volunteer Liability Extends immunity to volunteers helping in emergency situations, even if they receive payment for their services. The term volunteer is modified to mean a person who enters into services or undertaking of the person’s free will without compensation or expectation of compensation in money or other thing of value in order to provide a service, care, assistance, advice, or other benefit even if the volunteer is legally entitled to receive compensation for the services performed. The immunity is only applicable if the services were agreed upon in advance by all involved persons and that there is understanding that the services are provided on a volunteer basis.

SB12

Passed Passed 73-0 82-0

Passed 81-8 Oklahoma D.O. | October 2013

Passed 71-16

SB14

Asbestos/Silica Claims Creates the Asbestos and Silica Claims Priorities Act. SB 14 provides a procedural channel allowing judicial supervision and control of asbestos and silica litigation by giving priority to claimant with demonstrable physical impairment. The claim must have a report from a physician concluding the following: • the claimant has been diagnosed with mesothelioma or other asbestos –related malignancy; • the exposure to asbestos was a proximate cause of the diagnosed disease(s); • if the malignant asbestos-related condition was something other than mesothelioma: • the claimant has had an underlying nonmalignant asbestosrelated condition and at least 15 years have passed between the time of first exposure to the date of diagnosis.

For claimants with a nonmalignant asbestos-related condition, there are similar reporting requirements for the diagnosing physician. It also established a process where those who can demonstrate injury can have their trials heard first. Critics argue it merely makes it more difficult for people who suffer from asbestos-related illness to file a claim. Concerns were voiced that SB 14 is model legislation from an out-of-state think tank (American Legislative Exchange Council), and does not confirm to Oklahoma law and terminology (such as roster vs. docket). Additionally, it was mentioned during debate that asbestos warnings at the Capitol were taken down prior to special session. Motions were made to suspend the rules to align the terminology in the bill with Oklahoma statute and to exempt emergency personnel and children exposed to asbestos by the Moore tornados that occurred in May 2013. All motions failed along roughly party lines.

Passed 71-21

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There are concerns that language in the bill conflicts with the Oklahoma Constitution (prohibition of ex post facto laws.)

Products Liability Protects producers of inherently dangerous products used outside of what they are designed for. SB 13 does not provide immunity from suit for inherently dangerous products, but only provides an affirmative defense. In order for the defense to apply, all of the following must be shown: • the product was a common consumer product intended for personal consumption; • the risk posed by the product was known by the common consumer; • the product was properly prepared and reached the consumer without substantial change in its condition; • adequate warning of the risk posed by the product was given by the manufacturer or seller. 82-0 Passed The defense does not apply to any product liability lawsuit based on manufacturing defects or breach of warranty. There are concerns about pharmaceutical companies being granted this liability.

Oklahoma D.O.

Common Sense Consumption Act Creates the Common Sense Consumption Act. Protects against manufacturers, packers, distributors, carriers, holders, sellers, marketers, or advertisers of food products for any claim of weight gain, obesity or other conditions associated with weight gain or obesity. Exceptions are allowed if the plaintiff has evidence that the disease was caused by the entity’s material violation of a state or federal law related to the marketing, manufacturing, distribution, labeling, misbranding or sale of the food product.

SB13

SB15

Successor Asbestos Liability Creates the Innocent Successor AsbestosRelated Liability Act which provides liability insulation for successor companies in asbestos claims. Places liability limits and protections to any successor corporation that acquired a manufacturer of asbestos but did not continue in the asbestos business. Any damages assessed against such “innocent successor corporations” are limited to the fair market value of the acquired company at the time of the merger or consolidation.

Passed 82-0 Passed 77-4

Firearms Manufacturer Liability Limits liability on gun manufacturers and states that a firearm may not be deemed defective on the basis of its potential to cause serious injury, damage, or death. The exemption from liability does not apply to actions for deceit, breach of contract, or expressed or implied warranties, or for injuries resulting from failure of firearms to operate correctly due to defects/negligence in design or manufacture.

Passed 92-0

SB16 HB1005

Class Action Addresses class action lawsuits and attorney fees and is a companion bill to HB 1013. Denies a motion in a class action asserting lack of jurisdiction because an agency of this state has exclusive or primary jurisdiction of the action or a part of the action, or asserts that a party has failed to exhaust administrative remedies, but only if the class is subsequently certified and only as part of the appeal of the order certifying the class action.

Passed 80-10

HB1003 Oklahoma D.O. PAGE 24

HB1004

Forum Non Conveniens States that if the court wishes to move the claim or action to another venue it may do so in the interest of justice and for the convenience of the parties. This forum may be in state or out of state. The court must consider the following when determining whether to issue a motion to stay, transfer or dismiss the action: • whether an alternate forum exists in which the action may be tried; • whether the alternate forum provides an adequate remedy; • whether keeping the action in the court in which the case is filed would be a substantial injustice to the moving party; • whether the alternate forum can exercise jurisdiction over all the defendants properly joined in the action of the plaintiff; • whether the balance of the private interests of the parties and the public interest of the state predominates in favor of the action being pursued in an alternate forum; • whether the stay, transfer or dismissal would prevent unreasonable duplication or proliferation of litigation

Emergency Volunteer Health Practitioners Creates the “Uniform Emergency Volunteer Health Practitioners Act, which empowers the Oklahoma Department of Health, when an emergency is in effect, to limit, restrict, or regulate the duration of practice by volunteer health practitioners, the area in which they may practice, and the types of practitioners who may practice. and that there is understanding that the services are provided on a volunteer basis.

Passed 96-1

HB1006 Frivolous Redefines “frivolous” by simply defining it as an action or pleading “in bad faith or without any rational argument based in law or fact to support the position of the litigant”, and sets forth procedures for judges to punish parties who file frivolous lawsuits. Sanctions imposed for violations must be limited to what is sufficient to deter repetition of such conduct or comparable conduct by others similarly situated, and they can include directives of a nonmonPassed etary nature, an order to pay 82-0 a penalty into court, or an order directing payment to the movant of some or all of the reasonable attorney fees and other expenses incurred as a direct result of the violation.

Passed 82-15

Passed 79-19 Oklahoma D.O. | October 2013

HB1007

Peer Review In any civil action where a patient is claiming injuries as a result of negligence by a care health professional, the measure prohibits the use of factual statements made during any peer review process from subject to discovery. Peer review is a process for evaluating medical professionals. Furthermore, in cases where a patient has alleged that a health care facility was independently negligent as a result of permitting the health care professional to provide health care services to the patient, the measure allows the use of credentialing and recredentialing data to be used as evidence only if a judge or jury first finds the professional to have been negligent in providing health care services to the patient in the health care facility. Advocates claim that peer review findings should be treatedPassed the same as communications between lawyer 82-0 and client or between spouses. Critics claim that this will allow hospitals to “hide” evidence of malpractice, and subsequently empowers negligent doctors to continue practicing.

Passed 82-15

HB1008 Passed 96-0

Livestock Liability Includes agritourism activity within the Oklahoma Livestock Activities Liability Limitations Act, which involves livestock or a location where livestock are displayed and raised. An “agritourism activity” may include any activity, carried out on a farm or ranch that allows members of the general public, for recreational, entertainment or educational purposes, to view or enjoy rural activities, including farming, ranching, historic, cultural, harvest-your-own activities or natural activities and attractions.

HB1009

HB1011

Pleading Requirements In civil procedures, modifies pleading requirements by changing the amount of damages that must be plead in a general claim for relief from $10,000 to a fixed amount. If a plaintiff seeks less than the amount required for diversity jurisdiction, the defendant may file, for purposes of establishing diversity jurisdiction only, a Motion to Clarify Damages prior to the pretrial order to require the plaintiff to show by a preponderance of the evidence that the amount of damages will not exceed the amount required for diversity. If the court finds that damages will likely exceed the amount required for diversity, the plaintiff must amend their pleadings.

Passed 80-16

HB1013

Class Action Procedure Establishes rules for class action lawsuits and places limits on nonresident participation in state class action lawsuits. Also limits class membership, unless agreed to by the defendant, to individuals who are residents of the state. For non-residents, they must own property in the state, provided the property is relevant to the class action, or have a significant portion of the nonresident’s cause of action arising from conduct occurring within the Passed state. Requires court approval82-0 to settle, voluntarily dismiss or compromise on the claims, issues or defenses of a certified class. Outlines the factors that will determine the attorney fees for class counsel.

Passed 79-14

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Oklahoma D.O. | October 2013

Passed 97-0

Due Process for Teachers The measure prohibits an attorney who has represented or represents a school district at a personnel hearing to consider the termination of an administrator, teacher or support employee from being the hearing officer or judge at the due process hearing. Accordingly, a school district attorney is also prohibited from influencing, in any way, an executive session of the school district board of education that is held in conjunction with a due process hearing dealing with the related subject matter.

Oklahoma D.O.

Passed 94-2 School Protection Act Creates the School Protection Act, but concerns were made that this Act only protects school employees and volunteers from assaults, not other students. States that any person over 18 who purposely makes a false accusation of a criminal activity against an education employee to law enforcement authorities or school district officials will be guilty of a misdemeanor and may be fined up to $2,000. Students between ages 7-17 committing the same crime may be subjected to community service or other sanctions the court deems appropriate. Provides out-of-school suspension for students who assault education employees or school volunteers. Disciplinary actions taken by the school does not bar criminal prosecution of the student who caused the injuries. SB 1009 states that any education employee injured as a result of an Passed 82-0 assault or battery while in performance of their school duties is Passed 79-19 entitled to leave without a loss of leave benefits.

HB1010

HB1015

Seat Belts Regarding passenger restraint systems, provides that failure to properly secure a child while transporting the child in a motor vehicle is admissible as evidence in a civil action case unless the plaintiff is a child under the age of 16. Some concerns were that this is merely an opportunity for insurance companies to decrease or deny compensation to no-fault victims of car accidents (i.e. individual hit by drunk driver, was wearing seat belt, but had shoulder strap under, rather than over, the arm.)

Passed 82-15 Four Senate bills Passed and three 82-0 House bills relating to tort reform were not heard based on the presumption that legislation passed in 2011 achieved the requested changes. Also, thirteen bills were tossed aside upon their assignment to the House Rules Committee. Some portions of the above summaries were aided by the Office of the Speaker of the House as well as the Oklahoma House Minority Leader’s Office.

Legislature Makes Third Run at Affidavit of Merit

Lawmakers are trying for a third time to craft an affidavit of Passed 96-0 merit requirement for negligence lawsuits. SB1 is unique among the bills being considered in the special session currently underway at the Capitol. While the remainder of the bills simply re-install language that was part of a 2009 law that was found unconstitutional because of that bill’s construction, SB1 contains amended language.

Oklahoma D.O. PAGE 26

Sen. Anthony Sykes, R-Moore, presented the bill on the Senate floor. Unlike the language that was part of the original bill, Sykes explained that the new language expanded the affidavit of merit requirement to all negligence cases in which expert testimony would be required and created an indigency exemption for those unable to afford the certification. The Oklahoma Supreme Court ruled in June 2013 that the 2009 law’s affidavit of merit requirement created two classes of plaintiffs because the certification was required only for cases against state licensed service providers and potentially barred access to the courts for those unable to pay the costs of obtaining the affidavit. The affidavit, which must be rendered by an expert, must indicate the lawsuit has the potential of succeeding. It is touted as a way of discouraging and preventing frivolous lawsuits from being field. Senate Democrat Leader Sean Burrage, from Claremore, said he believed the Legislature’s “third bite of the apple” would again be found unconstitutional. The bill, he said, again cre-

ated two classes of plaintiffs--those who need an affidavit of merit and those who do not. He also said he believed the bill would still be a barrier for those unable to afford the pre-trial expert opinion. “The expert has to say you have a case even before they file it,” he said. Burrage and Sen. John Sparks, D-Norman, also argued it would be difficult to obtain a certificate of merit since much of the information and evidence needed to render an opinion would not be available without first going through the discovery process. The two senators noted it was in medical malpractice cases where the affidavit might be most applicable. “People have access to their own medical records,” noted Sparks, adding the records could be reviewed by another doctor who could render the expert opinion. Coincidentally, that is how the affidavit of merit was first approved. A 2003 lawsuit reform compromise included provisions for an affidavit of merit only in medical malpractice cases. The Supreme Court, however, ultimately found it to be unconstitutional because it treated malpractice cases differently from other negligence cases, creating two classes of plaintiffs. The 2009 language expanded the affidavit’s application to all licensed service providers. During the debate, Burrage noted it had applied to doctors, architects and others. Sykes humorously noted it was applicable to tugboat drivers, as well. The bill and its emergency clause passed the Senate 32-11.

OOA Represented at PT Interim Study

OOA Trustee Timothy J. Moser, DO, spoke on behalf of osteopathic physicians at an interim study on Sept. 3 at the State Capitol. Interim study 2013-H13-006 was heard by the House Public Health Committee regarding direct patient access to physical therapy services. Rep. Arthur Hulbert, a physical therapist, authored the interim study. Dr. Moser reported to the committee that PT involvement in the health care delivery system is valued, but the physician must always be the team leader coordinating patient care and is the only qualified member for initial examination and patient diagnosis. It was also mentioned that potentially harmful patient outcomes could result by expanding the scope of practice for PTs beyond their education and training without appropriate supervision and oversight. The actual legislation regarding direct access for physical therapists, HB 1020, passed this same committee but is dormant. Currently, patients in Oklahoma must be referred to a physical therapist by a physician or thirdparty provider.

Oklahoma D.O. | October 2013

Insure Oklahoma Extended

On September 6th, Governor Mary Fallin announced the state of Oklahoma has negotiated a one year extension with the federal government for the Insure Oklahoma program. The program provides health insurance for nearly 30,000 working, low-income Oklahomans. It is funded by the state’s tobacco tax and matched with federal dollars. Earlier this year, the federal government announced it would not continue its support of Insure Oklahoma due to coverage limits and the state should expect the program to expire at the beginning of 2014. The popular program has been in existence since 2005. Officials with the Oklahoma Health Care Authority spent months in negotiations with their federal counterparts. “This is a big win for Oklahoma and the tens of thousands of adults and children who currently buy health insurance through Insure Oklahoma,” said Fallin. “These Oklahomans and their families can now rest easy knowing that they won’t lose their insurance on January 1.” Insure Oklahoma also serves approximately 4,600 small businesses, which rely on it for assistance in providing employer-sponsored insurance. “It’s been a success for tens of thousands of families of modest means, who would be uninsured without it,” said Fallin. It’s also been the beneficiary of popular support; the people of Oklahoma even voted on a 2004 ballot initiative to fund it through tobacco taxes. Moving forward, I strongly encourage our federal partners to review Insure Oklahoma’s many successes and announce their support for a permanent, ongoing program.”

Explanation of Insure Oklahoma Services and Future Changes

The employer-sponsored insurance (ESI) component of Insure Oklahoma is a82-0 premium assistance program Passed for the purchase of private market health insurance policies. The Oklahoma Health Care Authority sponsors 60% of the premium, participating employers pay at least 25% of the qualified employee’s monthly premiums, the employee pays no more than 15% of their health premium. The program also assists with premiums for the employee’s spouse. The ESI program will remain intact with no changes in 2014. The individual insurance component of the Insure Oklahoma is called the Individual Plan (IP). IP helps selfemployed individuals, unemployed individuals seeking work or employees working for small businesses that do not have access to group coverage. Effective January 1, IP qualification will be reduced from 200 percent of the Federal Poverty Level (FPL) to 100 percent of the FPL. Because of those changes, roughly 8,000 IP members will be released from Insure Oklahoma and will qualify for coverage through the federal Health Insurance Marketplace. Insure Oklahoma IP will also see some co-pay changes to meet certain federal requirements.

Oklahoma D.O.

Senate Democratic Leader Scott Burrage also expressed his support of the extension. “We are pleased and relieved to see that tens of thousands of hard-working Oklahomans won’t be forced to lose their health insurance at the end of this year. We applaud Gov. Fallin, the Obama administration, and the Oklahoma Health Care Authority for working together to find a solution – however temporary – that will ensure Oklahoma small businesses and hard-working Oklahomans will continue to have access to health insurance. We are thankful that the thousands of individuals who will no longer have access to insurance through Insure Oklahoma will be able to access the federal Health Insurance Marketplace set up through the Affordable Care Act. We hope that these groups will continue to work together towards a solution to Medicaid expansion in Oklahoma.” Governor Fallin’s office outlined the Insure Oklahoma program moving forward:

INSURE OK

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Oklahoma D.O. | October 2013

INSURE OK FACTS: The program has two options:

EMPLOYEE SPONSORED

UNDER THE EMPLOYEE SPONSORED INSURANCE (ESI) PROGRAM businesses can help provide commercial health insurance for their qualified employees. The premium costs are shared by the state and federal Medicaid program (60 percent), the employer (25 percent) and the employee (15 percent). As of August 2013, there were 4,600 small businesses participating and 16,000 members enrolled. • Qualified businesses have 99 or fewer employees, are located in Oklahoma and offer a qualified health plan. • Qualified ESI members work for a qualified business, reside in Oklahoma, are between the ages of 19 and 64 and have family income at or below 200 percent of the Federal Poverty Level ($47,100 annually for a family of four).

INDIVIDUAL PLAN

UNDER THE INDIVIDUAL PLAN (IP) people who do not have access to commercial health insurance through their employer, including those who are self-employed or may be temporarily unemployed, to buy health care coverage directly through the Oklahoma Health Care Authority. The premium costs are calculated based on the individual’s family income. As of August 2013, there were 13,300 members enrolled in this plan.

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Though the Insure Oklahoma program was set to expire December 31, 2013, the federal government has approved a request for a one year extension with certain modifications which are outlined below: • Agreement extends Insure Oklahoma through December 31, 2014 • No changes in Insure Oklahoma through December 31, 2013 • No changes in Insure Oklahoma ESI plan through December 31, 2014 • Changes in Insure Oklahoma IP plan, effective January 1, 2014 o To qualify, income must be at or below 100 percent of the Federal Poverty Level ($23,550 annually for a family of four). This is a change from the current qualification level of at or below 200 percent of the Federal Poverty Level ($47,100 annually for a family of four). There are currently about 5,300 individuals who are at or below 100 percent of the Federal Poverty Level enrolled in the Insure Oklahoma IP. o IP members will have the following co-payments for services • Pharmacy: $4 generic prescriptions and $8 brand prescriptions (decrease from $5 and $10, respectively) • Inpatient Hospital Services: $50 per stay (no change) • Outpatient Services and Physician Visits: $4 per visit (decrease from $10 - $25 range) • Emergency Room Services: $30 per visit (no change) o Those individuals above 100 percent of the Federal Poverty Level qualify for the federal Health Insurance Marketplace and related advance premium tax credits, which will be offered to individuals and families earning up to 400 percent of the Federal Poverty Level. There are currently about 8,000 individuals in this category currently enrolled in the Insure Oklahoma IP.

For more information, please visit www.insureoklahoma.org or call 1-888-365-3742. Oklahoma D.O. | October 2013

What DO’s Need To

KNOW

AOA's Response to 2014 Physician Fee Schedule Proposals In its comments on the 2014 Medicare Physician Fee Schedule proposed rule, the AOA commended the Centers for Medicare and Medicaid Services' (CMS) for its ongoing efforts to emphasize the value of primary care services. Complex Chronic Care Management Services: The AOA supports the agency's efforts to address complex chronic care services. We encourage CMS to set the payment rate for these services at a level that takes into account the infrastructure physicians will need to adopt in order to facilitate robust care coordination. We ask that the agency review the scope of services with small and rural practices in mind, and develop less burdensome requirements. Misvalued Physician Fee Schedule (PFS) Codes: CMS proposes to limit the non-facility PE Relative Values Units (RVUs) for individual codes so that the total non-facility PFS payment amount would not exceed the total combined amount Medicare would pay for the same code in the facility setting. The AOA is concerned that the proposed policy may lead to access problems for beneficiaries. The AOA requests a minimum one-year delay in implementing this proposal. Physician Compare Website: For 2014, CMS proposes to expand the quality measures posted on Physician Compare by publicly reporting performance on all measures collected through the GPRO web interface for groups of all sizes participating in 2014 under the PQRS GPRO and for ACOs participating in the Medicare Shared Savings Program (MSSP). The data reported in 2014 would include performance rates for measures that meet a minimum sample size of 20 patients, and that prove to be statistically valid and reliable. Overall, we oppose expanding the information reported on Physician Compare until CMS can ensure the accuracy of the underlying database, as well as performance calculations. Physician Quality Reporting System: The AOA appreciates the agency's efforts to better align program requirements across the PQRS, EHR Incentive Program, Medicare Shared Savings Program, and value-based payment modifier. While we commend CMS for its efforts to make revisions to the PQRS to ensure adherence to the highest standards of care over time, some of the proposed revisions may be problematic. We recommend that CMS scale back its reporting requirement. Osteopathic Manipulative Treatment: The AOA addressed global designation of Osteopathic Manipulative Treatment (OMT) CPT Codes 98925-98929. The AOA is calling on CMS to reverse the assigned global designation from 000 back to XXX to accurately reflect that OMT provided to patients is often on the same day as E/M services. The AOA is hopeful that the revised OMT global periods will appear in the Final Rule.

Oklahoma D.O. | October 2013

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USPSTF Releases Final Recommendation on PAD and CVD On September 3, the U.S. Preventive Services Task Force (USPSTF) released its final recommendation statement on screening for peripheral artery disease (PAD) and cardiovascular disease (CVD) risk assessment with the ankle-brachial index (ABI). The Task Force concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for PAD and CVD risk assessment with the ABI in asymptomatic adults (an I statement). This statement updates the Task Force’s 2005 recommendation against screening for PAD with the ABI in asymptomatic adults.

Oklahoma D.O.

HHS IG Releases Audit of Medicare Recovery Audit Contractors The Department of Health and Human Services’ Office of Inspector General (OIG) released a report on September 4 summarizing audit findings and recommendations of the Medicare Recovery Audit Contractor (RAC) program. The OIG found that in 2010 and 2011, RACs identified half of all claims they reviewed as having resulted in improper payments totaling $1.3 billion. Inpatient hospitals accounted for 88% of all recovered or returned improper payments, while physicians accounted for 5%. Providers did not appeal the RACs’ decisions for 94% of claims identified with overpayments, but of those that were appealed (6%), almost half were overturned. The OIG recommends that CMS evaluate the effectiveness of steps it took to address vulnerabilities identified by RACs, or else a high level of improper payments could continue to occur. IT also recommends that the agency develop better metrics to evaluate the effectiveness and performance of the RACs.

As a reminder, you can get more information on the Marketplace on the CMS websites: 1. HealthCare.gov: This is the consumer site and provides general information about the Marketplace and health insurance. Consumers can sign up for email and/or text message updates and create an account. o Spanish Site: https://www.cuidadodesalud.gov o For Small Business Health Options Program (SHOP): • https://www.healthcare.gov/small-businesses/ • SHOP Hotline: 1-800-706-7893 (Not for Consumers) 2. Marketplace.cms.gov: This is our partnership page and has a wide variety of tools and resources to help you help people prepare to apply, enroll and get coverage in 2014. Here you will find: • Census data on where the uninsured live—down to the PUMA level; • Widgets and badges you can use on your own websites; • Multimedia presentations explaining the Marketplace; • Downloadable Brochures, drop-in articles, and other information in English, Spanish, Russian, Tagalog, Chinese, Korean, and Vietnamese; • You can also sign up for updates. • Training: http://marketplace.cms.gov/training/get-training.html (Additional Information Below as updated in weekly Region VI Insider)

3. New Health Insurance Marketplace Call Center for Consumers:

1-800-318-2596

4. CMS Product Ordering Website (POW) for Partners: visit http://productordering.cms.hhs.gov

5. For future calls please check the Open Door Forum page for updates and information about calls that will occur throughout 2013.

6. Small Business Administration - http://www.sba.gov/healthcare

7. Department of Labor, Employment Benefits Security Administration - http://www.dol.gov/ebsa or call Toll Free 1-866-444- 3272

Oklahoma D.O. PAGE 30

8. HIM Partnership States: o Please check out the important Arkansas resources mentioned on the call today at www.ARHealthConnector.org or call Toll Free 1-855-283-3483 o Please check for important New Mexico updates and resources mentioned on the call today at http://www.nmhix.com

9. For a list of Navigator awardees or more information about Navigators and other in-person assisters, please visit: http://cciio. cms.gov/programs/exchanges/assistance.html

10. Let us know if you would like to find out more about partnering with CMS by completing our Parnter Interest Form @ https://healthinsurancemarketplacepartners.eventbrite.com/

11. Click here to learn more about organizations participating in Champions for Coverage: http://marketplace.cms.gov/help-us/ champions-for-coverage-list.pdf.

12. To become a Champion of Coverage, visit: http://marketplace.cms.gov/help-us/champion-apply.html.

“Influenza Vaccine Payment Allowances - Annual Update for 2013-2014 Season” MLN Matters® Article — Released MLN Matters® Special Edition Article #MM8433, “Influenza Vaccine Payment Allowances - Annual Update for 2013-2014 Season,” was released and is now available in downloadable format. This article is designed to provide education on updated payment allowances for seasonal influenza virus vaccines when payment is based on 95 percent of the Average Wholesale Price, as outlined in Change Request 8433. It includes updated information about post-payment limits for influenza vaccines. “Same Day Billing for Mental Health Services and Primary Care Services” Fact Sheet — Released The “Same Day Billing for Mental Health Services and Primary Care Services” Fact Sheet (ICN 908978) was released and is now available in text-only format. This fact sheet is designed to provide education on same day billing for mental health services and primary care services. It includes same day billing guidelines and information about the National Correct Coding Initiative. Oklahoma D.O. | October 2013

The J

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Oklahoma D.O. | October 2013

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PLEASE RETURN FORM BY MAIL OR FAX MAIL: FAX TO: 4848 N. Lincoln Blvd. (405) 528-6102 Oklahoma City, OK 73105-3335

Oklahoma D.O.

City: _____________________________________ State: _______ Zip: _________________

OPIOID PRESCRIBING ///

GUIDELINES FOR OKLAHOMA EMERGENCY DEPARTMENTS (ED) AND URGENT CARE CLINICS (UCC) Opioid Prescribing Guidelines for Oklahoma Workgroup Brandenburg MA, Subera LE, Doran-Redus A, Archer P

1. Consider opioid medications for the treatment of acute pain only when the severity of the pain is reasonably assumed to warrant their use.

8. Long-acting or controlled-release opioids (such as OxyContin®, fentanyl patches, suboxone, and methadone) should not be prescribed from the ED/UCC.

2. When administering or prescribing opioids, it is suggested that health care providers start with the lowest possible effective dose for the management of pain.

9. For exacerbations of chronic pain, it is suggested that the emergency health care provider attempt to notify the patient’s primary opioid prescriber that the patient is under evaluation at the ED/ UCC. The emergency health care provider should only prescribe enough pills to last until the office of the patient’s primary opioid prescriber opens.

Oklahoma D.O. PAGE 32

10. The administration of intravenous and intramuscular opioids for the relief of exacerbations of chronic pain is discouraged, except in special circumstances. 11. Always consider risk factors for respiratory depression when prescribing opioids. Use caution when prescribing opioid medications to patients currently taking benzodiazepines and/or other opioids.

5. In patients suspected of opioid addiction, abuse, or diversion, health care providers should check the Oklahoma PMP and perform screening, brief intervention, and referral to treatment, if indicated.

12. Provide information about opioid medications to patients receiving an opioid prescription, such as the risks of overdose and addiction, as well as safe storage and proper disposal of unused medications.

6. In patients who routinely take opioids for chronic pain, it is ideal that one health care provider provide all opioid prescriptions, with rare exception. When an exception occurs and another provider deems it necessary to prescribe opioids (i.e., a new, acute injury or objectively diagnosed disease process/injury), Oklahoma PMP data should be reviewed, and only enough pills prescribed, if indicated, to last until the office of the patient’s primary opioid prescriber opens.

13. Health care providers are encouraged to consider non-pharmacological therapies and/or referral to specialists for followup, as clinically appropriate.

7. Health care providers should not provide replacement prescriptions for lost, destroyed or stolen controlled substances.

14. EDs/UCCs should maintain a list of local primary care and mental health clinics that provide follow-up care for patients of all payer types. 15. Emergency health care providers are required by law to evaluate an ED patient who reports pain. The law allows emergency providers to use their clinical judgment when treating pain and does not require the use of opioids when the risks of opioid therapy outweigh the benefits. Oklahoma D.O. | October 2013

BACKGROUND

Prescription drug abuse is Oklahoma’s fastest growing drug problem. Of the nearly 3,200 unintentional poisoning deaths in Oklahoma from 2007-2011, 81% involved at least one prescription drug.1 In 2010, Oklahoma had the fourth highest unintentional poisoning death rate in the nation (17.9 deaths per 100,000 population).2 Prescription painkillers (opioids) are now the most common class of drug involved in overdose deaths in Oklahoma (involved in 87% of prescription drug-related deaths, with 417 opioid-involved overdose deaths in 2011).1 In a 2010 National Survey on Drug Use and Health report, Oklahoma led the nation in non-medical use of painkillers, with more than 8% of the population age 12 and older abusing/ misusing painkillers.3 Oklahoma is also one of the leading states in prescription painkiller sales per capita.4 These guidelines were primarily taken and adapted from the opioid prescribing guidelines of Washington and New York City.5, 6 The Opioid Prescribing Guidelines for Oklahoma Workgroup reviewed and discussed each recommendation in the Washington and New York City ED guidelines in the process of selecting those guidelines most relevant to the practice of medicine in Oklahoma. Guidelines for prescribing opioids for health care providers, from Utah and Ohio were also reviewed by Workgroup members.7,8 The Workgroup created these guidelines in 2013 to help reduce the misuse of prescription opioid analgesics while preserving and supporting the vital role of the Emergency Department (ED) and Urgent Care Clinic (UCC) provider to treat patients with emergent medical conditions. The definition of UCC, for the purpose of these guidelines, does not include those patient-physician encounters in which longitudinal, either primary or ongoing specialty, care is being provided. It is recognized that some UCCs also have longitudinal medical clinics within the same workspace, or in close proximity, and it is not the intention of these guidelines to address patient-physician encounters more closely related to longitudinal care than otherwise. A second set of guidelines for office-based practice of medicine will be forthcoming.

gesics and acetaminophen, caution the patient about the maximum dose of acetaminophen they should take to avoid toxicity. Risks and benefits, patient allergies, and potential adverse reactions should be considered before using any analgesic medication or modality. The resources of both the patient and the hospital should likewise be considered when determining the best options for treating a patient’s pain. The federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide a med ical screening examination to determine whether an individual presenting to an ED has an emergency medical condition. If the hospital determines that a patient has an emer gency medical condition, the hospital must provide treatment as may be required to stabilize the patient’s medical condition.9 EMTALA, however, does not require the use of opioid analgesics to treat pain. ED/UCC providers may apply their professional judgment to determine whether prescribing opioid analgesics for pain is the appropriate course of treatment. Providers should document various therapies considered for their treatment plan, including risks and benefits.

2. When administering or prescribing opioids, it is suggested that health care providers start with the lowest possible effective dose for the management of pain.

If opioid analgesics are considered for the management of pain after patient discharge from the ED/UCC, start with the lowest possible effective dose. Higher doses increase the risk of adverse events such as respiratory depression and overdose.10,11, 12 These risks are especially pronounced for opioid-naïve patients.

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Oklahoma D.O.

3. When prescribing opioids for acute pain, prescribe no more than a short course, except in special circumstances. Most patients require opioids for no more than three days of pain control, with a maximum of 30 pills in most RECOMMENDATIONS cases. 1. Consider opioid medications for the treatment of acute Excessive quantities of opioid analgesics increase the risk pain only when the severity of the pain is reasonably as- of misuse, abuse, or diversion. In addition, initiation of sumed to warrant their use. opioid analgesic therapy in opioid-naïve patients may lead to inappropriate long-term use.13 For most patients with Opioid analgesics should not be considered the primary acute pain, a three-day supply is generally sufficient. When approach to pain management in patients being discharged considering the quantity of pills prescribed, it is important from the ED/UCC. Alternative and effective pharmacolo to take as-needed dosing into account. For example, a pa- gical interventions for acute pain exist, including non- tient taking opioid analgesics “every six hours as needed for steroidal anti-inflammatory drugs (NSAIDs), acetamino- pain” may need only one or two doses a day. There may be phen, and nerve blocks (e.g., for dental pain). Non-pharma- some acute conditions (e.g. rib fractures) for which severe cological therapies, such as fracture immobilization, may pain is expected to last more than three days and for which obviate the need for additional pain medications. Shortrisks of inadequate pain control may exceed risks of a longer acting opioid analgesics such as hydrocodone, immediate- supply of opioids. However, if the patient’s acutely painful release oxycodone, and hydromorphone may be prescribed condition outlasts a three-day supply of opioid medication, as adjuncts to relieve acute pain when the severity of the a re-evaluation of the condition is likely to be beneficial. pain warrants their use. They also may be prescribed when Consider expediting follow-up care if the patient’s condi- non-opioid therapies have not or are reasonably presumed tion is expected to require more than a three-day supply of to not provide adequate relief from pain.7 When prescrib- opioid analgesics. If follow-up care cannot be expedited, the ing combination preparations of prescription opioid anal

three-day limit may need to be minimally extended to allow the patient time to see their primary care provider.

4. Providers should query the Oklahoma Prescription Monitoring Program (PMP) for patients presenting with acute pain, prior to prescribing opioid medication. (In circumstances where a patient’s pain is resulting from an objectively diagnosed disease process or injury, a clinician may prudently opt not to review the Oklahoma PMP.) The PMP is a real-time database of scheduled prescriptions written to persons who filled a prescription in Oklahoma. The PMP can be accessed at http://www.ok.gov/obndd/ Prescription_Monitoring_Program/.

Oklahoma D.O. PAGE 34

Patients with a history of or current substance abuse are at increased risk of misusing opioids when prescribed.14,15 Emergency medical providers should ask the patient about a history of substance abuse prior to prescribing opioid medication for the treatment of acute pain. A non-opioid regimen can be offered to ED/UCC patients with acute pain and a history of substance abuse. A history of or current substance abuse should not exclude an ED/UCC patient from being prescribed opioids for acute pain, but it might prompt a discussion with the patient about the potential for addiction. When a patient with a history of opioid addiction presents with acute pain due to an objectively diagnosed clinical or traumatic condition requiring the use of opioids for pain control, very close follow-up is indicated, as the patient is at high risk for misusing opioid medi cations. The patient’s primary care provider should also be notified, if possible, of the patient’s treatment. Emergen- cy medical providers wishing to perform more extensive screening for the risk of opioid addiction are encouraged to use tools such as the Opioid Risk Tool.16 5. In patients suspected of opioid addiction, abuse, or diversion, health care providers should check the Oklahoma PMP and perform screening, brief intervention, and referral to treatment, if indicated.

Screening, brief intervention, and referral to treatment (SBIRT) has been shown effective in providing brief intervention, brief therapy and treatment referral to substance abusers who frequent EDs/UCCs, with substantial declines in illicit drug abuse.17 Among high-risk users of prescription opioids in Washington, at six-month follow-up, there was a 41% reduction in days of drug use (from 12.8 to 7.5 days) for individuals who received only a brief intervention, and a 54% reduction (from 14.4 days to 6.6 days) for individuals who received a brief intervention, followed by brief therapy or chemical dependency treatment.17 With proper training, brief interventions can be delivered in the ED/UCC by nurses, case managers, crisis counselors, social workers, or a chemical dependency professional. The 2010 National Drug Control Strategy recommends expansion of brief interventions in health care settings.18

Patients often find themselves in the ED/UCC after their dependence or addiction has led them to a turning point in

their life, such as a traumatic event or “hitting rock bot- tom.” Without immediate intervention the patient can easily fall back into addiction. The ED/UCC should maintain an easy to understand guide on local addiction recovery resources, including all payer types. 6. In patients who routinely take opioids for chronic pain, it is ideal that one health care provider provide all opioid prescriptions, with rare exception. When an exception occurs and another provider deems it necessary to prescribe opioids (i.e., a new, acute injury or objectively diagnosed disease process/injury), the Oklahoma PMP data should be reviewed, and only enough pills prescribed, if indicated, to last until the office of the patient’s primary opioid prescriber opens.

The emergency health care provider is not in a position to monitor the effects of chronic opioid therapy and therefore should not prescribe opioids for the treatment of chronic pain. Repeated prescribing of opioids from the ED/UCC is a counter-therapeutic, enabling action that delays patients from seeking appropriate pain control and monitoring.

Guidelines for the treatment of chronic pain from the Washington State Agency Medical Directors Group and the Medical Quality Assurance Commission recommend that all pain medicine be prescribed by one practitioner.19,20 The American Pain Society’s guidelines recommend that all patients on chronic opioid therapy should have only one clinician who accepts primary responsibility for their overall medical care.10

Prescribing opioids from the ED/UCC to patients with chronic pain should usually be limited to those situations in which the existence of acute pain can be attributed to a disease process or traumatic injury diagnosed with objective evidence. Opioid treatment of patients with chronic pain requires close monitoring of the patient’s pain and functioning. The emergency medical provider is not capable of providing this monitoring. The absence of prescription opioid monitoring places the patient at risk for harm from excess or unnecessary amounts of these medications. The ED/ UCC provider’s one-time relationship with the patient does not allow proper monitoring of the patient’s response to chronic opioid therapy.

7. Health care providers should not provide replacement prescriptions for lost, destroyed or stolen controlled substances. Patients misusing controlled substances frequently report their opioid medications as having been lost or stolen. Pain specialists routinely stipulate in pain agreements with patients that lost or stolen controlled substances will not be replaced. Most written agreements between chronic pain patients and pain management physicians, including the Health Resources and Services Administration (HRSA) toolkit sample pain agreement, state that prescriptions for opioids will not be replaced. EDs/UCCs should institute policies not to replace opioid prescriptions when lost, stolen, or destroyed.21 Oklahoma D.O. | October 2013

reinforces the idea that patients should obtain pain medicine only from the primary opioid pro vider. 2. Only enough opioid pain medication is prescribed to last until the patient can contact their primary prescriber, with a maximum of a three-day supply of opioids (rather than a quantity sufficient to last until the patient’s next scheduled appointment). 3. If the primary opioid provider cannot be reached, then the Oklahoma PMP should be queried. The ED/UCC provider should confirm that recent Methadone and/or suboxone should not be prescribed or opioid prescriptions reported by the PMP match administered as opioid substitution therapy from the ED/ what the patient reports. If the Oklahoma PMP UCC. Methadone and suboxone have a long half-life, and reveals recent opioid prescriptions from multiple patients who are part of a daily methadone or suboxone prescribers, the provider should not prescribe an treatment program that miss a single dose, will not go into opioid. Likewise, no opioids should be prescribed opioid withdrawal for 48 hours. Opioid withdrawal, by if the patient misrepresents a personal history of itself, is not an emergency medical condition. The opioid use; providing false information in an ef- emergency health care provider should consider the possi- fort to obtain prescription opioids is behavior that bility that the patient may have been discharged from a can signal opioid addiction or misuse. methadone or suboxone treatment program for noncom pliance or is not enrolled. The emergency health care pro- Urine drug testing for illicit and prescribed substances re- vider or admitting provider should call the methadone or quires a working knowledge of the potential for false posi- suboxone treatment program if the patient is admitted tive and false negative results and the need for confirmatory to the hospital. The patient’s status in the methadone or testing. A discussion on the limitations of urine testing is suboxone treatment program should be verified and the beyond the scope of these guidelines. Other chronic pain patient’s methadone or suboxone dose should be document- guidelines address urine drug testing in detail.19 Urine ed for continued dosing while hospitalized. drug testing has the potential to identify patients using illicit drugs or not taking medications they report being pre- 9. For exacerbations of chronic pain, it is suggested that scribed. Both of these situations are grounds for denying the emergency health care provider attempt to notify the further opioid prescriptions. Clinicians knowledgeable in patient’s primary opioid prescriber that the patient is interpretation of urine drug testing results are encouraged under evaluation at the ED/UCC. The emergency health to perform urine drug tests before prescribing opioids for care provider should only prescribe enough pills to last exacerbations of chronic pain. until the office of the patient’s primary opioid prescriber opens. 10. The administration of intravenous and intramuscular opioids for the relief of exacerbations of chronic pain is Opioid prescriptions for exacerbations of chronic pain from discouraged, except in special circumstances. the ED/UCC are discouraged. Chronic pain patients should obtain opioid prescriptions from a single opioid Parenteral opioids should be avoided for the treatment of prescriber who monitors the patient’s pain relief and func- chronic pain in the ED/UCC because of their short dura- tioning. Prescribing pain medicine from the ED/UCC for tion and potential for addictive euphoria. Generally, oral chronic pain represents unmonitored opioid therapy, which opioids are superior to parenteral opioids in duration of is not safe. action and provide a gradual decrease in the level of pain control. When there is evidence or reasonable suspicion The emergency medical provider should attempt to contact of an acute pathological process causing the acute exacer- the primary opioid prescriber prior to prescribing any opi- bation of chronic pain then parenteral opioids may be ap- oids. If the patient’s primary opioid provider feels further propriate. Under special circumstances, some patients may opioid pain medicine is appropriate, it can be prescribed receive intravenous or intramuscular opioids in the ED/ by that provider during office hours. In exceptional circum- UCC when this treatment plan is coordinated with the pa- stances, although it should not be expected and is not re- tient’s primary care provider. quired, the emergency medical provider may choose to prescribe opioid medication for acute exacerbations of 11. Always consider risk factors for respiratory depression chronic pain, when the following safeguards are followed: when prescribing opioids. Use caution when prescribing 1. The patient’s primary opioid prescriber is contact- opioid medications to patients currently taking benzodi ed first to approve further opioids for the patient. azepines and/or other opioids. If approved, a limited prescription can be pre Opioid analgesics, when combined with other central scribed from the ED/UCC to last until the patient nervous system depressants or given to patients with cer is able to see their primary opioid prescriber. This 8. Long-acting or controlled-release opioids (such as Oxy Contin®, fentanyl patches, suboxone, and methadone) should not be prescribed from the ED/UCC. Long-acting opioids should not be prescribed from the ED/ UCC because this treatment requires monitoring which the emergency medical provider cannot provide. Methadone and oxycodone are known to be associated with higher incidences of overdose death than any other prescription opioid.22

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tain underlying medical conditions, can increase the risk for overdose, especially in older patients. Avoid the combination of benzodiazepines and opioid analgesics as much as possible.10 In Oklahoma, about one-third of unintentional opioid overdose deaths involve a benzodiaz- epine, most commonly alprazolam (Xanax®).1 In addition, patients taking higher doses of opioids, including cumula- tive doses from more than one source, are at higher risk for respiratory depression. The Centers for Disease Control and Prevention estimates that the 20% of patients receiving opioids who were prescribed a combination of 100 or more morphine equivalents per day account for 80% of opioid overdoses, with half of these among patients with opioids from more than one prescriber.23 Opioid analgesics should be used with caution in older patients and those with sleepdisordered breathing, such as obstructive sleep apnea, obesity, or congestive heart failure.24 Doses may have to be ad justed in patients with renal or liver disease due to decreased clearance of the drug.

Patients should be informed of the risks of taking opioid analgesics and be reminded to take them as prescribed, not more frequently or in greater quantities. Risks of opioid an algesics include, but are not limited to: overdose that can slow or stop their breathing and even lead to death; fractures from falls in patients aged 60 years and older; drowsiness leading to injury; tolerance; and dependence. Respi - ratory depression is more common with use of alcohol, benzodiazepines, antihistamines, and barbiturates. Patients should be reminded to avoid medications that are not part of their treatment plan because they may worsen side effects and increase the risk of overdose.

Nearly three-fourths (71%) of people aged 12 and older who have used opioid analgesics for non-medical purposes reported obtaining them for free or buying them from family or friends.3 Patients should be told how to minimize risks to others by keeping their medication in a secure location, preferably locked; not sharing medication with anyone; and promptly disposing of unused opioids.

13. Health care providers are encouraged to consider non-pharmacological therapies and/or referral to specialists for follow-up, as clinically appropriate.

Opioids are just one of the numerous, therapeutic pain control options for most causes of chronic illness or injury. Opioid prescriptions from the ED/UCC for exacerbation or progression of chronic pain, not associated with palliative/end of life care, are discouraged in general. Patients with chronic pain who require opioid analgesics should obtain opioid prescriptions from a single prescriber who monitors the patient’s pain relief and function. Prescribing opioid analgesics from the ED/UCC for chronic pain is a form of unmonitored opioid therapy that is not optimal for patient care. In exceptional circumstances, the provider may

consider prescribing short-acting opioid analgesics for patients with acute worsening of chronic pain. Similarly, changing the opioid a patient is using chronically in an effort to improve pain relief (i.e., opioid rotation) is complicated and generally should not be done in the ED/UCC.25 14. EDs/UCCs should maintain a list of local primary care and mental health clinics that provide follow-up care for patients of all payer types. EDs/UCCs should encourage patients to seek primary care in non-emergent care settings. ED/UCC providers and staff should counsel over-utilizing patients on appropriate venues for their symptoms and provide patients with an up- to-date list of clinic resources. The emergency health care provider should not feel compelled to prescribe opioids due to the patient’s lack of a primary care provider.

15. Emergency health care providers are required by law to evaluate an ED patient who reports pain. The law allows emergency providers to use their clinical judgment when treating pain and does not require the use of opioids when the risks of opioid therapy outweigh the benefits. The Emergency Medical Treatment and Active Labor Act (EMTALA) does not require the emergency health care pro vider to provide pain relief for patients who do not have an emergency medical condition. Once a medical screening exam determines that a patient does not have an emergency medical condition, there is no obligation under EMTALA to treat a patient’s pain in the ED. The EMTALA definition of a medical emergency makes reference to severe pain as a symptom that should be investigated that may be resul- tant to an emergency medical condition. EMTALA does not state that severe pain is an emergency medical condition. The Center for Medicare Services (CMS) requires the hospital to have policies for assessing a patient’s pain and documenting the assessment. EMTALA does not obstruct the emergency health care provider from applying their professional judgment to withhold opioid treatment of pain for ED/UCC patients without an emergency medical condition.

Emergency health care providers working in EDs/UCCs should be supported by administrators when opioids are not administered or prescribed because prudent, clinical judgment dictates that the risks of opioid therapy outweigh the benefits.

Oklahoma D.O. | October 2013

OPIOID PRESCRIBING ///

GUIDELINES FOR OKLAHOMA WORKGROUP MEMBERS Mark Brandenburg, M.D., FACEP, FAAEM, Emergency Physician (Workgroup Chair)

Oklahoma Injury Prevention Advisory Committee

Pam Archer, M.P.H.

Oklahoma State Department of Health

Deborah Bruce, J.D.

Oklahoma State Board of Osteopathic Examiners

Larry Carter

Oklahoma Bureau of Narcotics and Dangerous Drugs Control

Laura Clarkson Board of Nursing Patti Davis Oklahoma Hospital Association John Foust, Pharm.D., D.Ph.

Oklahoma State Board of Pharmacy

Eric Frische, M.D.

Oklahoma Board of Medical Licensure and Supervision

Cecilia Guthrie, M.D., FAAP

Oklahoma Chapter of American College of Emergency Physicians

Jessica Hawkins

Oklahoma Department of Mental Health and Substance Abuse Services

Mike Herndon, D.O.

Oklahoma Health Care Authority

Timothy Hill, Ph.D., M.D., FACEP

Oklahoma Chapter of American College of Emergency Physicians

Lyle Kelsey, M.B.A., CMBE

Oklahoma Board of Medical Licensure and Supervision

Cathy Kirkpatrick

Oklahoma State Board of Veterinary Medical Examiners

Rachel Mack, DNP, APRN, C-NP

Oklahoma City University Kramer School of Nursing

Heidi Malling, M.D.

University of Oklahoma Health Sciences Center

Dan McNeill, PA-C, Ph.D.

Physician Assistant

Claire Nguyen, M.S.

Oklahoma State Department of Health

Young Onuorah

Oklahoma Department of Mental Health and Substance Abuse Services

Tracie Patten, Pharm.D.

Indian Health Service

Laura Petty, D.Ph. Pharmacist Oklahoma State Department of Health

Susan Rogers, J.D.

Oklahoma Board of Dentistry

Marie Schuble

Oklahoma Bureau of Narcotics and Dangerous Drugs Control

Layne Subera, D.O., FACOFP

Oklahoma Osteopathic Association

Mark Woodward

Oklahoma Bureau of Narcotics and Dangerous Drugs Control

Oklahoma D.O.

Avy Redus, M.S.

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Oklahoma D.O. | October 2013

ORGANIZATIONS ///

ENDORSING THESE GUIDELINES

Oklahoma Chapter American College of Emergency Physicians Oklahoma Osteopathic Association Oklahoma State Medical Association Pharmacy Providers of Oklahoma Oklahoma Society of Interventional Pain Physicians Oklahoma Hospital Association Oklahoma Board of Nursing Oklahoma State Society of the American College of Osteopathic Family Physicians Oklahoma Pharmacists Association

ADDITIONAL ORGANIZATIONS ///

REPRESENTED ON THE WORKGROUP Oklahoma State Department of Health Oklahoma State Board of Osteopathic Examiners Oklahoma Bureau of Narcotics and Dangerous Drugs Control Oklahoma State Board of Pharmacy Oklahoma Board of Medical Licensure and Supervision Oklahoma Department of Mental Health and Substance Abuse Services Oklahoma Health Care Authority Oklahoma State Board of Veterinary Medical Examiners Indian Health Service Oklahoma Board of Dentistry

OPIOID PRESCRIBING ///

GUIDELINES FOR OKLAHOMA

Oklahoma D.O. PAGE 38

Acknowledgments The Workgroup members would like to acknowledge and thank the Washington State Department of Health, Utah Department of Health, Ohio Department of Health, and the New York City Department of Health and Mental Hygiene for their work in the area of opioid prescribing, and willingness to share and collaborate with our Workgroup. Support Supported in part by the Preventive Health and Health Services Block Grant (2B01DP009043-12) from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. The contents are the sole responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Disclaimer These guidelines should be considered by clinicians, hospitals, administrators, public health entities, and other relevant stakeholders. The recommendations are an educational tool based on the expert opinion of numerous physicians and other health care providers, medical/nursing boards, mental and public health officials, and law enforcement personnel throughout the United States and in Oklahoma. These guidelines are not meant for patients in palliative care programs or with cancer pain. This document should not be used to establish any standard of care or legislation. No legal proceeding, including medical malpractice proceedings or disciplinary hearings, should reference a deviation from any part of this document as constituting a breach of professional conduct. Clinicians should use their own clinical judgment and not base clinical decisions solely on this document. The recommendations are not founded in evidence-based research but are based on promising interventions and expert opinion. Additional research is needed to understand the impact of these interventions on decreasing unintentional drug poisoning and on health care costs. Oklahoma D.O. | October 2013

REFERENCES /// 1. Oklahoma State Department of Health, Injury Prevention Service. Unintentional Poisoning Fatality Surveillance System. [Data file]. 2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) 2012 Retrieved from http://webappa.cdc.gov/sasweb/ncipc/dataRestriction_inj.html. Accessed September 11, 2013. 3. Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health. 2010 Retrieved from http://oas.samhsa.gov/2k8state/AppB.htm. Accessed September 11, 2013. 4. Centers for Disease Control and Prevention. Prescription Painkiller Overdoses in the U.S. 2011 Retrieved from http://www.cdc.gov/vitalsigns/painkil leroverdoses/. Accessed September 10, 2013. 5. Washington State Department of Health. (n.d.). Washington Emergency Department Opioid Prescribing Guidelines. Retrieved from http://washingtona cep.org/Postings/edopioidabuseguidelinesfinal.pdf. Accessed September 10, 2013. 6. The New York City Department of Health and Mental Hygiene. (n.d.). New York City Emergency Department Discharge Opioid Prescribing Guidelines. Retrieved from http://www.nyc.gov/html/doh/downloads/pdf/basas/opioid-prescribing-guidelines.pdf . Accessed September 10, 2013. 7. Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioid Analgesics for Treatment of Pain. 2009 Retrieved from http://health.utah. gov/prescription/pdf/guidelines/final.04.09opioidGuidlines.pdf. Accessed September 10, 2013. 8. Ohio Department of Health (n.d.). Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances (OOCS) Prescribing Guidelines. Retrieved from http://www.healthyohioprogram.org/ed/~/media/7496C0B75BD740E7A6BBF57306DF1E22.ashx . Accessed September 10, 2013. 9. Centers for Medicare and Medicaid Services. Emergency Medical Treatment and Labor Law Act (EMTALA). 1986 Retrieved from https://www.cms.gov/ EMTALA . Accessed September 10, 2013. 10. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid pain therapy in chronic noncancer pain. J of Pain 2009;10(2):113130. 11. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann of Int Med 2010;152(2):85-92. 12. Bohnert AS, Valenstein M, Blair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA2011;305(13):1315-1321. 13. Alam A, Gomes T, Zheng H, et al. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch of Int Med 2012;172(5):425-430. 14. Braden J, Russo J, Fan M, et al. Emergency department visits among recipients of chronic opioid therapy. Arch of Int Med 2010;70(16):1425-1432. 15. Edlund MJ, Fan M, DeVries A, et al. Trends in use of opioids for chronic non-cancer pain among individuals with mental health and substance use disorders: the TROUP study. Clin J of Pain 2010;26:1-8. 16. Partners Against Pain. Opioid Risk Tool. 2013 Retrieved from http://www.partnersagainstpain.com/printouts/Opioid_Risk_Tool.pdf. Accessed on September 10, 2013. 17. Washington State Department of Social and Health Services. Washington State Screening, Brief Intervention, Referral and Treatment Project. 2008 Retrieved from http://www.dshs.wa.gov/pdf/dbhr/WASBIRTPrelim091908.pdf. Accessed on September 10, 2013. 18. Office of National Drug Control Policy. National Strategy. 2010 Retrieved from http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/ ndcs2010_0.pdf. Accessed on September 10, 2013. 19. Agency Medical Director’s Group. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. 2010 Retrieved from http://www.agencymed directors.wa.gov/Files/OpioidGdline.pdf. Accessed on September 10, 2013. 20. Washington State Department of Health, Medical Quality Assurance Commission. 2011. Adopted Pain Management Rules, May 2011 (effective 1/2/12). Retrieved from http://apps.leg.wa.gov/WAC/default.aspx?cite=246-919-850. Accessed on September 10, 2013.

22. Centers for Disease Control and Prevention. Poisoning in the United States – Issue Brief. 2010 Retrieved from http://www.cdc.gov/homeandrecreational safety/rxbrief/. Accessed on April 19, 2013 23. Centers for Disease Control and Prevention. CDC Grand Rounds: Prescription Drug Overdoses – a U.S. Epidemic. MMWR 2012;61(01):10-13 (January 13, 2012). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm. Accessed on September 10, 2013.

25. Webster LR, Fine PG. Review and critique of opioid rotation practices and associated risks of toxicity. Pain Med 2012;13(4):562-70.

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24. Yue HJ, Guilleminault C. Opioid medication and sleep-disordered breathing. Med Clin of N Amer 2010;95:435-446.

Oklahoma D.O.

21. Washington State Health Care Authority. 2009. HRSA Toolkit. Retrieved from http://www.hca.wa.gov/medicaid/pharmacy/pages/toolkit.aspx. Accessed on September 10, 2013.

St. Anthony Family Medicine Residency 1000 N. Lee Oklahoma City, OK 73101

What Are The Appropriate Treatments of Proctalgia Fugax and Chronic Proctalgia and Are These Treatment Modalities Founded on Solid Evidence? DeKoda Bost, DO Family Medicine Resident, PGY-II Saint Anthony Residency Gregg Eichman, DO Faculty Mentor Saint Anthony Residency

Oklahoma D.O. PAGE 40

Toney L. Welborn, MD, MPH, MS Faculty Mentor Saint Anthony Residency Answer: Inconclusive Level of Evidence for the Answer: C Search Terms: Proctodynia, chronic proctalgia, proctalgia fugax, levator ani syndrome Date Search was conducted: February 26, 2013 Inclusion and Exclusion Criteria: Inclusion Criteria: case studies, randomized controlled trials, review articles, English language Exclusion Criteria: non-English language articles/reviews 7 articles reviewed, 5 used Summary of the Issues: Proctodynia is defined as severe rectal and sacrococcygeal pain caused by spasm of the pubococcygeus or levator ani muscles. It is further subdivided into two categories, proctalgia fugax and chronic proctalgia. Differentiation is made by the fact that proctalgia fugax is more of a severe, episodic type pain that lasts less than 20 minutes while chron-

ic proctalgia (also known as levator ani syndrome (LAS)) is more of a chronic or recurrent rectal pain with episodes lasting greater than 20 minutes.1 Unfortunately, proctalgia fugax and chronic proctalgia are largely underreported. Reportedly, proctalgia fugax is estimated to affect 4-18% of the general population, with a slight edge towards female predominance, with only 17-20% actually reporting their symptoms to their primary care physician. Fortunately, the pathophysiology and diagnostic measuring tools are similar for both as are potential treatment modalities. Formerly, it was thought these pain symptoms were due to the external anal sphincter and the striated muscle components of the sphincter, but newer theories have focused more on the smooth muscle portion of the internal anal sphincter. Limited studies have shown through anorectal manometry that patients with this disorder show a slightly increased resting anal pressure. An inherited form of proctalgia fugax has been identified. Pudendal nerve compression has also been shown to be a potential cause for proctalgia fugax. However this literature review will focus on potential treatment modalities and not go in depth on different types of the disease processes in great detail.1 Unfortunately, treatment guidelines are not based on limited clinical trials and therefore primary care physicians are left with choosing therapies with insufficient evidence. This literature review will focus on studies and reviews identified as possible treatment modalities including topical amitriptylineâ&#x20AC;&#x201C;ketamine, botulinum toxin injections, biofeedback/ electrogalvanic stimulation (EGS)/ digital massage, and cyclobenzaprine.

Summary of the Evidence: Davis et al.2 designed a retrospective study to evaluate the efficacy of topical amitriptylineâ&#x20AC;&#x201C;ketamine for perineal pain. The thought was this compound was typically used for various types of neuropathic pain so it might have some beneficial effects for refractory proctalgia. Chart review revealed numerous patients receive this compound for neuropathic type pain but a small subset had it prescribed specifically for genital/ rectal/perineal pain. After reviewing all potential patients medical records, only 13 met criteria for the study. The study admitted its numerous short comings, most notably a small patient sample but of the 13 patients, one had complete relief, six had substantial relief, four had some relief and two had no response. Resulting in 85% of participants reporting some level of symptom relief.2 Mata et al.3 designed a randomized, double-blinded, placebo-controlled crossover study to determine the efficacy and safety of botulinum toxin on chronic proctalgia. The study included overall pain intensity scores, anal sphincter pressures, pudendal nerve terminal motor latency, rectal sensory thresholds (threshold for desire to defecate), balloon expulsion test (time required to expel small balloon filled with saline), saline continence test (rectal saline retention), and anal endosonography. As with most other studies, the major limitation was small sample sizes. Twelve patients started the study, while only seven patients completed the study. Protocol included 25 units of botulinum toxin (total 100 units) being injected into each of four pre-chosen quadrants of the internal anal sphincter. The parameters that the study Oklahoma D.O. | October 2013

was designed to evaluate (as listed above) consistently demonstrated no clinically significant improvements. Therefore, the study was terminated early.3 The journal Gastroenterology4 reported a prospective, randomized controlled trial to compare the effectiveness of biofeedback (teaching pelvic floor relaxation techniques), EGS, and massage of the levator muscles. The first goal was to identify which treatments yielded greatest clinical benefit; second was to determine whether clinical benefits were sustained for at least one year; third was to determine if any physiological measures changed with treatment; and fourth was to identify patient characteristics to predict who is most likely to benefit from the above treatments. Patients all fit the Rome III criteria for LAS, but they were further divided into either “highly likely” of having LAS as reported by tenderness on palpation of the levator ani muscles or only “possible” of having LAS if they had an absence of tenderness. Among patients with “high likely” LAS, 87% experienced adequate relief via biofeedback, 45% with EGS, and 20% with digital massage. Number of pain days per month decreased from 14.7 at baseline to 3.3 after biofeedback, 8.9 after EGS, and 13.3 after digital massage. Pain intensity decreased from 6.8 at baseline to 1.8 after biofeedback, 4.7 after EGS, and 6.0 after digital massage (based on a 10-point scale). The patient's that had a “possible” diagnosis of LAS did not benefit from any treatment. Based on the items studied and compared here, biofeedback was superior to EGS, and EGS was superior to digital massage.4

2. Davis, MD, M., et al. (2012). Topical amitriptyline-ketamine for treatment of rectal, genital, and perineal pain and discomfort. Pain Physician 2012, 15, 485-488. Retrieved from http://www.painphysicianjournal.com/2012/december/2012;15;485-488. pdf 3. Mata, M., et al. (2009). Clinical trial: Effects of botulinum toxin on levator ani syndrome. Aliment Pharmacol Therapy 2009, (29), 985-991. Retrieved from http://www.ncbi. nlm.nih.gov/pmc/articles/PMC2730637/pdf/ nihms136448.pdf 4. Chiarioni, MD, G., et al. (2010). Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome. Gastroenterology, 138(4), 1321-1329. Retrieved from http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2847007/pdf/ni hms167716.pdf 5. Sheikh, MD, M., et al. (2012). Treatment of levator ani syndrome with cyclobenzaprine. The Annals of Pharmacotherapy, 46, Retrieved from http://www.theannals.com/ content/46/10/e29.full.pdf html

From the American Osteopathic Association Communications Department

HEALTH FOR THE WHOLE FAMILY DOs and other members of the profession consider the American Osteopathic Association’s “Health for the Whole Family” series a great way to promote the profession and educate patients about a variety of health topics. To use this month’s article, you have permission to simply make copies of the article (see page 42).

PAGE 41

Oklahoma D.O. | October 2013

Conclusion: The above literature review was conducted to answer the clinical question: What are the appropriate treatments for proctalgia fugax and chronic proctalgia and are these treatments founded on solid evidence? One complication in reviewing the literature is distinctions of proctalgia fugax and chronic proctalgia are attempted but there is much overlap in the definitions. Duration of symptoms is the main difference in diagnosis. All other Rome III criteria and pathophysiology seem to be inseparable. Unfortunately, there is limited evidence regarding treatment of these two disease processes. Evidence for biofeedback indicates it is the most helpful treatment at this time, with EGS being a second line therapy. Other measures seem to be less effective. There is room for more research to be done.

List of Articles Reviewed: 1. Barto MD, A., & Robson MD, K. (2012, October 9). Proctalgia fugax. Retrieved from http://www.uptodate.com/contents/proctalgia-fugax?source=search_Result&search= chronic proctalgia&selectedTitle=1~32

Oklahoma D.O.

There is a case report of a patient with LAS being treated with cyclobenzaprine. They hypothesized that since recurrent muscular spasm in the levator muscles is the reason for this syndrome then a muscle relaxant such as cyclobenzaprine would help with the spasms. Cyclobenzaprine is an atypical muscle relaxant as it works in the brain stem at alpha and gamma receptors and not at peripheral nerve junctions like other muscle relax-

ants. The regimen was 5 mg of cyclobenzaprine three times a day for one week. The patient had complete resolution of symptoms on day three with only the minimal common side effects of cyclobenzaprine noted. However, the authors reported that this was only one case study and there should be further investigation on this as a potential first-line agent for treatment of LAS.5

Sleep Apnea Wake-Up Call

Your snores could be a sign of a potentially serious condition. If they are loud and punctuated by periods of silence, it might be time to get tested for sleep apnea, a potentially serious sleep disorder that is tied to a higher risk of stroke, heart attack and early death. While there is no cure, Joseph A. Giaimo, DO, an AOA-board certified osteopathic internal and pulmonary medicine physician from Palm Beach Gardens, Fla. provides tips to help manage this chronic condition, avoid serious complications, and get a good night’s sleep. Sleep Apnea Snapshot According to Dr. Giaimo, there are two main types of sleep apnea. The most common form, obstructive sleep apnea, occurs when throat muscles relax and the airway collapses or becomes blocked while sleeping. “This obstruction causes shallow breathing or breathing pauses. Sufferers are left snorting, choking or gasping, five to 30 times or more each hour, all night long,” says Dr. Giaimo. “Conversely, the second most common type, central sleep apnea, occurs when your brain doesn't send proper signals to the muscles that control breathing. As a result, sufferers don’t breathe for brief periods of time,” he continues. Who is affected by this sleeping disorder? “People who are overweight and small children who have enlarged tonsil tissues in their throats are the most commonly affected by obstructive sleep apnea, while studies have shown people with a history of heart failure and stroke are the most at risk for central sleep apnea,” says Dr. Giaimo. Sleep Apnea Symptoms Most people who have sleep apnea are unaware they have it, since most of the symptoms occur during sleep. Dr. Giaimo recommends asking a family member or bed partner to help you note these common signs: • Excessive daytime drowsiness and sleepiness (which could lead to a motor vehicle accident) • Loud snoring • Breathing pauses during sleep • Abrupt awakenings accompanied by shortness of breath • Waking up with a dry mouth or sore throat • Difficulty staying asleep (insomnia) • Attention problems or hyperactivity (which is common in children with the disorder) • Poor memory “If you are experiencing breathing problems during sleep or suspect you might have sleep apnea, you need to consult a medical professional immediately,” advises Dr. Giaimo. “Your lungs may not receive enough air if the airway is partially or fully blocked during sleep, and as a result, a drop in your blood oxygen level can occur. These frequent drops in your blood oxygen level and reduced sleep quality can trigger the release of stress hormones, which raise your heart rate and increase your risk for high blood pressure, stroke, and heart attack,” he explains. “Treatment is necessary to avoid these complications.”

Oklahoma D.O. PAGE 42

Evaluation and Treatment Options While severe cases of sleep apnea might require surgery or an airway pressure device to regulate breathing while you sleep, in some cases, selfcare may be the most appropriate treatment. To alleviate the symptoms of sleep apnea, Dr. Giaimo suggests these tips:

• Lose excess weight. Even a slight loss in excess weight may help improve constriction of your throat. • Exercise (but not before bedtime). Getting 30 minutes of moderate activity, such as a brisk walk, most days of the week may help ease obstructive sleep apnea symptoms. • Avoid alcohol, caffeine and certain medications like sleeping pills, which relax the muscles in the back of your throat, interfering with breathing. • Sleep on your side or stomach rather than on your back. Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway. • Keep your nasal passages open at night. A saline nasal spray can help; however, avoid Afrin. • Stop smoking. Smoking worsens obstructive sleep apnea. • Make your bedroom a place to sleep, not to work or watch television.

Solution for Better Sleep “If you’re not getting enough rest, then there might be a real problem with your health,” says Dr. Giaimo. “Chronic daytime sleepiness and fatigue is not normal. Discuss your sleeping habits with your physician. Together, you can find a solution for better sleep.”

Preventive medicine is just one aspect of care osteopathic physicians provide. DOs are fully licensed to prescribe medicine and practice in all specialty areas, including surgery. DOs are trained to consider the health of the whole person and use their hands to help diagnose and treat their patients. Oklahoma D.O. | October 2013

Preventing Drug Overdoses in Oklahoma provided by: Lyle Kelsey, CAE, Oklahoma Board of Medical Licensure & Supervision

Drug overdose deaths in Oklahoma have risen sharply during the past decade, according to Oklahoma City Addiction Medicine physicians Hal Vorse, MD, and Billy Stout, MD. Between 2002 and 2010, the Oklahoma Bureau of Narcotics and Dangerous Drugs Control (OBN) reports the number of overdose deaths in the state rose from 470 to 814 per year. Preliminary data indicates there were at least 795 drug overdose deaths in Oklahoma in 2011. Seventy-seven percent of the deaths were due to the use of prescription drugs in combination with other prescription drugs or alcohol.

Since the Drug Enforcement Agency (DEA) classifies hydrocodone as a Schedule III rather than a more tightly controlled Schedule II drug, some physicians may conclude that it is safer to use. It is not safer, particularly when used with other depressant drugs. The State of Oklahoma only recently designated Tramadol and cariosprodol as controlled dangerous substances (CDS). Therefore many physicians may assume they are relatively harmless. However, they are addictive and also carry a significant risk of overdose. Many overdose deaths are preventable. Here are a few recommendations that could save hundreds of lives:

Many physicians consider such drugs...relatively harmless when used alone. Many physicians consider such drugs as benzodiazepines, hydrocodone and carisoprodol relatively harmless when used alone. When used in combination, however, they can become very lethal. All drugs which depress the central nervous system become synergistic in their toxicity when used together.

• Check the OBN’s Prescription Monitoring Program’s (PMP) history report on all patients, particularly those taking controlled substances. Be sure patients are not receiving prescriptions from other providers.

• Determine if the patient has a history of substance abuse.

• Make sure patients understand they must never take two or more substances at the same time-including alcohol-which depress the central nervous system.

• Do not prescribe opiates and benzodiazepines at the same time or decrease the dosage of each if they must be given together.

The Oklahoma State Medical Examiner’s Office reported the following drug overdose death statistics for 2009: • 351 single agent deaths • 441 two or more agent deaths

• Benzodiazepines (Xanax, Valium), 10 single agent deaths; 181 deaths with one or more other agents

• Carisoprodol (Soma), 2 single agent deaths; 46 deaths with one or more other agents

• Tramadol (Ultram, Ultracet), 5 single agent deaths; 14 deaths with one or more other agents

• Hydrocodone (Lortab, Vicodin, Norco), 20 single agent deaths; 124 deaths with one or more other agents

Oklahoma D.O. | October 2013

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Oklahoma D.O.

Drug overdose deaths now annually outnumber automobile accident fatalities in the Sooner State.

robin r. dyer, do President 2013 – 2014

oklahoma educational foundation for osteopathic medicine

Fall is upon us and the OEFOM is gearing up for the OEFOM Scholarship Program. Last year the program received several outstanding applicants and thanks to generous donations throughout the year, over $16,000 in scholarships were awarded during the OOA’s 113th Annual Convention in April. Many are unaware of the OEFOM and its mission and purpose. The OEFOM was founded on August 23, 1967 with the purpose to: • To promote the education of students in osteopathic medicine.

• To improve the practice of osteopathic medicine within the state of Oklahoma.

• To raise the standards of the health care of the people in the state of Oklahoma.

Oklahoma D.O. PAGE 44

• And to further the objects and purposes of this corporation and foundation, by soliciting gifts and grants of monies, to further said foundation.

• To make loans and grants to aid students studying osteopathic medicine, and to hold an conduct meetings, forums and seminars to dispense information to physicians, students, laity and allied professions.

The OEFOM is an arm of the Oklahoma Osteopathic Association and is made up of a 16-member board, comprised of DO’s, lay members and representatives from several osteopathic professions. The board meets quarterly to conduct the business of the OEFOM and to go over other important issues.

The OEFOM financially supported the construction of the OOA Central Office on Lincoln Boulevard in 1985. The foundation continues to own the building, debt free, that houses the OEFOM, OOA and the Oklahoma State Board of Osteo• To encourage and develop a program of continuing pathic Examiners. It is through the generous Quarterly Coneducation for the osteopathic physician. tributions that the OEFOM is able to finance the day-to-day activities and administration of the Foundation and continue • To hold forums, conduct meetings with laymen and to advocate for the profession. allied professions with the purpose of promoting As previously mentioned, the OEFOM is currently preparing better health care in Oklahoma. for the OEFOM scholarship program. Each year, the OEFOM scholarship committee reviews several applications • To encourage students to enter the field of from osteopathic students who are seeking financial assistance. osteopathic medicine, through cooperative health The monies for the scholarships are pulled from several acefforts with other agencies, through research and the counts, most funding coming from the OEFOM Scholarship expansion at the knowledge of the practicing Fund. Many directly contribute to this fund by honoring a osteopathic physician; and by the establishment of a deceased or living individual through a financial donation in college of Osteopathic Medicine or the endowment their name. This is known as a memorial contribution or a of a chair in Osteopathy in a state college, if feasible.

Oklahoma D.O. | October 2013

contribution honoring a living person. The OEFOM also has a Building Fund that helps maintain the up keeping of the building. As the building gets older, more repairs will need to be made to the building. This fund is funded through direct contributions. The OEFOM has several endowed accounts as well: OEFOM Endowed Student Scholarship Program The OEFOM Endowed Student Scholarship Program gives Oklahoma students financial assistance with their osteopathic training. You may honor or remember a loved one or friend who is living or deceased through a gift to the fund. Bob E. Jones Endowed Student Scholarship Program The Bob E. Jones Endowed Student Scholarship Program was established in October 1997. It provides needed financial assistance to Oklahoma osteopathic students in their quest to becoming a physician. The endowed program honors the memory of Bob E. Jones who was a loyal and effective leader, serving as Executive Director of the OOA for 30 years and made significant contributions to the osteopathic profession.

gain interest and provide the OEFOM with another source of revenue. OEFOM Endowed Heritage Fund The OEFOM Heritage Fund was established in September 2003 for the long term support of the educational mission of the OEFOM. Your gifts and bequests support a permanent endowment. With the uncertainties of the stock market and the economy, each penny counts with the OEFOM. Please know each contribution is greatly appreciated and going to help fund the future of our profession. I am honored to serve as the president of this foundation. Please join me today and contribute to your foundation. DO OK

Osteopathic Founders Foundation (OFF) Endowed Student Scholarship Program The OFF Endowed Student Scholarship Program provides annually a scholarship to a deserving and outstanding medical student. Your gift can be designated for this fund as a living memorial. OEFOM Endowed Building Maintenance Fund Contributions to this endowed fund will help maintain the Oklahoma Osteopathic Educational Center professional headquarters. The facility was opened in January 1986 and is owned by the OEFOM. This account was set up with the intent to

Contributing

Dr. Jim and Donna Riemer Dr. Harvey and Barbara Drapkin Drs. Tony and Sharon Little Drs. Tony and Sharon Little

In Memory of Francis Staff Lois L. Canfield Sremathi L. Vasudevan Dennis Fielder

Oklahoma D.O.

n OEFOM Memorials n

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Oklahoma D.O. | October 2013

October Birthdays Oct 1 Jenny J. Alexopulos B. Kelly Blake Jonathan A. Bryan Myra A. Gregory Gerald R. Hale Gregory D. Pickett Oct 2 Oliver A. Cerqueira Jessica K. Fisher Amanda G. Foster Philip H. Murta Kim S. Young Oct 3 Lois S. Beard Shannon N. Boughner Samuel A. Moore

Oklahoma D.O. PAGE 46

Oct 4 Tracey Way Childers Ryan P. Conley Billy G. Edwards Renee M. Frenier Douglas A. Powell Tiffany W. Sibley Oct 5 James H. Anderson Christopher R. Blevins Wayne A. Huey Huy Q. Luu Dawn A. Mayberry Paul A. Reel Sheila J. Stanek David. L Thompson Oct 6 H. Keith Boren Lisa L. Crawford Amy L. Gregory Lisa M. Hayes Zoobia Mirza

Oct 7 Lee A. Kirsch Emery L. Suderman Timothy W. Winter

Oct 8 Lauren Cathleen Hopkins Thomas W. McCulloh Jerry D. Scholz Glenn L. Smith Erica S. Starkey Kathryn Zackery-Martin Oct 9 Tiffany Rae Ferguson Kim K. Hunter Marshall L. Rea Christopher A. Shearer

Oct 10 Jarrod J. Mueggenborg Mark W. Newey Kelly L. Shuler Layne E. Subera - past president Oct 11 Corbin D. Harline Ryan C. Johnson Wendell L. Richards Robert M. Wakefield Oct 12 Debbie A. Gladd Grace R. Kennedy Ronald S. LaButti Karl E. Markert Timothy T. McCay Ryan L. Nelson Carl B. Pettigrew Louise E. Price John F. Rice Jess T. Roy Monica M. Woodall

Oct 13 Jeffrey M. Calava Billy G. Henderson Robert B. Lawson Derek M. Matheson M. Todd Reilly Michael F. Stratton Courtney L. Swartz Kyle C. Wooderson Oct 14 Linzi L. Stewart-Crawford Bradley C. Taylor Christine Calabrese Wilson Oct 15 Evan D. Cole Rick A. Gigante Jimmie Sue Hill Curtis A. Phillips Edward H. Yob Oct 16 Ruth M. Bennett John L. Cherry J. Michael Ritze Bruce A. Stafford Neal S. Templeton Oct 17 Ian D. Bushyhead D. Paul Campbell Christopher A. Edge Jessica T. Erbacher Weber Donald R. Klinger Colm P. McCauley Richard E. Mills Oct 18 Steven E. Cox John T. Galdamez Scott A. Mitchell Danny L. Resser Mark L. Wellington Keely W. Wheeler Oklahoma D.O. | October 2013

Oct 19 Clint J. Basener Stephen G. Bovasso Jefferey L. Davis Gregory P. DiSalvatore Steven D. Hinshaw Stephen G. Jaskowiak Shon D. Kendall Chris B. Slater Daniel K. Wooster Hooby P. Yoon Oct 20 Paul E. Battles Julie H. Dudley Jawaun M. Lewis W. Richard Loerke Garret C. Olson Timothy A. Soult Oct 21 John D. Conley Fred J. Crapse Jr. Robert G. Patzkowsky Jillian R. Riggs Gregory B. Vanzant Oct 22 Sheldon C. Berger W. Edward Clymer Christopher J. DeLong Christopher M. Lee Dale D. Reinschmiedt Patrice D. Wagner

Oct 23 Thomas W. Britt Scott A. Ghere John J. Harrison Wesley M. Ingram Leila D. See Oct 24 Thomas M. Auxter Vincel Ray Cordry Jr. Morris S. Couch Johnny D. Duncan Lee Vander Lugt Garrett R. Zelkind Oct 25 Colby L. Edwards Ryan A. Pitts Gregory A. Rogers Oct 26 Angela I. Carrick Rheydene Suzanne Ferguson Sharon K. Little Barclay J. Sappington Oct 27 Christopher L. Cole Cheryl B. Kroeker Kayse M. Shrum Keri D. Smith Jason M. Taylor

Oct 28 David E. Eisenhauer Anastasia C. Fisher James E. Magnusson Brian K. Miller Ruth A. Miller Brandon Rhinehart Steven S. Sands Oct 29 Misti K. Crawley James E. Forrestal Dixie L. Grant-Collins Johnathan Gray R. Kent Griffith Timothy F. Rathbun Kathryn Trusell Kenneth R. Watson Jr. Oct 30 Craig C. Cooper J. Douglas Duke II Scott M. Koch Felino A. Pascual Jack Michael Shearer Larry T. Shepher David R. White Oct 31 Nicholas J. Bentley Aaron P. Fieker G. Kirk Gastineau Jayson D. Henry R. David Hill Tracy A. Hoos II Leslie J. Rebtoy

PAGE 47

Oklahoma D.O. | October 2013

Oklahoma D.O.

The OOA wishes a very happy birthday to all of our DOâ&#x20AC;&#x2122;s who celebrate their birthday this month!

Bureau News: PMTC Executive Director Retires After 21 years. September 12, 2013 was the final meeting of the Physician Manpower Training Commission for retiring Executive Director Rick Ernest. Rick has been director of the commission for 21 years.

OSU Center for Health Sciences announces leadership changes

The commission still stands in operation and is chaired by Layne E. Subera, DO. Dr. Subera presented the plaque from Oklahoma’s Governor Mary Fallin in recognition for Rick’s 40 years of service to the state of Oklahoma and for his 21 years served at the PMTC.

In a move designed to strengthen OSU Medical Center for long-term success, Oklahoma State University has appointed Kayse M. Shrum, DO, the new President of the OSU Center for Health Sciences. Dr. Shrum will continue in her roles as Provost and Dean of the OSU College of Osteopathic Medicine. Howard Barnett will remain president of OSU-Tulsa and as chief executive officer of the OSU Medical Authority (OSUMA), which oversees the downtown Tulsa hospital. Dr. Shrum will now report to OSU President Burns Hargis. Barnett will begin serving as CEO of OSUMA pending approval of the OSUMA's trustees.

Oklahoma D.O. PAGE 48

Dr. Phung Named AOF Outstanding Resident of the Year The American Osteopathic Foundation recently named OSU College of Osteopathic Medicine alumnus Binh T. Phung, D.O., the 2013 Outstanding Resident of the Year. He was honored at the organization’s “Honors” celebration in Las Vegas on Sept. 29. Each year, AOF acknowledges two osteopathic physicians from across the nation. The award recognizes outstanding residents who demonstrate a combination of clinical promise, innovation, skills in health care and commitment to the profession. Phung, who completed his pediatric residency at OSU Center for Health Sciences and OSU Medical Center, received $5,000 as part of the award. As a medical student, Phung was president of the American College of Osteopathic Pediatricians Peds Club at OSU-COM and helped establish the Mini-Med School for Kids program, which teaches elementary school students about ways to combat obesity. Phung was named the OSU-COM 2010 Student Doctor of Osteopathy of the Year, which recognizes the overall achievements of outstanding students and emphasizes service to the community. He was also named OSU Medical Center Resident of the Year. Phung recently joined OSU Physicians Pediatrics and is serving as a clinical assistant professor at OSU-CHS.

The OSU Medical Center is seeking to be transferred to the state to secure a more stable funding base and more appropriately recognize its statewide impact. Barnett, who led negotiations to save the hospital from closing in 2008, will request transfer of the medical center to OSUMA from the Tulsa City Council.

Bureau on Membership The OOA Board of Trustees welcomes the following new members to the OOA family! Rola E. Eid, DO Plastic & Reconstructive Surgery Tulsa, OK Matthew E. Brown, DO Anesthesiology Tulsa, OK Oklahoma D.O. | October 2013

OOA Awards Nomination Form The Oklahoma Osteopathic Association’s Bureau on Awards will meet Thursday, December 5, 2013 to determine award recipients to be presented during the OOA’s 114th Annual Convention. These awards represent the highest honor the OOA can bestow in recognition of outstanding service and contribution to the osteopathic profession in Oklahoma. Only OOA members can submit an OOA Awards Nomination Form and all forms must be received in the OOA Central Office by November 28, 2013. Please complete this form by printing clearly or typing the name along with supporting information on why you are nominating this individual. Be sure to return the completed form to the OOA office by November 28, 2013 for consideration by the OOA’s Bureau on Awards.

DOCTOR OF THE YEAR AWARD The OOA Doctor of the Year Award is the most prestigious honor within the OOA. Nominees must: • Has been in practice for at least ten years • Provides his/her community with compassionate, comprehensive and caring medical service on a continuing basis • Directly and effectively involved in community affairs • Supports his/her state and professional associations and humanitarian programs Nominee Name: Supporting Information:

OUTSTANDING & DISTINGUISHED SERVICE AWARD

Honors a physician who has contributed significantly to the advancement of osteopathic medical education in Oklahoma Nominee Name: Supporting Information:

ROOKIE PHYSICIAN OF THE YEAR AWARD Honors a physician in his/her second year of practice who has exemplified significant contributions and service to his/her school, community and Association Nominee Name: Supporting Information:

AWARD OF APPRECIATION Honors an OOA Member or friend of the osteopathic profession in Oklahoma who has donated his/her time and efforts to improve mankind Nominee Name:________________________________________________ Supporting Information:

Oklahoma D.O. | October 2013

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OOA Member Name:___________________________________________________ Date:_________ Please return this form to the OOA Office by November 28, 2013 by mail: 4848 North Lincoln Boulevard, Oklahoma City, OK 73105-3335 or by fax: (405) 528-6102

Oklahoma D.O.

Honors a physician who has significantly contributed to improving the community and promoting osteopathic medicine Nominee Name: Supporting Information:

A.T. STILL AWARD OF EXCELLENCE

Classified Advertising OFFICE FOR RENT: 1,500 square feet in an excellent area with high traffic count. Established location. Completely remodeled, very nice. Easy access from all areas of town, 7300 S Western, OKC. Rent is $1250 per month with all utilities paid. Please call Dr. Buddy Shadid 405.833.4684 or 405.843.1709. OFFICE BUILDING FOR SALE: 6501 S. Western, OKC, OK 73139. Over 1 1/2 acres total size, 10,000 sq ft building divided into 3 doctors offices. 1200 sq foot private office upstairs with private bathroom and shower. 2 double sided fireplaces, over a dozen chandeliers, rough wood cathedral ceilings. Alarm and phone system in place, double glass doors in entrance, back patio with separate storage building. Larger office is fully equipped with exam tables, Pap table, chairs, medical instruments, QBC (CBC) machine, autoclave, medical supplies, and much more. For information contact: Captain David Simpson at (405) 820-5360.

Oklahoma D.O. PAGE 50

CLINIC FOR SALE: By owner. Fully equipped: LAB, XRAY, EKG. Well established clinic, near Integris Southwest Medical Center is available for sale. Clinic is well equipped and is ideal for one or more physician practice as well as a variety of specialties. Clinic has: waiting room with refrigerated water cooler, wheelchair accessible restroom, reception and staff work stations, Nurses station, 5 - 7 exam rooms with sinks and running water, large multipurpose procedure room, 3 private offices with built-in bookcases, (One Office with 3/4 Bath), additional staff and patient restrooms, large upstairs (currently used for storage) and variety of other medical equipment. Misys Medical Software. Large Parking Lot. “Must See Inside” the all steel building located at 2716 S.W. 44th St. in OKC to appreciate the effort placed upon providing convenient and up to date medical care. PRICE IS NEGOTIABLE. Doctor prefers to sell, but would consider leasing. If interested, please call: Evelyn Francis at (405) 249-6945. IMMEDIATE OKLAHOMA OPPORTUNITY with largest family medicine clinic in Muskogee, Ok. Excellent opportunity to assume a practice that is up and running. Senior physician of four physician group leaving to pursue new career opportunities. 2,000 active patients need a physician. Two physicians currently practice OB. Surgical OB experience a plus. On site x-ray and CLIA certified lab. Nursing and support staff in place. Income guarantee. Be your own boss, work hard and practice family medicine in its historical tradition with respect and loyalty of small town patients. Contact Evan Cole, DO, 918-869-2456, ecoledo@yahoo.com, Brad McIntosh, MD, 918-869-7356, drbamc@yahoo.com Jason Dansby, MD, 918-869-7387, jasonddansby@yahoo.com or Judy Oliver, RN, practice administrator, 918-869-7357. (leave a message if temporarily unavailable) Find us on the web at www.mfpclinic.com.

JOB AVAILABILITY: A growing convenient care provider has part-time openings for licensed physicians (Family, internal, general, physical medicine & rehab, sports medicine, occupational, etc.) in our Tulsa and Oklahoma City area location. We provide primary care/immediate care medicine. Patients can drop in (no appointment necessary) to our locations and see a doctor for a wide range of primary care and family health needs, including diagnosis and treatment of common illnesses and injuries, in-house, diagnostic testing, occupational therapy, and physicals. We provide quality health care for patients who have been injured on the job or may have some illness. Providing flexibility in scheduling to meet your lifestyle and income needs. Benefits: We are offering very competitive salaries. If interested please contact Arnita (405) 6815800 or email her at:2149okc@gmail.com CLINIC FOR SALE IN THE LAKE TEXOMA AREA. Please call (580) 564-2143 ext. 4043 for further information or inquiries. STAFF PHYSICIAN NEEDED: The Oklahoma Department of Corrections is seeking applicants for Staff Physician at our correctional facilities statewide. The state of Oklahoma offers a competitive salary and benefits package which includes health, dental, life and disability insurance, vision care, retirement plan, paid vacation, sick days, holidays and malpractice insurance coverage. For more information and a complete application packet contact: Becky Raines 2901 N. Classen Blvd., Suite 200 Oklahoma City, OK 73106-5438 (405) 962-6185 FAX (405) 962-6170 e-mail: braines@doc.state.ok.us DOCTORS WANTED: to perform physical exams for Social Security Disability. DO’s, MD’s, residents and retired. Set your own days and hours. Quality Medical Clinic-OKC, in business for 16 years. Call Jim or JoAnne at 405-632-5151. PHYSICIAN NEEDED: The practice of Terry L. Nickels, DO is currently seeking a part-time Family Physician with OMT Skills to help cover the office. If interested please contact Dr. Terry Nickels at (405) 301-6813. IMMEDIATE NEED: FP/ER/OB Physicians, FT,PT and Temp. Bimonthly pay. Paid malpractice and expenses including mileage. To join our fast growing team call Krystal @ 877-377-3627 or send CV to kernce@oklahomaoncall.com. Oklahoma D.O. | October 2013

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Calendar of Events November 6, 2013 Bureau on Legislation Dinner Bureau on Legislation Meeting

November 7, 2013 OOA Bureaus & Board of Trustees Meetings Oklahoma City, Oklahoma

December 5, 2013 OOA Bureaus & Board of Trustees Meetings & OEFOM Board of Trustees Meeting Oklahoma City, Oklahoma

Oklahoma D.O. | October 2013

Please contact Kathrine Kopec at 405-896-8058 for more information.

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January 31-February 2, 2014 Winter CME Seminar: "ABC’s of LABS: What’s New, What’s Hot and What’s Not" Hard Rock Hotel & Casino, Catoosa, Oklahoma

Convenient, Quality Healthcare in Your Home is Available Today with Physician HouseCalls.

Oklahoma D.O.

January 2, 2014 OOA Bureaus & Board of Trustees Meetings Oklahoma City, Oklahoma

Now recruiting Physicians, PA's, and NP's interested in working a flexible schedule.

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OKLAHOMA OSTEOPATHIC ASSOCIATION 4848 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105-3335

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Oklahoma D.O. PAGE 52

Please support your OOA and consider Rich & Cartmill, Inc. for your Professional Liability Insurance needs. For more information contact Scott Selman at 918-809-1461 or sselman@rcins.com

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