SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y
ADDICTION MEDICINE CONFRONTING LEGAL, ILLEGAL, CLINICAL, AND POLITICAL EPIDEMICS
What Is Recovery? Integrative Addiction Medicine Marijuana
Also Inside . . .
Mayor Lee Approves SFMS-Endorsed Sugar Sweetened Beverage Ordinances
SFMS General Meeting is September 14
Medicine and Menace
Addicted to the Internet Alcohol Abuse The Antidote to Opioid Overdose
VOL.88 NO.6 July/August 2015
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IN THIS ISSUE
SAN FRANCISCO MEDICINE
July/August 2015 Volume 88, Number 6
ADDICTION MEDICINE FEATURE ARTICLES
MONTHLY COLUMNS
10 Integrative Addiction Medicine: What Exactly Is It? Sharone Abramowitz, MD
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Membership Matters
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President’s Message Roger S. Eng, MD, MPH, FACR
12 Naloxone for Opioid Safety: The Antidote to Overdose Phillip Coffin, MIA, MD 14 Heartless in the Heartland? HIV and Hepatitis C Prevention Strategies in Addiction Medicine Stephen E. Follansbee, MD
16 Needle Exchange: The Perpetual Prevention Battle Steve Heilig, MPH 17 Pot Policies: Professional Perspectives David E. Smith, MD, and Steve Heilig, MPH
18 Cannabis and Teenagers: Clinical Treatment of Use Disorders in Adolescents Peter Banys, MD, MSc, and Timmen Cermak, MD
20 Novel Marijuana Preparations: Edibles and Beyond Ingeborg Schafhalter, MD 21 Early Warnings: Asian Binge Drinking David Pating, MD
22 Pharmacotherapy: Treatment for Alcohol Use Disorder Steven L. Batki, MD
24 What Is Recovery? What Does It Mean for Doctors and Their Patients? Lee Kaskutas, DrPH 26 Internet Addiction: What Is Normal? Murtuza Ghadiali, MD
28 Electronic Cigarettes: Rational Regulation Coming Steve Heilig, MPH
Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org
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Guest Editorial David Pating, MD, and Murtuza Ghadiali, MD
28 Classified Ad
32 Medical Community News 34 Upcoming Events
OF INTEREST 23 EHR and Meaningful Use Assistance Program 31 CMS and AMA Announce Joint Efforts to Help with ICD-10 Transition
ADVOCACY UPDATES 29 Local Advocacy: Mayor Ed Lee Approves SFMS-Endorsed Sugar-Sweetened Beverage Ordinances John Maa, MD 31 Governor Brown Signs Vaccine Bill
Welcome New Members PHYSICIANS Mabel Ann Chan, MD | Pediatrics Mark Alan Schrumpf, MD | Orthopaedic Surgery Edward Choi Shin, MD | Sports Medicine Christopher Guan-zhong Tang, MD | Otolaryngology RESIDENTS Joseph Robert Hall, MD | Psychiatry Michael Christopher Lubrano, MD, MPH | Anesthesiology Daria Leigh Thompson, MD | Pediatrics STUDENTS Rodell Santuray
MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members Mayor Lee Approves SFMS-Endorsed Sugar Sweetened Beverage Ordinances Three sugar sweetened beverage bills that had been endorsed by the SFMS were signed into law by Mayor Ed Lee on June 25. The legislation will target advertising of sodas, by requiring health warnings on posted ads in San Francisco and banning ads on publicly owned property, and by prohibiting the use of city funds for the purchase of sugary beverages. The unanimous passage of these bills by the San Francisco Board of Supervisors were reported by media outlets throughout the country, and was soon followed by the announcement from SFGH CEO Sue Currin that all sugar sweetened beverages would shortly be removed from San Francisco General Hospital and Trauma Center. These successes reflect the dedication of the SFMS and its leadership to promote the health of the public. More information about the SSB ordinances, including statements from all three Supervisors, can be found on page 29.
CURES 2.0 FAQ; DOJ to Postpone Universal Adoption of System until January 2016
The Department of Justice (DOJ), in an efforts to update Controlled Substance Utilization Review and Evaluation System (CURES), has launched a new version of the system on July 1. Accessing the new version of CURES will require Internet Explorer version 11, Firefox or Chrome Internet browsers. There is be no backward compatibility to earlier versions of this browser. This change, only recently revealed, will cut off controlled substance prescribers with health information technologies that require use of older versions of Internet Explorer. In response to concerns raised by the SFMS and CMA, the DOJ has agreed to maintain the current version of CURES until January 2016 for users who cannot access the new version because of browser compatibility issues. SFMS has posted a FAQ about the new system and registration changes at http://bit. ly/1dgNF4L.
Physician Practices May Not Be Ready by October ICD-10 Implementation Deadline; Available Resources to Ensure Seamless Transition
Survey results released by the California Medical Association (CMA) to evaluate physician readiness for ICD-10 transition found that many physician practices may not complete transition to ICD-10 by the October 2015 deadline. More than half of respondents (51%) indicated they were only minimally prepared, while 21% indicated they were not at all prepared. The results are concerning, particularly since Congress has reaffirmed that they want to move forward with the implementation of ICD-10 without further delays. Additionally, hospitals, and insurance companies have told lawmakers that they are ready for the October 2015 deadline and are pushing for Con4
gress to stick with the October 1 implementation date. SFMS is strongly encouraging physicians to develop an action plan to ensure a seamless transition. Available resources for physician members can be accessed at http://bit.ly/1Hx2ooO.
New Resource to Help Physicians Communicate Unanticipated Adverse Outcomes
Confused about discussions related to disclosure of unexpected adverse outcomes, apology versus sympathy, early resolution of injury-related complaints, and how to avoid unnecessary liability risks? SFMS has partnered with the Medical Insurance Exchange of California (MIEC) to launch a two-part blog post series to assist physicians handle potentially difficult circumstances with compassion, truthfulness, and candor. Visit http://bit.ly/1LsEwoP to access this guide and learn more about California’s “I’m Sorry” legislation.
California State Budget Update; Governor Calls Special Session to Discuss Medi-Cal Reimbursement Rate
Governor Jerry Brown has called for a special session of the Legislature to address “Health Care Financing” after he struck a deal with Democratic lawmakers last week. California legislators passed a $115.4 billion budget, part of a deal with Governor Brown to hold back on spending despite the state’s improving financial picture. The special session of the Legislature provides a new opportunity for SFMS/CMA and other stakeholders to push through a permanent and significant funding increase dedicated to providers of health care services, and to ensure the health care infrastructure exists to care for the Medi-Cal population. The Governor’s special session announcement was made on the same day that the State Auditor released its report of the Department of Health Care Services’ highlighting significant problems with Medi-Cal managed care plans’ network adequacy and access to care. The State Auditor found that not only were managed care plans providing the state with inaccurate data on availability and participation of in-network physicians, but the state was not verifying whether the data from the plans was accurate, and thus could not reliably determine whether the Medi-Cal networks meet California’s stringent network adequacy standards.
The budget includes: • $40 million to expand Medi-Cal to cover all low-income undocumented children, effective May 1, 2016 ($132 million when fully implemented). • $265 million to fund 7,000 additional preschool slots and 6,800 child care slots, plus a rate increase for all child care providers. • $97 million over the January budget for the California State University to expand enrollment and focus on increased success. • $226 million on a one-time basis to restore the 7 percent
SAN FRANCISCO MEDICINE JULY/AUGUST 2015 WWW.SFMS.ORG
reduction in service hours for In-Home Supportive Services. The announcement of the special session allows the Governor and legislative leaders to bypass the traditional legislative and budgetary calendar. SFMS/CMA will continue to work with its legislative allies and its coalition partners to either maintain funding for provider reimbursement rates in the budget or provide an alternative revenue source to support significant increases in provider reimbursement rates.
SFDPH Updates Health Advisories on Invasive Meningococcal Disease, Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and Ebola
The San Francisco Department of Public Health has issued updated health advisories regarding invasive Serogroup C meningococcal disease (IMD), MERS-CoV, and Ebola. Visit sfms.org to access the latest news and updates from SFDPH.
Highlights from AMA’s 2015 House of Delegates
The American Medical Association’s (AMA) House of Delegates tackled a diverse set of resolutions this year that are of interest to California physicians, including medical-only exemptions from school vaccination requirements, electronic health record (EHR) meaningful use, ICD-10 implementation, Medicaid rates and opioid abuse. Given the high level of interest in California’s Senate Bill 277 (Pan), which would eliminate the personal belief exemption for school vaccination requirements in California, AMA adopted a policy calling for immunization for all, and only allowing exemptions where medical reasons contraindicate vaccination. The California delegation presented a number of important resolutions that were adopted as policy, including reimbursement for end-of-life counseling, allocation of resources to study the impact of the Affordable Care Act Medicaid expansion, and support e-cigarette regulation. For more information, visit http://bit.ly/1MfXXl3.
SFMS Summer Networking Mixer a Success
More than forty physicians and residents participated in SFMS Physician Networking Mixer at Palmer’s on Fillmore. Attendees took advantage of the opportunity to meet SFMS leaders and connect with colleagues from a wide range of specialties and practice settings. SFMS would like to acknowledge the Cooperative of American Physicians (CAP) for their support of SFMS and our networking mixer series. Visit http://www.sfms.org/Events.aspx for a list of upcoming events, including SFMS’ General Meeting on September 14 at the Golden Gate Yacht Club with special guest Assemblymember David Chiu. This is a wonderful opportunity both to meet with SFMS leadership and to learn firsthand the issues SFMS and CMA are advocating for on behalf of physicians and their patients in San Francisco and California.
July/August 2015 Volume 88, Number 6 Editor Gordon Fung, MD, PhD Guest Editors David Pating, MD, and Murtuza Ghadiali, MD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Roger S. Eng, MD President-Elect Richard A. Podolin, MD Secretary Kimberly L. Newell, MD Treasurer Man-Kit Leung, MD Immediate Past President Lawrence Cheung, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD John Maa, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD
Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD
Term: Jan 2014-Dec 2016 William J. Black, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD
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JULY/AUGUST 2015 SAN FRANCISCO MEDICINE
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RECEIVE MORE THAN $6,000 A YEAR IN SAVINGS AND SERVICES, INCLUDING:
FOR $3 A DAY, SFMS/CMA MEMBERS
SFMS/CMA Member Benefit
Value
Patient referral service via SFMS’ phone referral line and online physician finder tool . . . . . . . . . . . . . . . . . . . . . . . . . $200 Access to exclusive physician networking events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150 Personal physician webpage for practice promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 Subscriptions to San Francisco Medicine and SFMS Membership Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 One-on-one assistance with practice management experts from Center for Economic Services on . . . . . . . . . . . . . *$150 reimbursement and practice operation issues . *value hourly rate with a practice management consultant Access to objective written analyses of major health plan contracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 Discounted employment contract review service with a contract attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Special member rate for AAPC’s ICD-10 training seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200/session Discounted registration for the Western Leadership Academy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300 CME tracking and credentialing service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20 HIPAA-compliant communication via DocBookMD, enabling physicians to instantly exchange patient information . . . . $100 with other physicians at the point of care 15% off temper-resistant security prescription pads and printer paper with Rx Security . . . . . . . . . . . . . . . . . . . . $162 .75 30% off your current bill for medical waste management and disposal services through EnviroMerica . . . . . . . . . .*$1,000 *based on average savings
30% off on Epocrates products, including Epocrates Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50 Up to 10% discount on life insurance through Mercer Health & Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 Member-only savings on office supplies and magazine subscriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Access to webinars and seminars ranging from business essentials for physicians, EHR adoption best practices, . . . $400 and effective coding/billing strategies, including our exclusive value-based payment model workshop with CMS Region IX Administrator in May 2015 . For a list of full member benefits, visit http://www.sfms.org/membership/membership-benefits/full-member-benefits.aspx.
PRESIDENT’S MESSAGE Roger S. Eng, MD, MPH, FACR
Reshaping Today’s Physician for Tomorrow Think left and think right and think low and think high. Oh, the thinks you can think up if you only try! —Dr. Seuss In past generations, a doctor was a collector of information. Now, a doctor has to be an analyst of information. —Malcolm Gladwell A number of SFMS members, including Drs. George Fouras, Brian Grady, and Shoshana Ungerleider, had the opportunity to mix and mingle with other health care leaders at the Western States Leadership Academy in Hollywood, May 29–31. Cosponsored by the California Medical Association and Texas Medical Association, this annual event brings together health care leaders from all backgrounds to network and engage on issues affecting health care. This year’s keynote featured New York Times best-selling author Malcolm Gladwell. In his keynote, Gladwell illustrated how many of society’s challenges can be placed in one of two categories: puzzles and mysteries. According to the theory, puzzles occur when there is not enough information to solve a problem. Mysteries, on the other hand, arise when there is more than enough information. Tackling a mystery thus becomes a matter of sifting through the abundance of data, rather than uncovering new information to reach a conclusion. During the Cuban Missile Crisis, the Kennedy administration based important decisions on limited knowledge of the goings-on in Russia and Cuba. They had to make decisions based on scraps of information, like working a jigsaw puzzle. Compare this with more recent events, such as 9/11. The NSA knew there were terrorists training to fly planes into skyscrapers, but at the time this information was buried among 40,000 other terrorist tips, alerts, and observations. How does this apply to health care? Health care has many mysteries, as most problems today are. While the knowledge base of medicine grows at an exponential rate, our capacity to synthesize this information is finite. There’s just too much info to sift through. Does the world categorize doctors as puzzle solvers or mystery solvers? Gladwell cited the position of a football quarterback to answer this question. NFL quarterbacks drafted with the first 50 picks perform worse than those chosen later in the draft. Moreover, the IQ test doesn’t predict success. Why is it? Is it due to lack of effort or data? Tremendous effort put forth by each pro team with armies of scouts doesn’t translate into success. Gladwell’s conclusion is that the job of the NFL quarterback is so complex and unquantifiable that you can’t use a checklist. The same holds true for physicians. To ensure quality care, patients rely on the physician’s experience, guidance, understanding, and support. But the world is not letting physicians play this role. “In past generations, a doctor was a colWWW.SFMS.ORG
lector of information. Now, a doctor has to be an analyst of information,” Gladwell stated in the keynote. Physicians must take a different approach to solving the information-laden problems of today, an approach that requires good judgment and understanding.
To reshape the way doctors are perceived by society, we must work to change the health care paradigm that currently recognizes us as puzzle solvers rather than mystery solvers.
Today’s physicians need a health care system that is flexible and open to enable doctors to do what they need to do. New technologies, from iPhone apps to EHRs, should help augment the patient-physician relationship, not compete with it. Government, health plans, and start-ups are making these initiatives with little or no doctor input. Doctors need to take a leadership role to ensure that proper change occurs. Until people come up with alternatives, they will stick with what they have. Canadians have already gone through this process and want access above all else. They are willing to trade quality for it. What’s America’s priority? We need societal consensus about what we want. In many circles of the high-tech world, they believe “Big Data,” artificial intelligence, and consumer-driven portable technologies will solve many of health care’s ailments. Rarely do they include physicians in the equation. However, if we still believe that the patient-physician human interaction remains the foundation of our system, we need to emphasize this. If we believe that patients need to have discussions with their doctor for 30–60 minutes, we need to advocate for this, as the system currently doesn’t allow for it. We doctors are in the best position to drive the agenda to address such issues. Malcolm Gladwell believes that good mystery solvers are those who are broad rather than deep. They have humility and are open to ideas and evidence. They respect disparate perspectives. If you believe, like I do, that Mr. Gladwell is on to something, there is much work to be done to change our current culture. Next year’s Western States Leadership Academy will be in our hometown, May 13–15, 2016. I look forward to engaging with many of you in the event’s discussion of improving health care. Connect with Dr. Eng via Twitter @RogerEngMD or send him an email at reng@sfms.org. JULY/AUGUST 2015 SAN FRANCISCO MEDICINE
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Confidence The feeling you have when you are affiliated with Hill Physicians. Scott Li-Ju Huang, D.O.
Hill Physicians provider since 2008. Uses Ascender preventive care reminders and Hill inSite to review eClaims and eligibility.
At Hill Physicians, we continue to improve upon coordinated care, with remarkable results. We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include: • Fast, accurate claims payments • Free eReferrals and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have joined Hill. Feel confident in the future of your practice and your patients by affiliating with Hill Physicians Medical Group.
For more about the advantages of affiliating, visit HillPhysicians.com/JoinUs.
Hill Physicians’ 3,800 healthcare providers accept HMOs and many PPOs from Aetna, Anthem Blue Cross, Blue Shield, CIGNA, Easy Choice, Health Net, Humana, SCAN, San Francisco Health Plan, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.
GUEST EDITORIAL David Pating, MD, and Murtuza Ghadiali, MD
Surfing the Wave of Drug Addiction San Francisco physicians face new waves of street drug abuse every four to six years. In the last two decades, we’ve struggled to meet the challenge of heroin, club drugs (GHB, rohypnol, MDMA or “ecstasy,” ketamine), methamphetamine, and most recently OxyContin—each new drug posing ominous risks to select subcommunities, including secondary epidemics of HIV and hepatitis. Across these cycles, alcohol, tobacco, and marijuana abuse remain equally challenging and ubiquitous. Our physician response to these “epidemics” is all too often knee-jerk. Starting with denial and shock, we frequently lag behind the latest wave until our friends with cooler heads at the SFDPH, UCSF/SFGH, and SFMS help us prevent, treat, and regulate the crisis—allowing us to keep our heads above water. In the latest epidemic of overdose deaths due to OxyContin, statewide opioid prescribing guidelines, citywide use of naloxone, and FDA regulatory recommendations have turned the opioid epidemic downward. Deaths are decreasing. Unfortunately, the cure carries the cost of stricter restrictions on clinical practice—a side effect of exaggerated controls. As this wave subsides, the putative marijuana tsunami looms—with legalization of marijuana anticipated to be on the 2016 ballot. It should not be the role of physicians to dictate the merits of legalization. We can only speak to its health risks and benefits, both of which are significantly overhyped. Medical marijuana use is already legal in California and twenty-two other states, and “recreational” use is legal in four. In the bellwether state of Colorado, where recreational production, sale, and use have been legal since 2012, physicians report increases in adolescent use, novel cannabis formulations, and ingestion-related emergencies. If we are to avoid these health impacts, let’s not wait for the epidemic to crash ashore—cool heads must prevail. The best lessons to tame an anticipated cannabis-related health crisis can be extracted from public health efforts to curtail alcohol and tobacco abuse. These remain our nation’s number-one preventable health risks. We have mitigated these risks through sound regulations, good clinical practice, and lots of public education. This needs to be our plan for marijuana, too. Some lessons from previous efforts can guide us in this regard: Lesson One: Negative neighborhood impact from alcohol and tobacco is directly related to the density of their sales and distribution. More density means more crime and lower district health. Local laws need teeth to promote rational land use for marijuana sales and distribution. Lesson Two: Adolescent alcohol/tobacco use is inversely proportional to the perception of risk. Any marketing and sales of cannabis to youth must be strictly avoided. The labeling and types of cannabis products sold must be regulated. WWW.SFMS.ORG
Lesson Three: Physicians must ask patients about alcohol, tobacco, and marijuana abuse—and provide simple advice for safe use. Lesson Four: Treatment for alcohol, tobacco, and marijuana dependence works, if it’s done right! The good side of any marijuana legalization is that cannabis production and sales can be taxed and regulated. Funds collected can rationally improve prevention, treatment, and enforcement. The role of San Francisco Medical Society members will be to guide these funds to efficient use. We have done this before by successfully sponsoring legislation to limit electronic cigarette marketing and use, as well as warding off assaults on needle exchange and drug treatment. Our efforts go back as far as the first known mention of SFMS in local newspapers, which detail local health authorities requesting our medical association to investigate “opium dens” in Chinatown—to recommend ways to decrease this “Oriental” problem. More recently, in the 1960s the SFMS helped assure the survival of the Haight Ashbury Free Medical Clinic, David Smith’s pioneering substance abuse treatment program born from the loins of the “Summer of Love,” when compassionate, nonjudgmental care for drug addiction was rare. SFMS even led the way on the establishment of addiction medicine as a subspecialty, convincing the AMA to form its first work group to address unrelenting tides of alcohol and drugs. As can be read within these pages, the SFMS continues to be the spark for enlightened drug addiction policy, from needle exchange, e-cigs, access to naloxone, and tobacco taxation to pay for health expenses and legislation that bans smoking in workplaces to the next wave of Internet addictions and powdered alcohol (to which you just add water to get drunk). SFMS has helped us clinicians surf the waves of drug addiction, allowing us all to keep our heads coolly above water.
David Pating, MD, is chief of addiction medicine at Kaiser San Francisco, past-president of the California Society of Addiction Medicine and a San Francisco City and County health commissioner. He is a member of the SFMS board of directors and editorial board for San Francisco Medicine. Murtuza Ghadiali, MD, is assistant chief of addiction medicine at Kaiser San Francisco, chair of CSAM’s 2015 State of the Art in Addiction Medicine and an assistant clinical professor at UCSF. JULY/AUGUST 2015 SAN FRANCISCO MEDICINE
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ADDICTION
INTEGRATIVE ADDICTION MEDICINE What Exactly Is It? Sharone Abramowitz, MD A tragic prescription opioid epidemic is shaking health care, and it is bringing attention to modern medicine’s
shadow side. Chronic pain is a classic mind-body illness that conventional medicine treated as something pharmaceuticals alone could fix. Like the rest of American culture, our health care system is biased toward the quick fix of “a pill for every ill.” Whether it’s a student believing Adderall will put her on the fast track toward good grades or a man reaching for Viagra, we quickly reach for drugs (legal and illegal) to resolve dis-ease. Cartesian dualism, a belief in the separation of mind from body, encouraged the approach of treating somatic ills with only somatic solutions.1 This overreliance on “a pill for every ill” has been profitable for some (acetaminophen/hydrocodone was the most-dispensed medicine in the U.S. from 2009 to 20132), but it shortchanges the prevention and treatment of chronic conditions such as pain, obesity, diabetes, and substance use disorders (SUDs). Integrative medicine addresses mind-body dualism by opening modern health care’s toolbox to include holistic modalities. Integrative medicine principles3 include: • A partnership between the patient and the practitioner • Consideration of all factors that influence health, wellness, disease • Use of conventional and alternative methods to facilitate the body’s innate healing response • Appropriate consideration given to use of less invasive and less harmful interventions, when possible, while addressing the whole person in addition to the disease • The concept that medicine is based on good science, is inquiry driven, and is open to critical consideration of new paradigms
Integrative medicine and addiction medicine are a good fit. Addiction treatment benefits greatly from contemporary pharmaceuticals, like buprenorphine or naltrexone, but it was understood from the time that Carl Jung consulted in the 1930s with Rowland H, an A.A. cofounder, that more than somatic medical approaches were needed to heal alcoholism.4 In this instance, Jung recommended spiritual healing be a part of the alcoholic’s recovery process. So integrative addiction medicine validates what addiction treatment has involved since A.A.’s founding: a healing of mind, body, and spirit. But just as addiction neurophysiology has advanced since the Bill W. era, so have other integrative treatment modalities’ evidence base, including mindfulness practices, psychotherapies, and nutrition’s impact on brain health.5 We can define integrative addiction medicine (to paraphrase the American Board of Integrative Medicine3) as: focusing on the whole of the person (mind, body and spirit) suffering with SUDs; affirming the 10
importance of relationships to recovery (including the one between clinician and patient); informed by evidence; and making use of all appropriate health care professionals, disciplines, and therapeutic approaches (including conventional medical approaches, recovery communities, psychotherapies, and relevant complementary traditional healing approaches) to achieve optimal health and healing for the individual in recovery from SUDs.
In clinical practice, how does an integrative addiction medicine approach look? As an integrative addiction psychiatrist, I would approach a patient in early alcohol recovery (who is post acute withdrawal and does not require residential treatment) by working with that individual from several parameters. First, I would address his health problems, being sure he gets appropriate conventional medical care for, let’s say, alcoholic hepatitis. Secondly, I would prescribe evidence-based early relapse prevention medications, like naltrexone and gabapentin. Next, by using a motivational interviewing approach, I would invite the patient to engage in recovery communities that he would accept. Further assessment of other needed psychotherapies would include treatment for comorbid psychiatric disorders, like PTSD. So far, this is likely standard practice for most addiction medicine specialists. So what may I also do from an integrative medicine standpoint? Commonly, folks in early recovery have sleep problems. So instead of just prescribing trazadone, I would introduce sleep hygiene and insomnia CBT approaches. I might try melatonin for a brief time. I would also recommend the practice of downtime before bed and avoidance of electronics use. After explaining how we can trigger the parasympathetic rest-and-relaxation response using the breath, I would also introduce relaxation-breathing practices by teaching one within
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the office. Through a collaborative approach, I would find a regular practice that this patient is willing to engage in. It might be a regular use of a popular app such as Headspace. It could be a willingness to go to a local meditation center, attend Refuge Recovery meetings (where meditation and Buddhist philosophy are integrated), or engagement in a mindfulness-based stress reduction or a mindfulness-based relapse prevention course. Perhaps this patient could benefit from a complementary approach, such as acupuncture with a practitioner experienced in recovery, or yoga, tai chi, or other energy work. These approaches allow patients, in my experience, to more easily come down off medications like gabapentin, because they now have mindbody practices and tools other than pills to use. As patients engage in early recovery, they become more aware of their bodily states and energy. This can be challenging and turned into a positive or a negative. Patients need guidance in conscious health practices regarding keeping their mood and physical states in balance via instituting new healthy exercise and nutrition practices. A.A. talks about H.A.L.T. (hungry, angry, lonely, and tired) as relapse triggers. I help patients move toward exercise and nutrition plans. As they improve these practices, they often become more aware of themselves as somatic beings. Addicted patients too easily like medicine’s reliance on pills to fix ills. When it comes to their whole health, we should use healing approaches that are consistent with the message of SUD recovery: Healing requires lifestyle changes on the relational, emotional, physical, and spiritual dimensions. Recovery and wellness both require a whole-health approach.
Sharone Abramowitz, MD, is UCSF trained and board certified in psychiatry and addiction medicine. She has been a primary care faculty member for twenty-five years and behavioral health and addiction medicine director at Highland Hospital, where she began the nation’s first premedical student health coach project. She has an integrative psychiatry and addiction medicine private practice in San Francisco and Oakland and is a member of the American Academy of Integrative Health and Medicine. She has received advanced training through the Center for Mind-Body Medicine. She is on the California Society of Addiction Medicine’s executive council; is vice chair of their upcoming October 21-24 State of the Art in Addiction Medicine conference at the Hyatt Regency, San Francisco Airport; and chaired their 2013 conference. She is a member of the Motivational Interviewing Network of Trainers and specializes in training physicians and other health care providers in brief motivational interviewing. Her website is www.Abramowitz-Psychiatry.com.
References
1. Robinson H. Edward N. Zalta, ed. Dualism. The Stanford Encyclopedia of Philosophy. Nov 3, 2011 (winter 2011 edition). 2. IMS Institute. Medicine use and shifting costs of healthcare: A review of the use of medicines in the United States in 2013. 2014: IMS Institute for Healthcare Informatics, NJ. http://www. imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Health%20Institute/Reports/Secure/IIHI_US_Use_ of_Meds_for_2013.pdf. 3. American Board of Physician Specialties. http://www.abpsus.org/integrative-medicine-defined. 4. Bill Wilson’s letter to Dr. Carl Jung. January 23, 1961. 5. Rakel D. Integrative Medicine (third edition). Elsevier. Philadelphia, PA. 2012. WWW.SFMS.ORG
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NALOXONE FOR OPIOID SAFETY The Antidote to Overdose Phillip Coffin, MD, MIA Heroin overdose deaths started to decline around 2000, when San Francisco instituted drug treatment on demand
and made available the overdose antidote naloxone to some heroin users in the Haight-Ashbury district. An analysis done in 2002 showed that heroin deaths had all but stopped in the Haight, and the largest share of heroin overdose deaths were happening at single-room occupancy units in the Tenderloin and South of Market. In 2003, the Drug Overdose Prevention and Education (DOPE) Project started providing naloxone to drug users there, and the number of heroin overdose deaths have dropped precipitously— just ten deaths per year for the past three years of available data. The DOPE Project primarily serves syringe exchange programs and single-room occupancy hotels, with increasing presence at opioid substitution programs, medical clinics, and correctional reentry programs. Participants receive a five-to-ten-minute education on overdose and naloxone administration and how to respond to an overdose event. The DOPE Project recorded 1,067 overdose reversals from 2010 through 2014. There have been two recent changes in the heroin market that impact this positive outlook. First, San Francisco has been undergoing changes to opioid prescribing practices. Some of these changes emerged from health plans, such as restrictions on opioid dose or formulation, while others came from Medical Board or other institutional guidelines, such as routine urine toxicology, pain agreements, and required use of the Prescription Drug Monitoring Program (PDMP/CURES). While there is little to no data yet regarding the impact of these changes on opioid prescribing, diversion, or mortality, increases in heroin use indicators suggest that a shortage of opioid analgesics may be leading some individuals to shift to illicit opioids. Second, a new formulation of heroin referred to as “gunpowder” emerged in 2012 (see Figure 1). Gunpowder is far more potent than San Francisco’s traditional black tar heroin. In the middle of that year, there was a fourfold increase in the number of naloxone reversals reported to the DOPE Project, almost exclusively for heroin-related overdoses. Even more notable, whereas DOPE Project participants usually showed up for a refill four to five months after reversing an overdose, now they were returning within a month. This increase has sustained, with ongoing growth in the number of people trained and the number of reversals reported. Usually increases in drug overdose are first detected by the local medical examiner. This time, however, the mortality numbers for 2012 remain unchanged from 2011. Did the widespread presence of naloxone in the community of heroin injectors prevent a spike in heroin-related mortality?
Prescription Opioids
There’s more to this story. Prescription opioid overdose mortality has increased nationally, and San Francisco is no exception: 12
Figure 1: Gunpowder heroin found in San Francisco, 2012 while only 31 people died of heroin overdose in San Francisco from 2010 to 2012, 300 died from prescription opioids. Most prescription opioid decedents were 35 to 64 years of age (78 percent), male (67 percent), and non-Hispanic whites (71 percent). The most frequent causal opioids were methadone (49 percent), morphine (30 percent), oxycodone (24 percent), and hydrocodone (24 percent). Compared to heroin deaths, prescription opioid deaths were more likely to involve benzodiazepines and less likely to involve cocaine. These deaths are also more dispersed throughout San Francisco than heroin deaths have historically been, although there remains a substantial focus in neighborhoods such as the Tenderloin and South of Market (see Figure 2).
Naloxone for Patients Who Use Opioids
In response to these and data that the majority of decedents known to be in primary care had been prescribed opioids, in 2013 the San Francisco Department of Public Health (SFDPH) initiated a pilot program at six clinics to co-prescribe naloxone with opioid medications. The National Institutes of Health-supported Naloxone for Opioid Safety program provided training to staff at each clinic, access to supplies for a naloxone “kit” (including nasal atomizers, patient brochures, and baggies), and technical assistance for pharmacies (naloxone is covered by MediCal and most other California payors). The evaluation involved patient interviews, prescriber and pharmacist surveys, and a review of patient charts. Final data are pending from the analysis; however, the intervention was very well received by patients, prescribers, and pharmacists. Overall, providers issued naloxone prescriptions to 38 percent of patients receiving long-term opioid therapy. Based on this experience, and new California Board of Medicine guidelines recommending naloxone prescription for patients on chronic opioids, SFDPH initiated an academic detailing program to educate community providers about naloxone co-prescription. A total of forty-four providers were reached and forty accepted the intervention, with highly positive
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Figure 2: Opioid analgesic deaths by neighborhood in San Francisco, 2010–2012 (Source: California Electronic Death Record System) feedback. Materials for primary care prescribing of naloxone can be found at www.prescribetoprevent.org. These programs recommend considering naloxone prescriptions for any patient using opioids long-term. The rationale for this broad recommendation is multifaceted. First, clinicians are not effective at determining who is at risk for opioid-related respiratory depression. Tools based on retrospective data help us identify obvious high-risk cases, but more often we don’t know who might suffer from a future overdose. Second, in most studies, about half of overdose events occur from prescribed opioids that have been diverted, whether intentionally or unintentionally. There have been several cases of naloxone being used effectively at home by parents after accidental pediatric ingestions—a time-sensitive intervention for a young hypoxic brain. When the apartment of one of our San Francisco patients was burgled, the thief took only the opioid medications . . . and the naloxone. The third reason for such a broad prescribing protocol is to minimize stigma. Patients taking prescription opioids do not see themselves at risk for “overdose,” partly due to problems with the term. “Opioid-induced respiratory depression” is more accurate, as most victims are not intentionally using more opioids than they can handle. Indeed, the major risk factors for “overdose” involve concomitant use of other substances—from alcohol to benzodiazepines—and changes in opioid dose. Those with other chronic comorbidities and acute medical problems are also at higher risk, and there’s a strong case for a genetic contribution. By having a general policy of offering naloxone to patients who use opioids chronically, providers can tie naloxone to “risky drugs” rather than “risky patients.” Fourth and finally, offering naloxone can be a valuable opportunity to discuss the risks related to opioid therapy. Even if never used to reverse an overdose, simply providing an antidote to opioids may be sufficient to reduce risky behavior or encourage patients to explore adjunctive pain management. Physicians at U.S. Army Base Fort Bragg in North Carolina noted a decline from eight overdoses a month in the fort emergency department and twelve deaths a year to no overdoses whatsoever after they began co-prescribing naloxone to patients on opioids. There were no reported uses of naloxone WWW.SFMS.ORG
either, suggesting that the act of prescribing naloxone was changing behavior. According to a provider at the Fort: “[W]hen I prescribe naloxone . . . there’s that realization of how important this is and how serious this is in their eyes.” San Francisco providers, noting that prescribing naloxone feels more collaborative than other opioid stewardship interventions, echoed a similar sentiment: “By being able to offer something concrete to protect patients from the danger of overdose, I am given an opening to discuss the potential harms of opioids in a nonjudgmental way.” Patients have responded in kind: “I had never really thought about [overdose] before . . . it was more so an eye-opener for me to just look at my medications and actually start reading [about] the side effects, you know, and how long should I take them. . . . I looked at different options, especially at my age.”
Naloxone Everywhere?
The SFDPH and the DOPE Project have collaborated in several additional efforts to ensure naloxone is at the site of potential overdose events, such as prerelease trainings in the San Francisco County Jail. Partnering with the San Francisco Police Department, the DOPE Project trained 324 officers in all five downtown stations in naloxone administration, and all first-aid bags were equipped with naloxone in January of 2015. The training is now integrated into the Police Academy. In addition, the San Francisco Fire Department is developing a protocol to allow issuance of takehome naloxone kits following an opioid overdose managed by paramedics. While there is little hope of “reaching zero” opioid overdose deaths, due in part to social isolation, wide availability of naloxone will, we hope, help minimize related morbidity and mortality.
Conclusions
Prescription opioids far surpass heroin as the cause of overdose deaths in San Francisco. As opioid prescribing is declining, data suggest that heroin use is increasing. Wide availability of naloxone appears to have minimized heroin-related death and potentially blunted an expected spike in mortality in 2012. Providing naloxone to people who use opioids—whether licitly or illicitly—is a critical element of responding to opioid overdose and may be a useful tool in navigating chronic opioid use among primary care patients. Between 13,000 and 16,000 people inject heroin in San Francisco today. Studies conducted worldwide, including here, show that about 15 percent of heroin injectors overdose each year and 1 percent of injectors will die from overdose. This means that in San Francisco, according to the numbers, from 130 to 160 people will die from heroin overdose every year. Indeed, in the 1990s that was true. But public health interventions in San Francisco have done far better than anyone might expect. Phillip Coffin, MD, MIA, is an infectious disease clinician and substance use researcher. A graduate of UCSF, with a residency at Columbia University and fellowship at the University of Washington, Dr. Coffin returned to San Francisco in 2012 to direct substance use research at the SFDPH. He is also an assistant clinical professor of HIV/AIDS at UCSF.
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HEARTLESS IN THE HEARTLAND? HIV and Hepatitis C Prevention Strategies in Addiction Medicine Stephen E. Follansbee, MD This year, it took an epidemic of new HIV infections in a poor area of Indiana to alert the governor of that state to the needs of his citizens. The recent epi-
demic of HIV associated with injection opioid use illustrates many important issues. There have been 160 cases of HIV identified in a small community centered in Austin, Indiana, population 4,000. Not widely reported is the fact that 85 percent of those newly diagnosed individuals are also hepatitis C infected. There is one private, fee-for-service physician in the area, in a state that outlaws needle exchange programs. Recently Indiana Governor Mike Pence signed a bill that would allow any of the ninety-two counties in Indiana to apply for an exception to the needle exchange program ban if they can demonstrate either a hepatitis C or an HIV outbreak. Challenges in that community remain, including linkage to care, treatment for both HIV and hepatitis C, and overcoming the stigma of residents having a “gay” disease.
Missing from all of the articles that I reviewed on this outbreak was a discussion of one of the most significant advances in the prevention of new HIV infection.
Pre-exposure prophylaxis, or PrEP, is chemoprophylaxis against HIV. It involves the daily administration of a single oral tablet containing two active medications, tenofovir and emtricitabine, available now only by the brand name Truvada®. This article will review the rationale, management, drug-drug interactions, and concerns regarding this newly introduced approach to HIV prevention. It will discuss the responsibility of addiction medicine specialists to help monitor this effective intervention. The article will also address the issue of hepatitis C prevention in the setting of PrEP.
Why should addiction medicine specialists be concerned about HIV and hepatitis C prevention?
These are not just Indiana diseases. It is estimated that about 50,000 new cases of HIV infection occur annually in the U.S. The majority of these are in men who have sex with men (MSM). The percentage of new cases in men associated with drug addiction is stable and remains at about 11 percent of new cases. The situation in women is different; more than 70 percent of new cases in women are associated with sexual transmission from partners who are using drugs. The situation for hepatitis C is more ominous. In the U.S., recognition of hepatitis C infection is on the increase. It is estimated that only about 50 percent of hepatitis C-infected individuals are diagnosed. Many of those 14
individuals known to be infected, and certainly many of those not known to be infected, are not linked to routine medical care. They are unknowingly susceptible to the well-known risks of serious sequelae. They are also the source of new infections. The CDC reports about 29,700 cases of new hepatitis C infection in 2013 (the last year for which there are published numbers), but the estimated range is up to 101,400 cases. There has been an increase of 150 percent in reported new cases of hepatitis C in the last four years. Yet, despite mandatory reporting, the actual number of acute cases is estimated to be 13.9 times higher than the reported cases in any year. Acute hepatitis C infection is asymptomatic in at least 70–80 percent of infections. Thus, those newly infected may not be seeking medical care, and, importantly, they may not be monitored for new infection if they are in medical care.
What are the similarities and differences in risk for acquiring HIV and hepatitis C?
There is no vaccine for either of these viral illnesses. Both can be transmitted sexually, although sexual transmission for hepatitis C is less efficient. Thus, barrier precautions (condoms in men, cervical dams in women) help reduce sexual transmission. Both are transmitted by drug use, by secretions, and through blood contaminating shared devices. Nearly thirty years of evidence shows that needle exchange programs and encouraging individually dedicated works or devices decrease transmission of both hepatitis C and HIV. Another similarity is that reducing the viral load of the infected partner should also reduce the chance that the individual transmits the virus. An important concept is the impact of “community viral load” on transmission risk within an at-risk community. The lower the average or mean viral load in that community, the lower the risk of new infection. This concept is better established for HIV transmission, but it makes sense for hepatitis C transmission as well. It is estimated that half of new HIV infections are acquired from an individual who was infected in the prior twelve months and most likely does not know that he or she is infected. The HIV viral loads of many of the 160 individuals diagnosed in Scott County, Indiana, were extremely high. This suggests they were recently infected and the virus level had not dropped to the set point that can remain stably elevated before symptoms of HIV occur. The medical care impetus to get everyone with HIV identified and onto treatment as soon as identified as HIV positive is not only related to reducing the long-term damage from untreated HIV infection but also to reduce the risk for transmission. Of course, HIV treatment is not curative but just suppressive of viral replication. Hepatitis C is now a curable infection, although expensive, with oral regimens often lasting eight to twelve weeks. Imagine the impossible situation in which hepatitis C were eradicated through cure in the U.S. The result would be no new in-
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fection! Identifying people with new or established and untreated hepatitis C infection and initiating treatment should reduce the risk of transmission in their community of partners. The new difference now is that HIV transmission can be significantly reduced by PrEP. In contrast, there is no chemoprophylaxis for preventing acquisition of hepatitis C infection.
Is there evidence that PrEP works in injection drug users or their partners?
The answer is yes. Although the study that led to expanding the licensed indication for tenofovir/emtricitabine in the U.S. was done in men and transgender women who have sex with men (iPrEx), there have been subsequent reports of success in other populations. The success was as high as 92 percent in iPrEx, but it ranged from 49 percent with tenofovir alone (Bangkok Tenofovir Study) in injection drug users to 62–75 percent reduction in heterosexually transmitted disease (PREP2 Study and Partners PrEP Study). If blood levels of tenofovir were monitored and detected, the effectiveness increased to 90 percent, similar to efficacy in the iPrEx study. The success in every study is correlated with daily use of the single tablet. Although there are studies underway, there are no data to support intermittent or less frequent use of tenofovir/emtricitabine than the daily use for which the medication is now licensed. There are data to support post-exposure chemoprophylaxis using combinations of HIV medications for twenty-eight days after a single documented exposure. However, this approach should not be applied to people with ongoing risk for acquisition of HIV. They should be considered for PrEP. There is no post-exposure prophylaxis against acquisition of hepatitis C infection.
Are there important side effects and drug-drug interactions that addiction medicine specialists should be alert to in clients on PrEP?
Most of the time, PrEP will not be prescribed by an addiction medicine specialist. Some practitioners may choose to be involved in PrEP administration if they are seeing clients on a daily basis, particularly if they are administering other medications each day. This would be an important step to encourage adherence. Patients being considered for PrEP should have been screened for active hepatitis B infection. Although PrEP has no activity against hepatitis C, both components are potentially active against hepatitis B. Thus, hepatitis B infection should be identified and assessed prior to PrEP. Of course, if not immune or infected, patients should be vaccinated against hepatitis B. The toxicity of PrEP has been reported to be low. However, individuals considering PrEP should be screened for preexisting renal impairment or risk factors for renal disease, including a congenital or acquired single kidney. The use of any medication associated with risk for renal impairment should be reviewed with the practitioner prescribing PrEP. In addition, tenofovir is an important inducer of P-glycoprotein (MDR1) efflux transporter. Therefore certain medications such as the new anticoagulants dabigatran and edoxaban should be avoided, as well as the anticancer drug nintedanib. Importantly, PrEP does not prevent other sexually transmitted infections. Specifically, there are reports of individuals at risk for both HIV and hepatitis C acquiring hepatitis C despite apparently successful prevention of HIV acquisition. WWW.SFMS.ORG
Summary of responsibilities of the addiction medicine specialist in the setting of PrEP. If there are clients who fit one or more considerations for PrEP, they should be screened for new HIV infection and referred for evaluation. Screening includes both an HIV antibody test and an HIV viral load to detect more recent infection. Supporting PrEP should go a long way to encourage adherence and decrease the risk of new infection. The need for a medication should be evaluated frequently. If a patient no longer fits the criteria, there should be discussion of discontinuation of PrEP, with assurance that it can be reinitiated if appropriate. Encourage adherence. That means discourage sharing PrEP with others. Sharing tablets would decrease the effectiveness for the person for whom the prescription is intended. It may also cause unforeseen consequences in the recipient receiving the tablets without a prescription. Adherence is once-a-day oral administration at present. Adherence should be monitored in every case, often by prescription refill history. There should not be automatic refills generated without a request from the client, linked to provider approval after review of ongoing safety and possible acquisition of HIV in the interim. Two-drug treatment of HIV is not standard of care. Thus PrEP should not be continued if the client has acquired HIV despite PrEP. In general, the first response to nonadherence should not be a threat to discontinue PrEP. It should be a discussion with the client about reasons for nonadherence and ways to increase adherence. If there is suspicion or confirmation that a client has acquired HIV on PrEP, he or she should be referred immediately to an HIV specialist for evaluation. PrEP should have been discontinued in the interim. Linkage to care is critical and should be confirmed in every case. In many cases, since HIV infection is reportable by name, this linkage will be mandated by the local department of public health. Monitor all other medications to make sure that new medications with potential renal toxicity (long-term NSAID use, for example) have not been introduced without appropriate monitoring. Make certain that clients have been screened for hepatitis B and are immunized if appropriate. Clients starting PrEP should be screened for hepatitis C infection. If they are not infected, they should be reminded that PrEP is not prevention for hepatitis C. They should be encouraged to use their own equipment if they have ongoing drug use and to use barrier precautions for sexual exposure. They should be moni-
Continued on the following page . . .
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Heartless in the Heartland? Continued from the previous page . . . tored for asymptomatic infection. There are no strict guidelines, but ALT measurement every three months, with a good baseline result, should be adequate. Even modest rises (two to four times or more above baseline) should prompt evaluation for etiology, including possible acute hepatitis C. PrEP is an exciting advance in the prevention of new HIV infection. It is expensive, although there are manufacturer assistance programs and other avenues for access. The generic version of tenofovir should be available in 2017. Hopefully that will lead to significant cost reduction. The use of PrEP should be coupled with appreciation for its potential toxicity. Continuation should be based on continued dialogue regarding indications for use and other advances in HIV prevention. Addiction medicine specialists have an important role in assuring the safety and success of PrEP for HIV prevention in their practices. They also have an important role in monitoring for other serious infections, such as acute hepatitis C, that may be silent and are not prevented by PrEP. For more information, visit http://www.cdc.gov/hiv/pdf/ prepguidelines2014.pdf. Stephen Follansbee, MD, is a retired HIV and infectious diseases specialist in San Francisco. Since completing his postgraduate training at UCSF, he practiced for sixteen years with the Infectious Diseases Associates Medical Group and then another sixteen years with Kaiser Permanente in San Francisco. He is a clinical professor of medicine at UCSF and longtime member and past-president of the SFMS. Since retirement his main activities have been to say “no” to most requests for new responsibilities and to say “yes” to becoming certified in scuba diving.
MEDICAL USE OF MARIJUANA DOESN’T INCREASE YOUTHS’ USE, STUDY FINDS Benedict Carey Marijuana use did not increase among teenagers in
the states in which medical marijuana has become legal, researchers reported Monday. The new analysis is the most comprehensive effort to date to answer a much-debated question: Does decriminalization of marijuana lead more adolescents to begin using it? The study found that states that had legalized medical use had higher prevailing rates of teenage marijuana use before enacting the laws, compared with states where the drug remains illegal. Those higher levels were unaffected by the changes in the law, the study found. The report, published in The Lancet Psychiatry, covered a 24-year period and was based on surveys of more than one million adolescents in 48 states. The research says nothing about the effect of legalizing recreational use, however. “We have a war going on over marijuana, and I think both sides have been guilty at times of spinning the data,” said Dr. Kevin Hill, an assistant professor of psychiatry at Harvard and director of the substance abuse consultation service at McLean Hospital. “It’s nice to have a scientifically rigorous study to guide policy.”
Excerpted from The New York Times, June 15, 2015. 16
NEEDLE EXCHANGE: THE PERPETUAL PREVENTION BATTLE Steve Heilig, MPH In the mid-1980s, when HIV was spreading fastest in San
Francisco but not even named that yet, a small group of volunteers calling themselves Prevention Point began handing out sterile injection equipment in alleyways and on corners. Their aim was to prevent transmission of the new and very lethal disease, which was spreading not only via sexual contact but also among intravenous drug users (IVDUs) and their contacts. What they were doing was illegal under various laws. But it was a time of public health crisis, and health authorities, seeking to avoid a knee-jerk reaction and desperate to do anything that might slow the epidemic, took a close look. The SFMS hosted a meeting of public health, medical, addiction, gay, political, and other leaders. It was a heated discussion. Political leaders, including then-mayor Dianne Feinstein, were vehemently opposed to what was termed an “insane” effort. Addiction medicine leaders were also opposed, although on more rational grounds of not wanting to encourage drug use. Public health authorities seemed open to looking the other way but wanted support from medicine and others. The official stalemate persisted for years. Meanwhile research built that (1) needle and syringe programs (NSPS) could indeed interrupt transmission of not only HIV but hepatitis and other pathogens, and (2) such programs did not appear to endorse or lead to more injection drug use. As it turns out, they also save money by preventing HIV cases and removing contaminated injection equipment from the community. By the late 1990s, the SFMS felt confident enough in the science, and local anecdotal evidence (this author was a volunteer at an exchange program, in part for that purpose), to adopt a policy in support of needle exchange programs and to ask the CMA and AMA to do likewise. Our policy resolution in favor was adopted by both medical associations in 2000. Our Representative Nancy Pelosi ordered a review by the U.S. Surgeon General and Secretary of Health, with confirming general support for such programs. By 2004, the World Health Association had also done a review of programs around the world, stating a “compelling case that NSPs substantially and cost effectively reduce the spread of HIV among IDUs and do so without evidence of exacerbating injecting drug use at either the individual or societal level.” A further benefit was that such programs allowed trusting contact with IVDUs that could facilitate getting them into drug treatment. Local addiction medicine leaders, convinced by this evidence, changed to a supportive stance. Hundreds of such programs now operate in the U.S. However, federal funding for such programs was banned in 1988, overturned in 2009, and banned again in 2011, despite all evidence. Current efforts are funded via state and local public and private sources. Outbreaks of HIV infection in recent years have spurred debates about funding bans in other states, while California tends to support the programs as an integral part of our overall HIV-control strategy.
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POT POLICIES Professional Perspectives David E. Smith, MD, and Steve Heilig, MPH The debate about “legalizing” marijuana is far from new—our nation has been debating this for many decades. It is
a somewhat newer issue among medical associations, however. Thus when the California Medical Association’s board of directors in 2011 unanimously adopted a policy statement—developed with the impetus and input of the SFMS—advocating decriminalization, taxation, regulation, and research of cannabis, it was front-page news all over the state and beyond. This debate has become even more relevant as the possibility of legalization in our state increases—polls show a strong majority of Californians support liberalization of our cannabis laws, and mainstream politicians such as Lieutenant Governor Gavin Newsom are in favor as well. What about the most relevant medical specialty association? At the American Society of Addiction Medicine (ASAM) annual meeting this year, all aspects of the marijuana question were debated. It is clear that there is a substantial divide between the addiction medicine doctors practicing in states where marijuana is legal and “medical” marijuana is allowed and the states where marijuana is still illegal. The ASAM White Paper supports continued illegality and is backed by National Institute on Drug Abuse (NIDA) and the federal government. They stress the increasing rates of use among youth and the increasing incidence of those with marijuana use disorders entering treatment. All addiction medicine physicians agree with this concern, particularly for those of us who treat adolescent addiction and marijuana dependence. However, this increase in marijuana-related health problems has occurred in all states, including those where marijuana is illegal and enforcement is strict. ASAM addresses the public relations campaign in the media to legalize marijuana, criticizing it for underestimating the dangers of marijuana. But ASAM does not mention the past history of “Reefer Madness” approaches by the government, which overstated the dangers of marijuana and poisoned the information environment for youth—who in general do not trust current information about the dangers of marijuana any more than they ever had. At the ASAM panel on cannabis, Dr. Greg Bunt discussed the difference between legalization and decriminalization, which is also covered in the White Paper, which stated, “Marijuana decriminalization at the state level removes criminal penalties for the possession and use of marijuana while the sale and production of the drug remain illegal. Full legalization embraces the commercialization of production, sale, and use of cannabis.” Marijuana can have many negative health consequences. The primary psychoactive component in marijuana is THC, and tolerance and dependence to THC can occur with regular heavy use, particularly with the more potent forms of cannabis that are an increasingly part of the youth drug scene. Cannabis withdrawal WWW.SFMS.ORG
symptoms include irritability, anxiety, insomnia, appetite disturbance, and depression. Further, with the more potent forms of cannabis, including rapid delivery systems such as butane hash oil (BHO) intoxication, psychosis and drug-precipitated psychosis are regularly seen in treatment programs. Age of first use is an important risk factor in the development of mental health problems, including early-onset schizophrenia in at-risk youth. In addition, marijuana intoxication causes short-term effects on the brain, including memory and learning. ASAM is concerned that many of the marijuana reform proposals ignore the negative health consequences of marijuana. However, the California Society of Addiction Medicine (CSAM), ASAM’s largest state chapter, acknowledges the negative health problems with marijuana but recommend a different strategy for marijuana policy in California. Core tenets of the CSAM Marijuana Policy—and of the CMA— are: 1. Current state law does not effectively regulate marijuana use in California. 2. National and local antidrug campaigns have been largely ineffective. Forty years of increasingly strict criminal sanctions have had little impact on widespread drug use, while creating conditions that encourage narco-trafficking. 3. Incarceration of nonviolent drug offenders has substantially contributed to California’s prison overcrowding crisis. Early-onset addiction in youth should be viewed as a pediatric disease, as the signs and symptoms occur early in the developmental cycle, well before full-blown addiction surfaces. Excessive reliance on incarceration places criminal justice in the position of treating what is largely a public health problem. Treatment for substance abuse works and should be society’s response to individuals dependent on cannabis, particularly for youth, who are the most vulnerable to marijuana’s effects. But even long-standing adolescent programs are facing closure due to the withdrawal of funding. We should stress that the drive to legalize marijuana should not be used or seen as a platform to promote any idea that marijuana for youth is benign but rather that current policy is a failure and we need to find a better public health strategy. It is clear that addiction medicine is divided on what that policy should be and whether final decisions will be based on medical evidence rather than public hysteria. It would be a shame if public policy moves on ahead of medical expert opinion in this case. Dr. Smith is a past president of both CSAM and ASAM, founder of the Haight-Ashbury Free Clinics, and a lifetime SFMS member. The SFMS’s Steve Heilig is a former Robert Wood Johnson fellow in drug policy and a member of Lieutenant Governor Gavin Newsom’s Blue Ribbon Commission on Marijuana Policy (https:// www.safeandsmartpolicy.org/). JULY/AUGUST 2015 SAN FRANCISCO MEDICINE
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CANNABIS AND TEENAGERS Clinical Treatment of Use Disorders in Adolescents Peter Banys, MD, MSc, and Timmen Cermak, MD At this time in history, there are few organized treatment resources for adults and adolescents in trouble with marijuana. There is actually more need for treat-
ment, especially for youth, than there are available treatment programs. This briefing summarizes the options and challenges for physicians working with their most severely affected adolescent patients with cannabis use disorders (CUD). It is our thesis that young-onset marijuana users are at greatest risk because, during school years, they are particularly vulnerable to many kinds of psychosocial disruptions that impact education and learning. A minority of regular (ten to nineteen days per month) and heavy (at least twenty days per month) users may also transition to meeting criteria for dependence for some period of time. For the most part, research outcomes studies have tested the same treatment methods that have been previously developed for other addictive drugs, including twelve-step meetings, psychotherapy, cognitive-behavioral treatments, and motivational interviewing. Youth studies rightly favor approaches that include a strong family component. All appear to produce moderate short-term benefits and significant rates of relapse. And, although a number of pharmaceuticals have been tested to reduce craving and/or relapse, none have been approved for use in cannabis dependence or withdrawal.
Natural History of Cannabis Use
Marijuana use, even heavy use, is not the same as problematic CUD. For most youthful users, marijuana dependence will be a self-limiting process. Unfortunately, only a few studies describe the transition from regular recreational use to dependent use. Although heavy users of marijuana are at higher risk for CUD, especially if they initiate use in the early teen years, the majority do not go on to a lifelong course of addiction. Most teens will transition out to low or no regular use in their twenties and thirties. Approximately 3.9 percent of recent-onset users will develop dependence within twenty-four months of first onset of use. Risks for dependence increase for onset before late adolescence, for low income, and for polydrug use prior to cannabis initiation. As of 2015 in California, before any legalization initiative, 8 percent of high school juniors are already heavy users, using marijuana twenty or more days each month, and another 3 percent are regular users, using ten to nineteen days each month. Marijuana use is one of many factors that is clearly associated with decrements in school performance. At present it is not possible to tease out relative causality among other associated factors, such as alcohol and drug use, family and peer-group effects, and culture. We believe that risks to educational progress are much greater than risks for persistent addiction or brain damage. 18
Therapeutic Options California offers few public resources for treatment of severe cannabis addiction. Fewer treatment facilities specialize in adolescent treatment of substance abuse. One example is Thunder Road Adolescent Treatment Center in Oakland, but most such programs are unstably funded. For-profit residential substance abuse facilities developed for adults, often structured with spa-like amenities, sometimes offer residential tracks for adolescents. Their costs can be astonishingly high, and their longer-term outcomes are poorly documented. What is mostly missing are group support systems in the home community capable of providing flexible outpatient alternatives. For teens from families with means, one treatment option is a month or more in a wilderness program, most of which are in remote rural settings (to interfere with running away). Such programs offer extended forced separations from family and peers and emphasize self-reliance activities, such as camping, to foster a greater sense of responsibility and altruistic activities, such as peer collaboration. They are something of a blend of Outward Bound, ropes courses, and boot camp—all in the service of socialization into recovery and abstinence. This is, of course, only an initiation of treatment. Sustained treatment support remains difficult to find, in part because so little is offered within the school system. Those with insurance may turn to pediatricians or child psychiatrists, who typically only offer individual counseling, often with no expertise in addiction. The juvenile justice system remains a major provider of services for youth without means, but outcomes data are hard to find. The California Department of Corrections and Rehabilitation (CDCR) provides education, training, and treatment services for California’s most serious youth offenders. Most of these substance abuse services are actually offered as part of a community-based probation system. Many juvenile marijuana arrests in fact are plea-bargained and more likely lead to probation than incarceration. There are several comprehensive reviews of treatment for cannabis use disorder. Five forms of treatment offered in several combinations have been studied, including (1) motivational enhancement therapy, (2) cognitive behavioral treatment, (3) adolescent community reinforcement approach, (4) multidimensional family therapy, and (5) family support network. The Cannabis Youth Treatment Study showed that, while the initial interventions were often effective, half of the adolescents experienced intermittent relapse one or more times after discharge. Two-thirds still reported substance use or related problems at twelve-month follow-up. The researchers concluded that cannabis diagnoses are best understood as chronic conditions
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requiring a need to focus more on long-term monitoring and care. For adults with CUD, few programs specialize in marijuana-only treatment, but many programs provide competent outpatient or residential services, mostly consisting of individual, group, and twelve-step meetings. Physicians and certified counselors who specialize in addiction medicine are also good referral resources. In some communities, marijuana anonymous (MA) meetings may be available. For a national directory of available alcohol and drug detox and treatment programs, go to www.findtreatment.samhsa.gov or www.csam-asam.org/member/search.
Motivating Change
Adult heavy users usually establish therapeutic contact themselves, often in response to a partner’s pressure, but for adolescents, the parents are more likely to make the initial contact with a clinician. Most heavy marijuana users are not reluctant to discuss their use if their rationales for use are explored rather than attacked. Several common themes run through patients’ denial that marijuana can cause problems. Generally speaking, most heavy users will state that they can quit any time they so desire, that marijuana is beneficial for them, that authorities and parents are hypocrites given their own use of alcohol and pills, and that they notice no difference in function when they quit for a few days. “Everyone I know uses weed.” “It can’t be harmful—it’s natural and organic.” “No one ever died from a marijuana overdose.” “It makes me feel better. I feel more aware of things around me.” “It helps me study boring subjects.” “I have a medical marijuana card, and I have a right to treat my mood.”
Individual assessment and treatment depends on developing a nonconfrontational therapeutic relationship, beginning with eliciting the patient’s experience with marijuana, often initially presented by the adolescent as entirely positive. Inevitably there have been some personal costs, and getting to them will evoke the cognitive dissonance that is needed to drive change. The principles of motivational interviewing respect patients’ ambivalence and encourage them to wrestle with their own positive and negative facts. [See SFMS June 2015 journal edition for practical “Motivational Inteviewing” tips.—Ed.]
Withdrawal Medications Among the most common symptoms seen in the first twenty-one days of cannabis withdrawal are anger, irritability, anxiety, restlessness, decreased appetite, sleep difficulties, dream rebound, diverse physical complaints, and depressed mood. And it is well established that daily users will continue to excrete metabolites and test positive for cannabis for a month or more after cessation, although the clinical significance of this has not been established. There is a small amount of research on medications, including oral THC, to reduce symptoms of cannabis withdrawal, and some medications may help in the short term. However, there are no approved meds to reduce craving or to reduce the odds of relapse. N-acetylcysteine (NAC), a research compound that is available over the counter, more than doubled the odds of having negative urine cannabinoid tests as compared with placebo, with benefits detectable within a week of treatment initiation. For cannabis-dependent patients who have discontinued use, gabapentin substantially reduced withdrawal and craving symptoms, reduced sleep and mood disturbances, and improved executive functions within the first week, an important factor in patients’ ability to make effective use of treatment. Other agents being studied include chemicals called FAAH inhibitors, which may reduce withdrawal by inhibiting the breakdown of the body’s own cannabinoids. Future directions include the study of substances called allosteric modulators that interact with cannabinoid receptors to inhibit THC’s rewarding effects. For a review of medications, see www.drugabuse. gov/publications/research-reports/marijuana/available-treatments-marijuana-use-disorders. Conclusions: Since California’s Prop 215 increased the availability of medical marijuana, we have seen a steady increase in marijuana diversion and usage among adolescents. Paradoxically, legalizing marijuana increases opportunities to regulate its distribution and use, thereby protecting our youth. As clinicians who work with young adult and adolescent marijuana addicts, we favor stronger regulation and enhanced public commitment to youth treatment. Both of these measures are essential to improve the clinical management of cannabis use disorders in adolescents. Peter Banys, MD, MSc, is clinical professor of psychiatry at UCSF. Timmen Cermak, MD, is an addiction psychiatrist in private practice. Both are members of Lt. Governor Gavin Newsom’s Blue Ribbone Commission on marijuana law reform.
DSM-V Criteria for a Substance Use Disorder
The Diagnostic and Statistical Manual 5 defines a substance use disorder as the presence of at least 2 of 11 criteria, which are clustered in four groups: Impaired Control Taking more or for longer than intended Unsuccessful efforts to stop or cut down use Spending a great deal of time obtaining, using, or recovering from use Craving for the substance
Risky Use Recurrent use in hazardous situations Continued use despite physical or psychological problems that are caused or exacerbated by substance use
Social Impairment Pharmacologic Dependence Failure to fulfill major obligations due to use Tolerance to effects of the substance Continued use despite problems caused or exacerbated by use Withdrawal symptoms when not using or using less Important activities given up or reduced because of substance use WWW.SFMS.ORG
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NOVEL MARIJUANA PREPARATIONS Edibles and Beyond Ingeborg Schafhalter, MD Since California legalized medical marijuana in 1996 (Prop 215), twenty-three states have followed suit.
Four more states also legalized recreational use after 2012. By 2014 the cannabis market exploded 74 percent to become one of the fastest-growing drug markets in the U.S. While smoking from “joints” or water pipes or eating in “brownies” remain the most common ways to use cannabis, expanding markets have created new opportunities to sell novel, attractive preparations to eager consumers.
New marijuana edibles sold as KifKats, Pot Tarts, Gummy Bears, Lolly Pops, Hashees, Nugtella, or Canna Cola mimic familiar candies and drinks. These edible cannabis products range from simple cookies and candies to cannabis-infused honey and designer foods. Some have even entered the home kitchen with the publication of designer recipes in The Stoner’s Cookbook (http://www.thestonerscookbook.com/meals/). Most of these legalized edibles are well labeled, listing TCH content in milligrams, making them safer but also more available to an audience of inexperienced users unaccustomed to edibles. When ingested, oral marijuana absorption is less predictable than when smoked, taking anywhere from thirty minutes to two hours to show effect. THC peak concentration typically occurs one to five hours post ingestion. THC bioavailability is 6 percent when orally administered and 27 percent when inhaled. However, the production of potently active liver metabolites such as 11-hydroxy THC, which is five to ten times more psychoactive than the THC originally ingested, leads to prolonged activity. Despite differing time course and bioavailability, oral and smoked cannabis produce comparable behavioral and physiological responses.
Marijuana wax, also known as “ear wax,” “wax,” shatter,” “honeycomb,” “oil,” “crumble,” “sap,” “budder,” “pull-and-snap,” or “BHO”(for “butane hash oil” or “butane honey oil”), is far more powerful than smoked or edible cannabis. Shatter, which is amber-colored, transparent, and glass-like, has a reputation for being the purest and cleanest form of marijuana extract. Cannabis wax refers to the softer, opaque oils that lose their transparency after extraction. Unlike the transparent oils in shatter, the molecules of cannabis wax crystallize as a result of agitation. Wax is more than 80 percent pure THC, which results in a quicker “high” and therefore is regarded as the strongest form of marijuana. The process of ingesting wax is called “dabbing” or taking a hit of a “dab.” The process of producing wax is called “blasting,” while producers are known as “blasters.” In blasting, marijuana is placed into a long tube or pipe, which is hit with a rush of highly flammable butane. This process extracts THC, 20
forming a hardened, extremely potent form resembling wax. While marijuana in California typically costs between $15 and $20 per gram, wax ranges between $70 and $100 per dab.
Sublingual or mucosal marijuana is distributed as mints,
hard candy, or drops, which are placed under the tongue. THC is rapidly absorbed into the arterial system by this means and quickly transported to the brain and body. To titrate to the desired effect, marijuana users need only use a few drops or mints, wait for the desired effects, and dose again as needed. Also available are tinctures that contain 75 percent ethanol or are made as a concentrated elixir, which can be flavored for better taste. The effects of all of these sublingual preparations are usually felt within fifteen to sixty minutes and last for four to six hours.
Dermal marijuana, compounded into a compress, salve,
tincture, balm, massage oil, or bath soap, can be applied directly to the skin and is absorbed locally. It is debated whether THC in this form can reach the central nervous system, as animal studies showed no TCH plasma concentration after application of cannabis to the skin. This suggests that topical applications of THC would have no psychoactive effect; however, benefits to painful or inflamed areas have been reported. Dr. Ingeborg Schafhalter-Zoppoth is an internist and primary care physician at CPMC/SPMF board-certified in internal medicine and addiction medicine. After completion of her medical training in Austria she worked as researcher at UCSF and finished her residency in internal medicine and primary care at Alameda County Medical Center. She also works as clinical educator for the CPMC internal medicine residency program where she teaches outpatient management, addiction medicine, and quality improvement.
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EARLY WARNINGS Asian Binge Drinking David Pating, MD It is a common myth that Asians don’t drink (or use drugs)! Listening to their parents, these “model” citizens are
indoctrinated since their teens: ”Drink beer? Why you not drink textbook!?” Observing the dense sea of Asian Pacific Islanders (API) awash in San Francisco’s ballooning tech industry, it is obvious that many API young adults did drink from their textbooks. But my colleagues and I who work in San Francisco’s drug treatment programs notice early signs of some young Asians drinking from beer bottles, too. With “happy hours” and “free beer on tap” a standard employee benefit at many tech companies, we stand wondering if this is early warning of an alcohol bubble. Right now, as a result of Asia’s supernova economy, China is in fact witnessing its largest drug epidemic in centuries—binge drinking, perhaps its most significant drug problem since the Opium Wars. (Actually, tobacco smoking is China’s worst drug epidemic.) Bottom line: Young Chinese men and women in China are drinking a lot! With success comes its trappings—including alcoholism. Still, in the U.S., Asians constitute fewer than 1 percent of persons in alcohol or drug treatment, despite their accounting for 5 percent of the U.S. population. In my San Francisco drug treatment program, fewer than 1 in 20 patients enrolled last year were API. Often I’ve wondered how this was possible when APIs constitute 35.8 percent of San Francisco’s population (2010), making it one of the most heavily API-populated U.S. cities. Is this a health disparity? Or maybe the myth is true. The fact is, Asian’s do drink less and use drugs less than other racial or ethnic groups; and when they drink, they have less severe consequences. Most of this is Genetics 101. Asians have evolved dominant or partially dominant genetic variants of aldehyde dehydrogenase (ALDH2: Chinese 31 percent, Japanese 45 percent, Koreans 29 percent) and alcohol dehydrogenase (formerly ADH2, now ADH1B: Chinese 92 percent, Japanese 84 percent, Korean 96 percent), which are rare in whites. These genes cause the typical “flushing” reaction observed when many Asians drink alcohol. Recent research suggests the ALDH2*2 allele may have evolved in those Asian regions where wet rice farming was prevalent. Where there is wet farming, so goes the risk of fecal-oral contamination. As the old song plays: “Did you wash your hands or are they wet with hepatitis B?” It is hypothesized that genes, which discouraged drinking, offer some protection against significant morbidity (liver cirrhosis and hepatocellular carcinoma) associated with problem drinking in those with hepatitis B. In short, these alleles are ancestral gifts—despite what non-Asian fraternity brothers may jeer. But the protective effects of genes can be overwhelmed by cultural influences. Richer Asian countries swim in an ocean of alcohol. Korean and Japanese men, especially those on business junWWW.SFMS.ORG
kets, drink like whales. There are also variations by age and nativity. Younger API individuals, as well as those born in the U.S., both drink and use more drugs than their older cousins born overseas. Fortunately, other genetic variants among Asians may increase their response to medications for alcoholism treatment. Up to 80 percent of API may have improved pharmacologic response to naltrexone, experiencing more sedation, subjective intoxication, and lower alcohol craving on this anti-drinking medication. Asians also do as well as non-Asians in rehab therapy programs, despite concerns about “fitting in.” When API individuals enter treatment, family issues and medical concerns predominate; and they prefer more pills, medications, and private counseling than other modalities. Less fortunate is the fact that API individuals with alcohol problems rarely seek treatment, even when it would be beneficial. Despite rapid acculturation, familial shame and cultural stigma about mental health problems persists—even among SF techies. All this has led to the myth, “Asian’s don’t drink!” And the new variant myth,” . . . because they’re all gambling!” Which a quick scan of California’s 2006 Problem Gambling Survey indicates is also untrue: Asians gamble less and seek treatment just as rarely (as non-Asians). So what can we conclude? Asian Pacific Islanders who admit to alcohol and drug problems with desire to enter treatment are rare fish. They should be praised and encouraged. While retrospective trends suggest the prevalence of alcoholism in API is low, with the flood of young and wealthy techies into San Francisco, many of them of East and South Asian ancestry, my colleagues and I wonder if we will see a techie bubble of alcohol and drug use atop the wave of Silicon Valley’s prosperity. For now, Asian binge drinking serves as our early warning. For author bio, see page 9. JULY/AUGUST 2015 SAN FRANCISCO MEDICINE
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PHARMACOTHERAPY Treatment for Alcohol Use Disorder Steven L. Batki, MD Alcohol use disorder (AUD) is a major public health problem that contributes prominently to the global burden of disease. While there are several approved medi-
cations for the treatment of AUD, the available pharmacotherapies are hampered by limited adoption into clinical practice. Despite the large numbers of patients who suffer from AUD, medications are greatly underused and only 8 percent of adults in the United States who have AUD are treated with medications.
AUD Medications Overview
Four medications are currently approved by the Food and Drug Administration (FDA) for the treatment of AUD: disulfiram, acamprosate, oral naltrexone, and extended-release injectable naltrexone (XR-NTX). A non-FDA-approved fifth medication, topiramate, has substantial evidence supporting its efficacy in reducing alcohol use.
Disulfiram (Antabuse)
Disulfiram is the oldest of the available AUD medications and has been in use since the 1950s. Disulfiram’s mechanism of action is inhibition of the enzyme acetaldehyde dehydrogenase, causing accumulation of acetaldehyde following the ingestion of alcohol, leading to an intensely aversive physical reaction almost immediately following a drink. The anticipation of this adverse consequence is thought to limit the resumption of alcohol use following disulfiram initiation. Disulfiram can be clinically useful in highly motivated patients who have already stopped using alcohol. There have been few well-controlled studies of disulfiram’s effectiveness. The largest rigorous, controlled study showed only questionable efficacy, while a recent meta-analysis failed to find evidence for disulfiram’s efficacy in improving alcohol consumption outcomes. The risk of liver toxicity has led to the recommendation for liver function tests (LFTs) before treatment with disulfiram is initiated, and periodically during treatment. Disulfiram treatment requires commitment to abstinence from alcohol use because of the hazardous effects of the disulfiram-alcohol reaction. Treatment can only be started in patients who have already stopped drinking and who have made a commitment to maintaining abstinence. Disulfiram can only be used for relapse prevention, not to aid in the initiation of abstinence or in reducing alcohol use. It cannot be used with individuals who are still drinking, in contrast to other medications for AUD.
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Acamprosate (Campral) Acamprosate, a structural analog of amino acid neurotransmitters such as taurine, is thought to modulate the NMDA receptor. Acamprosate may reduce alcohol use through reversing some of the hyperexcitability-related neuroadaptations produced by chronic heavy alcohol use. Acamprosate has been shown to reduce relapse rates and craving for alcohol in European studies. A recent meta-analysis, based largely on European studies, shows that acamprosate was associated with reduction in measures of alcohol consumption. However, intent-to-treat analyses from United States controlled clinical trials, e.g., the COMBINE study and others, have all failed to show that acamprosate has greater efficacy than placebo in reducing alcohol use in American patients. In addition to its apparent lack of efficacy in American studies, acamprosate treatment poses challenges to adherence because of the complex dosing regimen of two large tablets taken three times a day.
Oral Naltrexone
Oral naltrexone (NTX) hydrochloride, a mu-opioid receptor antagonist, was approved in its oral form for the treatment alcohol dependence in the United States in 1994. NTX is both safe and well tolerated, and its use has been associated with reduced rates of relapse, briefer relapse periods, and reduced drinking during relapses. Subsequent studies have generally supported the initial findings of efficacy, although oral NTX has only a small to moderate effect size for alcohol use reduction. NTX may not work optimally for all AUD patients and may be most efficacious for patients with a positive family history of AUD. Nevertheless, NTX, a once-daily medication, is probably the first-line pharmacotherapy for patients with AUD. Of great importance: It cannot be used with patients using opioid analgesics because it would put such patients into severe opioid withdrawal. Liver function monitoring is also recommended with NTX.
Extended-Release Injectable Naltrexone (Vivitrol)
NTX is also available in a monthly extended-release intramuscular injectable dosage form, which was FDA-approved in 2005 and which offers considerable adherence benefits. Injectable extended-release formulations of NTX are used to treat both opioid and alcohol dependence. A single injection of extended-release naltrexone (XR-NTX) is capable of releasing NTX for one month following injection. Monthly injections of XR-NTX significantly reduce heavy drinking days over placebo injection and are well tolerated. XR-NTX appears to be more effective in participants with at least a brief period of abstinence prior to
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medication start, but it does not require abstinence in order to be used. The XR preparation of NTX may reduce the severity of NTX adverse effects (e.g., nausea) by avoiding the peak daily blood levels and the first-pass metabolism of the oral form. With oral NTX, adverse events can lead to treatment discontinuation, whereas XR-NTX provides continued coverage while side effects subside. XR-NTX promises to improve adherence and possibly improve tolerability, two factors important for successful treatment of patients with AUD. Like oral NTX, it cannot be used with patients who are taking opioid analgesics, and it also requires periodic monitoring of liver function tests.
Topiramate: An Efficacious Non-FDA-Approved AUD Medication
Topiramate (Topamax and other brands) is an FDA-approved anticonvulsant and migraine treatment medication that has been shown to be significantly more efficacious in reducing alcohol use than placebo in several double-blind controlled clinical trials. Patients treated with TOP, compared with those on placebo, had more days abstinent, fewer drinks per drinking day, fewer heavy drinking days, and lower levels of craving alcohol. Topiramate (TOP) modulates the effects of excitatory amino acids and facilitates gamma-aminobutyric acid (GABA) action in the midbrain—effects that have been shown to be associated with clinical benefit in the treatment of alcohol dependence and in reducing the aversive effects of alcohol withdrawal. TOP is not extensively metabolized and is primarily eliminated unchanged in the urine. It can therefore be used with patients with impaired hepatic function, although the dose needs to be reduced in patients with renal insufficiency. TOP is generally dosed twice per day. While quite effective, TOP has numerous adverse effects, such as cognitive impairment including memory problems, and rare serious side effects, such as narrow-angle glaucoma and nephrolithiasis, so dosage needs to be slowly titrated to maximize tolerability. It can also cause metabolic acidosis and taste alterations in some patients.
Summary
Alcohol use disorder is undertreated with medications, and pharmacotherapy is generally neglected as a treatment intervention in patients with AUD. Oral naltrexone is probably the best first-line medication, although it cannot be used in patients who are on opioid analgesic treatment. Extended-release naltrexone offers considerable adherence benefits over oral NTX. Acamprosate is less reliable in its effectiveness and much more difficult to adhere to due to the large number of pills required per day. Disulfiram may benefit some patients, but they must be abstinent before starting treatment. Topiramate may be the most robustly effective of the AUD treatment medications, but it poses challenges with respect to adverse effects. Steven L. Batki, MD, is a professor at UCSF Department of Psychiatry, chief of SF VA Medical Center Addiction Services (ARTS), director of the Addiction Research Program and UCSF Addiction Psychiatry Fellowship Program, and consulting addiction psychiatrist at Alta Mira Recovery Programs in Sausalito.
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EHR and Meaningful Use Assistance Program The Office of Health Information Technology at Medi-Cal is providing $37 million for technical assistance to eligible professionals to encourage meaningful use of certified electronic health records (EHRs). Lumetra Healthcare Solutions is a recipient of the funding and will be enrolling eligible professionals into the program. Eligible professionals include specialists, small and solo professionals as well as professionals practicing in medium to large size practice settings. All professionals must have at least 30% Medi-Cal in order to qualify for services.
The services available to eligible professionals include:
1. Provide education, training, and outreach to assist eligible professionals implement and attain meaningful use of certified EHR technology. 2. Provide implementation and project management support to the eligible professionals over the entire EHR implementation process 3. Provide support for practice and workflow redesign 4. Assist eligible professionals in connecting to available health information organizations (HIOs) 5. Assist eligible professionals in attesting to meaningful use
Meaningful Use Incentive Program
Currently there is a Notice of Proposed Rule Making (NPRM) under consideration at CMS to make changes to the meaningful use requirements for Stage 1 and Stage 2 for 2015 through 2017 to align with the approach for Stage 3. Initial meaningful use measures included 13 core objectives, 5 menu objectives and 9 Clinical Quality Measures (CQM’s) across 3 domains. The NPRM will change the requirement to 9 core measures, 2 public health measures and the CQM’s will remain the same. Further, the NPRM will allow eligible professionals to use a 90 day reporting period in 2015 regardless of which stage of meaningful use they are at. The NPRM is anticipated to be approved this summer with changes effective immediately. Eligible professionals should also be aware that 2016 is the final year to register for the Medi-Cal incentive program and receive the full incentive payments of $63,750. The Medi-Cal Technical Assistance program can provide resources to eligible providers to ensure incentive payments are maximized. For those professionals who are not eligible for the Technical Assistance program, Lumetra offers a reduced rate to provide services to members of the San Francisco Medical Society. Lumetra offers a customizable suite of services that will help you optimize HIT, increase efficiencies, maximize incentive payments, improve patient care and ensure HIPAA compliance. For more information, please contact Kim Snyder at ksnyder@ lumetrasolutions.com or (415) 677-2162.
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WHAT IS RECOVERY? What Does It Mean for Doctors and Their Patients?
When patients tell you that they are “in recovery” from alcohol or drug problems, what does that mean—and what is the course of care that you should engage
in with them? A recent NIH study about how recovering individuals define recovery provides clues that can help guide your treatment. The “What Is Recovery?” study gathered online surveys from 9,341 individuals in recovery regarding how they defined recovery. More than 95 percent said that their definition of recovery involved “taking care of my physical and mental health more than I did before.” Thus, when you treat a person in recovery, it is likely that they will be motivated to be compliant with your advice. This is probably not what you would expect from someone who has a current alcohol or drug problem, which highlights one of the ways that recovery can change patients’ attitudes toward their health. Patients new to recovery may have a long list of health problems due to their prior inattention to their health, so you may have to spend longer time than usual with them in order to identify the full spectrum of issues you’ll need to treat. Another element of recovery that almost everyone said belonged in their definition was “being honest with myself.” This level of self-awareness should translate to their being able to have candid interactions with you. Therefore, you should be able to ask sensitive questions to patients in recovery and to expect honest answers. If the patient is relatively new to recovery, you should perhaps not assume that everything in their chart is accurate, since those in active substance abuse may not have been totally forthcoming in prior visits with you. A third element of recovery that was endorsed by almost all the study respondents was “taking responsibility for the things I can change.” You should therefore not be surprised if a patient in recovery is proactive rather than passive in terms of their role in developing and carrying out a treatment plan. You also should be aware that many individuals in recovery (especially those attending twelve-step groups such as Alcoholics Anonymous or
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Lee Kaskutas, DrPH
Narcotics Anonymous) believe that they are not responsible for their disease of alcoholism or drug addiction but that they are responsible for doing something about it. It may thus be helpful for you to similarly explain to such patients the extent of their responsibility for health problems that you might discover, so as to assuage any concerns they might be feeling about self-blame and to delineate what (and how much) they can do to address a given health problem. It is our hope that these commonly accepted elements of recovery will be encouraging to physicians who treat recovering individuals, as it tells them that patients in recovery most likely are motivated to take care of their health, be honest about their health issues, and be proactive in following your guidelines. This way of being stands in contrast to the stigma associated with alcoholism and drug addiction and signals the positive elements of recovery that can be expected. Importantly, you cannot assume that every patient in recovery from alcohol or drug problems will be completely abstinent from alcohol and drugs. Over a quarter of the participants in the “What Is Recovery?” study said that nonproblematic alcohol or drug use was part of their definition of recovery. Yet 83 percent said recovery was no use of alcohol, 84 percent said recovery was no abuse of prescribed medication, and 76 percent said that
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recovery was no use of nonprescribed drugs. This gets to the issue of individuals becoming abstinent from their “substance of choice” but seeing it acceptable to use other substances. One caveat about the recovery definition and how it relates to your interactions with patients in recovery: In the survey, respondents were not asked whether they had achieved every element of recovery that they endorsed—they were only asked how they defined recovery. That is why the physician advice above uses words and phrases like “it is likely that . . . ” and “should” when referring to the patient’s current state when they present to you for care. For more information about how the survey questions were worded, the demographic characteristics of the study sample, and a full list of the elements of the recovery definition, visit the study website at http://www.WhatIsRecovery.org. When treating a patient who is still involved in active, severely problematic alcohol or drug use, you might consider making a referral to Alcoholics Anonymous or Narcotics Anonymous (AA/NA), especially if there is uncertainty regarding the availability of alcohol or drug treatment for which the patient is eligible. However, you may find that patients are resistant to AA/ NA because of the spiritual nature of those programs, because they can feel like cults, or for a myriad of other reasons. To give you ideas about how to deal with these objections, the MAAEZ manual (Making AA Easier) may be helpful. MAAEZ is a group format, evidence-based intervention that works by helping patients feel comfortable with the culture and fellowship of AA. The manual can be downloaded from http://www.ARG.org. You may also have your own concerns about the efficacy of twelve-step programs such as AA/NA and thus be leery of referring patients to those groups. It is very difficult, perhaps even impossible, to conduct a randomized clinical trial of these programs, since study subjects cannot be forced to attend nor can they be stopped from attending these widely available mutual aid groups. For a discussion of the available evidence on the effectiveness of AA/NA, my article “AA Effectiveness: Faith Meets Science,” published in the Journal of Addictive Diseases in 2009 (volume 28), may be of interest; go to www.ncbi.nlm.nih.gov/pmc/ articles/PMC2746426/. Lee Ann Kaskutas, DrPH, is a senior scientist at the Alcohol Research Group of the Public Health Institute and Adjunct Associate Professor in the School of Public Health at the University of California, Berkeley. In 2007, Dr. Kaskutas received ASAM’s R. Brinkley Smithers Distinguished Scientist Award. She is currently working with a member of ASAM’s board of directors to develop a protocol for using the “What Is Recovery?” definitions to guide innovative process groups in treatment settings and in recovery-oriented systems of care. Information provided here was originally published in Kaskutas LA, Borkman TJ et al. Elements that define recovery: The experiential perspective. Journal of Studies on Alcohol and Drugs. November 2014; 75(6), 999-1010. Reprinted with permission from Alcohol Research Documentation, Inc., publisher of the Journal of Studies on Alcohol and Drugs (www.jsad.com).
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The Doctor’s Friend: Alcoholics Anonymous For patients experiencing alcohol or drug use problems, addiction treatment, including counseling and self-help, medications, or both, are recommended. For patients unable or unwilling to consider treatment, Alcoholics Anonymous offers an important self-help adjunct or alternative.
Why go to AA? Alcoholics Anonymous is an international fel-
lowship of men and women who have had a drinking problem. It is nonprofessional, self-supporting, multiracial, apolitical, and available almost everywhere. There are no age or education requirements. Membership is open to anyone who wants to do something about his or her drinking problem. To participate in AA, most people simply attend a local AA meeting. Meeting schedules are available at www.aasf.org or www.aa.org.
Research studies find higher rates of abstinence among people who go to AA during treatment:
• Higher AA attendance during treatment predicts more days of abstinence six months later. • When drinking does occur, those who go to AA drink significantly less. • Frequency of AA meeting attendance after treatment predicts abstinence a year later. • Seventy-three percent of those who go to AA regularly— meaning weekly—remain chemically free, compared with only 33 percent of the nonattenders.
Other positive benefits:
• Studies find AA involvement leads to new relationships with people who don’t drink. • Going to more AA meetings leads to less depression. • Persons attending AA have higher-quality relationships with friends, spouse, or partner.
Getting the Most out of AA
• Go to an AA meeting in the next 7 days that you haven’t been to before. • Talk to someone you do not know, who has more sobriety than you, after a meeting. • Ask someone you don’t know, who has more sobriety than you, for their telephone number. Talk to them on the phone (don’t just leave messages). • If you do not have a sponsor, ask someone to be your temporary sponsor this week. • If you have a sponsor, connect with them today or tomorrow, even for a 2-minute check-in. • Do something social (go to coffee, have a meal, take a walk,) with one or more people from AA who have more sobriety than you.
The most important types of AA involvement are reaching out to other members of AA for help, and using a sponsor. For advice for newcomers, go to “What is AA?” at www.aa.org. JULY/AUGUST 2015 SAN FRANCISCO MEDICINE
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INTERNET ADDICTION What Is Normal? Murtuza Ghadiali, MD It’s hard to imagine what life was like before smartphones! These amazing devices organize our lives, connect us
to others, fetch us information, and deliver us entertainment. They have become so indispensable that we can’t stop using them— even when driving. Increasingly, many of us are sucked into virtual connections to the point that they become more salient than current reality. For these individuals, the whole day consists of “comings and goings” on the Internet. When this interferes with real life, some experts conclude these persons have “Internet addictions.” For proponents of hyper-modernism, the difference between normal and abnormal Internet use is not so clear. It is disappointing that the newly revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) did not provide clear guidance for diagnosing individuals with Internet-related behavior problems. While recognizing gambling disorder as a new behavioral addiction, characterized as a cognitive, behavioral, and emotional condition marked by overwhelming behavioral salience; use of gambling to modify mood; development of tolerance and withdrawal upon cessation of gambling; and including irritability, loss of interest in other activities, and interpersonal conflicts that develop as a consequence of the excessive gambling—only provisional criteria for Internet gaming disorder was included in DSM-5, which some experts praise for its similarity to the gambling criteria but criticize for its failure to capture the uniqueness of Internet-related conditions. Instead, Internet problems were relegated to section III of DSM-5 for further study. The authors of DSM-5 explain: “The Internet is now an integral, even inescapable, part of many people’s daily lives; they turn to it to send messages, read news, conduct business, and much more. But recent scientific reports have begun to focus on the preoccupation some people develop with certain aspects of the Internet, particularly online games. The ‘gamers’ play compulsively, to the exclusion of other interests, and their persistent and recurrent online activity results in clinically significant impairment or distress. People with this condition endanger their academic or job functioning because of the amount of time they spend playing. They experience symptoms of withdrawal when pulled away from gaming. “Much of this literature stems from evidence from Asian countries and centers on young males. The studies suggest that when these individuals are engrossed in Internet games, certain pathways in their brains are triggered in the same direct and intense way that a drug addict’s brain is affected by a particular substance. The gaming prompts a neurological response that influences feelings of pleasure and reward, and the result, in the extreme, is manifested as addictive behavior. “Further research will determine if the same patterns of excessive online gaming are detected using the proposed criteria. At this time, the criteria for this condition are limited to Internet gam26
ing and do not include general use of the Internet, online gambling, or social media.” As carefully worded as this statement appears, it seems overly cautious and possibly culturally biased. In South Korea, the most Internet-connected country in the world, Internet gaming addiction is already considered one of the most serious public health hazards. Online gaming is a major part of the culture, with more than 35 percent of the population participating—far more than any other country. Online gaming addiction affects scores of youth (ages ten to nineteen), seriously impacting up to one in ten in the latest estimate. Many of these children end up being hospitalized or sent to boot camps to be rehabilitated. The limited available research and diagnostic criteria for Internet gaming addiction come mostly from the physicians in South Korea and China. They unequivocally document the psychological consequences of addiction to the Internet, which include their patient’s sacrificing real-life relationships, sleep, work, and education while experiencing increased aggression and hostility, decreased well-being, and elevated feelings of loneliness as a result of their Internet use. No doubt Internet addiction is here, now! How did we get here? Internet use paralleled the growth of the Internet. In precomputer ages, humans escaped everyday life problems by engaging in the fictional worlds of books and theater or by engaging in social diversions, hobbies, and sports. For some, television was the major distraction. When television transitioned to computers, things accelerated. Just as Moore’s Law predicted the industrial doubling of computer chip processing speed and power every eighteen months to two years, the logarithmic growth in computer usage did not lag far behind. Indeed, for Generation X children raised on Atari games like Frogger and Qbert, whose grainy graphics and antique joysticks provided hours of fun, boredom was not uncommon. Today, with computerized artificial intelligence rivaling our human capacity for multilateral thinking, developers have unleashed endlessly captivating games like World of Warcraft, a massively multiplayer
SAN FRANCISCO MEDICINE JULY/AUGUST 2015 WWW.SFMS.ORG
online role-playing game (MMORPG), successfully ending all pangs of boredom. Forty-six percent of all online gamers play MMORPGs, many of them young millennials playing for hours or days at a time. Within the imaginary universe of these games, thousands of players from all over the world adopt virtual personas or avatars to inhabit artificial worlds. Meeting to do battle, these individuals acquire status and power that leads to progress in the virtual environment. Back in the real world, these players even gain admiration and reputation in the gaming community for their virtual achievements, leading some sociologists to report enhanced social connectedness as a byproduct of online Internet use. Still, many parents worry about the effects of intense online gaming or Internet usage on their children’s developing brains and personalities. While there is evidence that Internet activity may increase hand-eye coordination, strategic thinking, and working with others, the truth is we don’t know the impact of these activities long term. The American Academy of Pediatrics nonetheless recommends no more than two hours of screen time for children per day. This includes television, phones, tablets, and video games. Unfortunately, Kaiser Family Foundation research shows that the average duration of screen time for school-age children is about eight to ten hours per day. Moreover, studies demonstrate excessive Internet gaming can result in problems with impulse control; reduced behavioral inhibition; and poorer executive functioning, attention, and general cognitive performance. Meanwhile, functional neuroimaging studies of gaming brains demonstrate brain changes in the orbitofrontal cortex and the cingulate gyrus regions similar to those observed in the brains of patients with alcohol and drug addictions. On a slightly positive note, frequent gaming does enhance visual-perceptual and visual-motor integration. These are important skills in an increasingly visually oriented digital culture. How do we fix Internet addictions? We know even less about the best way to approach treatment. In the U.S., Olganon (Online Gamers Anonymous) is available through its website, chat groups or, in some areas, in-person groups. Specialized treatment centers have opened in the last five years in the U.S., mostly based on models established for alcohol and drug treatment. In Asia, the trend is toward army-like boot camps for children, where computers are banned and children are encouraged to play sports. In Japan, “fasting camps” are popular, where individuals suffering from Internet and gaming addiction are helped by being cut off from technology completely. In South Korea, Internet gaming addiction is viewed as a significant concern for public health, and up to 24 percent of children are hospitalized. On a more practical level, until more evidence is available, it might be easier to prevent Internet addiction than to treat it. My colleagues and I recommend this simple advice for patients and parents: • Limit screen time (as is reasonable). • Know what your children are doing online: the sites they visit and to whom they are chatting. • Talk with them about their experiences. • Watch for behavioral or emotional changes associated with online usage or gaming, and limit use accordingly. • Encourage healthy doses of physical and/or social activity.
In summary, Internet Addiction (or Internet Gaming Disorder) is a symptom of our growing dependence on computer technolWWW.SFMS.ORG
ogy during our hyper-modern stage of human cultural evolution. In Asia, whose industrial growth has already led to the widespread technological adoption of ultra-fast Internet speeds, we see the good and bad sides of this evolution. It remains unanswered whether the problems resulting from Internet addiction witnessed among South Korean youth are the harbinger of a coming epidemic in the U.S. For author bio, see page 9.
References Psychol Res Behav Manag. 2013 Nov 14;6:125-37. doi: 10.2147/PRBM.S39476. eCollection 2013. Internet gaming addiction: current perspectives. Kuss DJ1. DSM-5 Factsheet: Internet Gaming Disorder, May 2013. http:// www.dsm5.org/Documents/Internet%20Gaming%20Disorder%20Fact%20Sheet.pdf (accessed June 14, 2015)
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ADDICTION
ELECTRONIC CIGARETTES Rational Regulation Coming Steve Heilig, MPH The advent of electronic cigarettes has presented a number of challenges to long-standing antitobacco advocacy. First, these “vaping” devices have not automatically
been subject to tobacco regulations, leading to a free-market explosion in products, marketing, and use. Second, research on the real impacts of e-cig use has lagged behind this expansion. And third, the putative use of e-cigs as a tobacco-cessation intervention has posed a divisive conundrum to those of us who would otherwise welcome almost anything that would substantially decrease smoking. The SFMS has long supported “harm reduction”—when it is shown to actually reduce net harm. E-cigs are heavily marketed to, and used by, young people—including previous nonusers of tobacco, which seems to negate much of the argument that these are primarily smoking cessation devices. Into this regulatory void have jumped countless vaping entrepreneurs—manufacturers, marketers, vaping stores and lounges. From their practices and behavior much can be learned—not the least of which being that when their use and profits appear threatened in any way, they can react vehemently—like addicts, even. Last year, the SFMS brought a resolution to the CMA urging more regulation of e-cigs, which was adopted. It is modeled on policy in effect in San Francisco. In June, this policy was adopted by the AMA as well:
Electronic Cigarette Regulation San Francisco Medical Society RESOLVED: That CMA supports a ban on the advertising of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids; and be it further RESOLVED: That CMA believes that e-cigarettes should be regulated, at the state and local level, consistent with tobacco products until such a time that they are approved by the FDA as smoking cessation aids; and be it further RESOLVED: That CMA supports education of the public on the known and potential health impacts of electronic cigarettes and other nicotine delivery devices; and be it further RESOLVED: That CMA supports that electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking-cessation aids be taxed to generate funds, which could be used for, but not be limited to 1) support for research into their efficacy as smoking-cessation aids and their health impacts and 2) education on their known and potential health impacts. State legislation is progressing, which would put some of this resolution into law. SB 140, by our own State Senator Mark Leno, places e-cigarettes under the Stop Tobacco Access to Kids Enforcement Act and in June passed the Senate. “E-cigarettes are addicting a new generation of smokers to nicotine, which contains toxic chemicals and is highly addictive,” said Leno. “We must take action now in order to protect our youth and Californians of every age from harmful firsthand and secondhand e-cigarette emissions.”
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SAN FRANCISCO MEDICINE JULY/AUGUST 2015 WWW.SFMS.ORG
LOCAL ADVOCACY Mayor Ed Lee Approves SFMS-Endorsed SugarSweetened Beverage Ordinances
John Maa, MD
of Supervisors was reported by media outlets throughout Europe, North America, Asia, and the Middle East and was soon followed by the announcement from SFGH CEO Sue Currin that all sugarsweetened beverages would be removed from San Francisco General Hospital and Trauma Center. These successes reflect the dedication of the SFMS and its leadership to promote the health of the public. The next steps are to extend these legislative and public policy wins to other cities across California, and to begin preparations for a soda tax that will likely be placed on the San Francisco ballot for November 2016. One key for success in the 2016 endeavor will be to further strengthen our relationships with Supervisors Scott Wiener, Malia Cohen, and Eric Mar, who have courageously championed this effort over the years in City Hall.
A wave of national media coverage followed the Prop D and Prop E soda tax campaigns in November 2014. When the final campaign reports were released to the public, it was revealed that a total of more than $10 million had been spent to defeat Prop E (including expenditures before the reporting period began), making it the highest total expended to defeat a ballot initiative in San Francisco history. The Berkeley soda tax (Prop D) generated $116,000 in revenue for the city within the first month of operation in 2015, and the success of Berkeley to become the first city in America to pass a soda tax inspired new legislative efforts in Illinois, Hawaii, and Vermont to adopt statewide soda taxes. In California, a double-pronged approach was adopted in Sacramento and local cities. On the Assembly side in the Legislature, a statewide soda tax (AB 1357) was introduced by Assemblyman Richard Bloom (D-Santa Monica) with coauthor David Chiu (DSan Francisco), while on the Senate side Senator Bill Monning (D-Carmel) reintroduced the soda warning label (SB 203) that had passed the State Senate in 2014. In Davis, the City Council unanimously approved an ordinance making milk and water the default options for kids’ meals in restaurants. Meanwhile, back in San Francisco, a trio of sugar-sweetened beverage bills that had been endorsed by the SFMS moved swiftly through City Hall and were signed into law by Mayor Lee on June 25. One of the bills sought to prohibit the advertisement and sales of sugar-sweetened beverages on city property, as an extension of a 2010 executive directive by then-Mayor Gavin Newsom to ban “calorically sweetened” soft drinks from city vending machines. The unanimous passage of these bills by the San Francisco Board WWW.SFMS.ORG
***** Here at the Board of Supervisors, I worked with Supervisors Malia Cohen and Eric Mar to pass legislation making San Francisco the first city in the country to require public health warnings on sugar-sweetened beverage advertisements and to ban these ads on public property. We also passed legislation to ban the use of city funding for the purchase of sugar-sweetened beverages. This groundbreaking legislation comes on the heels of last November’s election, when a soda tax measure we placed on the ballot earned 56 percent of the vote, which—while short of the two-thirds approval needed—demonstrated residents’ serious concerns about the health impacts of sugar-sweetened beverages. More than most, our health care community understands these impacts, and we’ve been lucky to have the support of the San Francisco Medical Society on all of these measures. I’ve had the honor of attending numerous debates, round tables, and community meetings with members of the SFMS, whose staunch support has provided essential credibility for these important public health measures. The health warning legislation, in particular, will raise awareness of the health impacts of sugar-sweetened beverages and improve community health. Requiring health warnings will provide information people need to make informed decisions about what beverages they consume. These drinks aren’t harmless—indeed, quite the opposite. The puppies, unicorns, and rainbows depicted in soda ads aren’t reality. What is real is that these drinks are making people sick and that we need to make that fact clear. With this package of legislation, San Francisco will remain at the cutting edge of smart approaches to improving public health.
—Supervisor Scott Wiener, District 8
The SF Board of Supervisors’ unanimous approval to prohibit advertisements for sugar-sweetened beverages on publicly owned property will align our City’s policies more closely with our existing public health goals. Our residents, particularly our youth, deserve to be in an environment where residents are ex-
Continued on page 31 . . .
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LOCAL ADVOCACY Continued from page 29 . . . posed to messages and advertisements that promote health, not harmful substances. I am proud to have worked on this package of legislation. Thanks to my colleagues, Supervisors Scott Wiener and Eric Mar, and the amazing network of San Francisco Medical Society physicians and community health advocates for their partnership and efforts on this.
—Supervisor Malia Cohen, District 10
San Francisco is once again helping to lead the nation in finding real-world solutions to obesity and diabetes with the passage of a package of ordinances aimed to combat chronic diseases caused by the consumption of sodas and other sugary beverages. These are significant, nation-leading policies that will be replicated in cities and states around the nation. I would like to acknowledge the San Francisco Medical Society and their network of physician activists for tirelessly championing this public health initiative. SFMS was one of the earliest endorsers and a coalition partner of Proposition E (San Francisco soda tax) and has continued to support public health education campaigns and beverage policy reforms.
—Supervisor Eric Mar, District 1
CMS and AMA Announce Joint Efforts to Help with ICD-10 Transition On July 6, CMS and AMA jointly announced that on a oneyear grace period for the implementation of ICD-10. SFMS, CMA, and AMA have been strongly advocating for such a grace period with advance payments since April 2014. Most recently, physician leadership from the Big Four State Medical Associations (CA, FL, NY, TX) met with CMS staff to urge adoption of this grace period as a life line for small practices. The ICD-10 Ombudsman was a direct result of this meeting with CMS. • For a one year period starting October 1, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors. • To avoid potential problems with mid-year coding changes in CMS quality programs (PQRS, VBM and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores (i.e., for PQRS, VBM, or Meaningful Use). CMS will continue to monitor implementation and adjust the duration if needed. • CMS will establish an ICD-10 Ombudsman to help receive and triage physician and provider problems that need to be resolved during the transition. • CMS will authorize advanced payments if Medicare contractors are unable to process claims within established time limits due to problems with ICD-10 implementation. This is a significant announcement and a huge victory to protect physician practices during the transition to ICD-10. For more information, visit http://bit.ly/1HIjX5e.
GOVERNOR BROWN SIGNS VACCINE BILL After a hard-fought battle led by CMA, SFMS and many other medical, public health, and parents’ groups, Gov. Jerry Brown has signed into law Senator Richard Pan, MD’s SB277, which closes loopholes for school vaccine exemptions. Many thanks to all who helped and especially to our legislative representatives David Chiu, Mark Leno, and Phil Ting or voting yes.The bill was proposed following a recent rash of outbreaks of vaccine-preventable diseases in the state. Since December 2014, California has had at least 136 confirmed cases of measles across more than a dozen counties. Nearly 20 percent of those cases have required hospitalization. “On behalf of the 40,000 members of the California Medical Association, I want to thank Senators Pan and Allen for their leadership in authoring this bill and the entire California State Legislature for sending it to Governor Brown,” said Richard Thorp, M.D., CMA Past President. “SB 277 is based in fact and science and will help increase community immunity across the state. This is sound public health and we hope Governor Brown’s swift signature on the bill shows how important it is for California. We applaud his fast action to keep Californians safe.”
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MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD, MBA
Dignity Health Saint Francis Memorial Hospital received an “A” grade for hospital safety in the latest Hospital Safety Score from the Leapfrog Group, which rates how well hospitals protect patients from preventable medical errors, injuries, and infections. This is our third consecutive “A” grade from the Leapfrog Group — a testament to the dedication of our staff, who always put patient safety first. Such recognition is not absent of effort, as we also attribute our stellar quality performance to Drs. Clement Jones (Ortho-Spine Surgery) and Gary Aguilar (Ophthalmology), who have successfully led Saint Francis’s Board and Medical Staff Quality Committees. The Leapfrog Group is a national, nonprofit hospital safety watchdog. The Hospital Safety Score uses twenty-eight measures of publicly available hospital safety data to produce a single A, B, C, D, or F score, representing a hospital’s overall capacity to keep patients safe from preventable harm. Leapfrog’s announcement adds to a growing list of recent accomplishments for Saint Francis Memorial Hospital. Last year, we were one of two hospitals in San Francisco to be recognized as Top Performers on Key Quality Measures by the Joint Commission. Recently, we received a five-star rating from Healthgrades for the quality of our hip replacement surgery program. We have also had the honor of being Healthgrades five-star recipients in heart failure survival, respiratory failure, spinal fusion surgery, and stroke survival. Also last May, Saint Francis held its annual medical staff dinner to welcome Dr. Todd Strumwasser, Dignity Health senior vice president of Operations for the Bay Area Service Area, and his wife. Dr. Strumwasser, who began his position earlier this year, was welcomed by Dr. David Malone, chair of the board of trustees, and Dr. Robert Harvey, chief of staff. The event, held at the St. Francis Yacht Club, was attended by 140 physicians and their spouses and hosted by Saint Francis Memorial Hospital Interim President/CEO Jim Houser. 32
St. Mary’s
Robert Weber, MD
The Sister Diane Grassilli Center for Women’s Health at Dignity Health St. Mary’s Medical Center offers comprehensive screening and diagnostic women’s health services in one location, with a streamlined approach. With the support of its directors, Drs. Pamela Lewis and Diana Hilbert, the center has received full accreditation as a Breast Imaging Center of Excellence by the American College of Radiology, a designation that represents the national gold standard. We have also been recognized by Healthgrades for excellence in women’s health services. The Sister Diane Grassilli Center for Women’s Health offers customized care and the latest in technology, including the most comprehensive breast imaging capabilities available in San Francisco. Our sophisticated breast imaging technology, such as whole-breast ultrasound and 3D mammography (tomosynthesis), is 20 percent more effective than traditional twodimensional mammography. Additionally, the center offers a wide range of women’s health services, including stereotactic- or ultrasound-guided breast biopsy, MRI-guided biopsy, pelvic ultrasound, bone density testing, laboratory drawing stations, evaluation for urinary incontinence, and genetic counseling. St. Mary’s is also proud to have a fulltime oncology Nurse Navigator at the Sister Diane Grassilli Center for Women’s Health, who provides personalized support to our patients as they undergo cancer treatment. Nurse Navigator Cheri Goudy, RN, is a trained oncology nurse with more than twenty years of experience working with cancer patients. She is nationally certified as a Breast Imaging and Oncology Nurse Navigator and meets with patients individually to answer questions, discuss test results, and serve as a guide through complex appointments and diagnoses. With our highly trained professionals and state-of-the-art equipment, St. Mary’s is able to offer our patients efficient and convenient services to help diagnose, treat, and better understand women’s health conditions.
CPMC
Edward Eisler, MD
Grant Davies, currently CEO of Sutter’s North Bay Hospitals, has been appointed Sutter Health Valley Area CEO of Hospitals. The medical staff at CPMC would like thank him for his devotion and dedication in making CPMC a special place to practice, work, and bring patients. We wish him well in his new endeavors. After a remarkable thirty-plus-year career with the Sutter Health network, Pat Fry has announced his decision to retire in January 2016. In 1982, Pat joined Sutter Health as an administrative resident at Sacramento’s Sutter General Hospital. In just ten years, he rose to the position of CEO of Sutter General and Memorial Hospitals. Pat went on to hold region and division executive leadership positions, assuming the position of Sutter Health’s chief operating officer in 2000. Congratulations to Chief Operating Officer Sarah Krevans, who will succeed Pat. This past June, a thirty-six-hour marathon kidney transplant chain was completed at UCSF and California Pacific Medical Centers in a highly coordinated event that also involved ferrying kidneys between the two hospitals in specialized transport vans. The two San Francisco hospitals, both experienced transplant centers that typically compete for prowess in the field, joined forces for the unusual swap, which is considered to be the longest kidney transplant chain performed in one city over such a short period of time. Sutter Health has begun a three-year research and innovation collaboration with AstraZeneca to explore how to improve the delivery of care to patients with cardiometabolic conditions. The collaboration aims to improve outcomes regarding the management of diabetes, hypertension, and high cholesterol and their complications, including heart attack, stroke, limb loss, and even death. Researchers will explore how to reengineer the delivery of cardiometabolic care by improving access to and understanding of electronic health record data, testing new care models, and experimenting with leading-edge technologies.
SAN FRANCISCO MEDICINE JULY/AUGUST 2015 WWW.SFMS.ORG
SFVAMC
C. Dianna Nicoll, MD, PhD, MPA
There is a wide range of addiction services available at the San Francisco VA Medical Center (SFVAMC) in Behavioral Health clinics. An intensive outpatient program offers three-times-a-week treatment for new patients. After stabilization, patients can move on to continuity treatment provided by the Drug and Alcohol Treatment Clinic or the Substance Use PTSD Program, which is specifically designed for veterans with co-occurring addiction and posttraumatic stress. The Opioid Treatment Program provides specialized opioid pharmacotherapy, including the full opioid agonist methadone or the partial agonist buprenorphine or the opioid antagonist naltrexone—the latter in its extendedrelease, injectable form. A major focus is to improve access to addiction services by providing treatment to veterans who are not ready for total abstinence, and so a Transitions Program, with drop-in groups, is offered to those who are not ready for formal addiction treatment. Real-time consultation in the primary care setting is also provided, and the Prescription Opioid Safety Team consults with primary care providers on the management of addiction when it accompanies chronic pain and opioid analgesic use. The SFVAMC was one of the first VA medical centers in the country to adopt the Overdose Education and Naloxone (Narcan) Distribution initiative, which trains patients and family members to use Narcan for treatment of overdose. Education and research is integrated into the clinical addiction services. Future addiction psychiatry specialists are trained through the joint SFVAMC/UCSF/ Kaiser Addiction Psychiatry Fellowship Program, and clinical research is conducted in order to design and test new treatments for alcohol and substance use among veterans.
WWW.SFMS.ORG
Kaiser
SPMF
Bill Black, MD, PhD
These are exciting times for the physicians of Sutter Pacific Medical Foundation. Sutter Health is in the midst of a restructuring throughout northern California. In the greater Bay Area, Sutter is combining the three legacy business operating units, Sutter Health’s West Bay, East Bay, and Peninsula Coastal Regions, to form the new Sutter Health Bay Area (SHBA) operating unit. The new SHBA will include the circa 2,000 physicians of Sutter Pacific, Sutter East Bay, and Palo Alto Medical Foundations (SPMF, SEBMF, and PAMF). Our restructured health care delivery system will best serve our patients, providing continuously integrated service whether they seek care close to home or work, important for the highly mobile population of the Bay Area. The restructuring will enable the physicians of SPMF, Sutter East Bay Medical Foundation, and Palo Alto Medical Foundation to strengthen and extend clinical service lines such as cardiovascular services, organ failure, women’s services, and neurosciences to patients from San Francisco to San Ramon, from Santa Cruz to Santa Rosa, and beyond. SPMF physicians are now meeting regularly with those from SEBMF and PAMF to look for opportunities and synergies, and our foundation-based medical groups are enjoying a growth spurt in 2015 that has already outpaced all of 2014. Sutter is also consolidating east of the Bay Area, merging the Central Valley and Sacramento Sierra Regions, along with their Sutter Gould and Sutter Medical Foundations into a single operating unit. All this restructuring is coincident with other changes in Sutter, including the restructuring of Sutter’s hospital affiliates and the recently announced retirement of Sutter Health’s CEO Pat Fry, with Sutter Health COO Sarah Krevans poised to take the helm. But back on the ground, for the physicians of SPMF (or the soon-to-be new SHBA medical foundation), and for the patients we serve, all of these changes are just about improving the care and service we provide on a daily basis.
Maria Ansari, MD
Since 1992, Kaiser Permanente has provided comprehensively integrated quality addiction treatment for over 3.6 million members in Northern California. Today, we have a robust network of 17 Chemical Dependency Recovery Programs in Northern California, which offer high-touch and high-tech treatment 365 days a year. We provide the latest evidenced based medical, psychiatric, and recovery-based treatment, which has become industry standard for addiction care in California. Serviced by our multidisciplinary teams, which utilize psychologists, nurse practitioners, social workers, drug counselors, and physicians, our members can choose from a vast array of intensive outpatient services that include specialty adult recovery treatment and relapse prevention groups, adolescent and family treatment, harm reduction therapy, and groups for Gay Men, womenonly, and African Americans. In addition, we contract with an outstanding network of residential programs for those unable to achieve sobriety at home. We are also committed to preventing and detecting alcohol and drug problems whenever possible. Working with our Medicine and Family Medicine physicians, we have implemented system-wide alcohol screening and brief advice throughout our Primary Care Departments. In 2014 alone, we successfully screened two million patients for alcohol problems in Northern California. We also promote the safe use of opioids and naloxone for patients at risk for overdose. As an organization devoted to preventive health and overall wellbeing, Kaiser Permanente is investing in Addiction Medicine for the future. As co-sponsors of the joint UCSF-Kaiser Fellowship in Addiction Psychiatry and the training site for San Mateo County’s Psychiatry Residency Program, Kaiser Permanente San Francisco aims to provide and expand the appropriate resources both for today and the tomorrow.
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UPCOMING EVENTS 8/20: MGMA Workshop: Sustaining the Independent Group Practice | 4:00 p.m.–6:00 p.m., Golden Gate Urology, 139 Townsend Street, Mezzanine Level | The Northern California Medical Group Management Association extends complimentary registration to all SFMS members and their staff to the practice management seminar series. Operating a thriving medical practice is becoming more challenging with the decline in reimbursement, increased burden of paperwork and regulations, and the rapid changes in the health care landscape. As value-based payment models emerge, medical groups need to be appropriately positioned to move from a productivity-based environment to a value-based environment. The August seminar led by presenter Frank Gamma, JD, MBA, FACMPE, explores operational strategies and options for tapping into various sources of capital and for streamlining processes to ensure financial viability. Please RSVP to Ben Borchers at ben@prevailims.com.
H E L P E N D P R O S TAT E C A N C E R
Third Annual 5K Run/Walk 1 Mile Walk
Kids Superhero Dash For Dad Saturday, September 19, 2015 • 9:30 a.m. LAKE MERCED Skyline and Harding Rd. San Francisco, CA Support the one in seven American men affected by prostate cancer at this family-friendly event. Run or walk the 5K or 1 mile and receive a tech shirt and refreshments after the race. Kids 9 and under can take part in the Kids Superhero Dash for Dad and receive a cape.
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9/1: Risk Management CME Program & Dinner | 5:30 pm Registration & Dinner; 6:00 pm – 9:00 pm CME program Hotel Kabuki, 1625 Post Street| The Cooperative of American Physicians is hosting a complimentary and informative threehour program offers practical tips on risk management for physicians. The CME program will cover current and evolving risks in medicine, physician-patient relationship, and guidelines for informed consent. RSVP by August 25 to Elizabeth Gomez at (213) 473-8729 or egomez@CAPphysicians.com to secure your seat. 9/14: SFMS General/All-Member Meeting | 6:00 p.m.–7:30 p.m., Golden Gate Yacht Club | Calling all SFMS members! Join SFMS at our General Meeting at the Commodore Room inside the Golden Gate Yacht Club. Members are welcome to stay for the board meeting immediately following the General Meeting. This is a good opportunity to meet with SFMS leadership and to learn firsthand the issues SFMS and CMA are advocating for on behalf of physicians and their patients in San Francisco and California. Featured speakers include Assemblymember David Chiu and Mayor Ed Lee (invited). Please RSVP to Posi Lyon at plyon@ sfms.org or call (415) 561-050 x260. 9/25: Special Hope Foundation Conference: Effective Health Care for Adults with Developmental Disabilities | 8:00 a.m.– 4:00 p.m., California Endowment Oakland, 1111 Broadway, Oakland | Is California on the right track to provide effective and accessible health care for adults with developmental disabilities? Health care providers, funders, researchers, advocates, policy makers, and other thought leaders will collaboratively look at managed health care for adults with developmental and intellectual disabilities at this one-day, information-sharing symposium. For more information or to RSVP, please contact Kathy Bradley at (515) 480-6858 or kathybradley53@gmail.com.
SAN FRANCISCO MEDICINE JUNE 2015 WWW.SFMS.ORG
Premiums are based in part on age. The longer you wait, the higher your premium rate may be. You’ve worked hard all your life to provide a good standard of living for you and your family and KEEP your current lifestyle in retirement. But long-term care costs can get in the way. If you develop a debilitating long-term condition, you may need long-term care. Once you’re 65 years old, Medicare will help pay your medical costs. But Medicare does not pay full benefits for extended-care, assisted-care facilities, custodial care or nursing home facility expenses. If you need this type of care, you could face big expenses: • The national average cost of a year in a nursing home is $87,600.* • The 2014 median annual cost for an assisted-living, one-bedroom apartment with a private bath, or a private room with a private bath was $42,000.* Many of us think Medicare is going to cover long-term care expenses, but find the coverage very limited. That’s why millions of responsible Americans help protect their lifestyles with long-term care insurance. But finding the right protection isn’t easy. It’s tough to compare policies with different benefits, features, limitations, costs, spouse coverage and more. The San Francisco Medical Society/CMA can help, with a special benefit for members: Long-Term Care Resources, a unique long-term care buying service. This program allows you to work with a long-term care insurance representative who will give you all the information about benefits and rates of different, highly rated long-term care providers. Call Long-Term Care Resources today to receive information at 800-616-8759, or visit www.myltcplan.com/sfms. * Genworth 2014 Cost of Care Survey, February 2014, https:// genworth.com/corporate/about-genworth/industry-expertise/costof-care.html, viewed 1/27/15
Call 800-616-8759 or visit www.myltcplan.com/sfms Sponsored by: 69962 (7/15) Copyright 2015 Mercer LLC. All rights reserved. 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com Mercer Health & Benefits Insurance Services LLC •
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