June 2017

SAN FRANCISCO MARIN 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 A R I N M E D I CA L S O C I E T Y

PAIN MEDICINE PERSPECTIVES AND PRACTICES

THE OPIOID EPIDEMIC LOCAL RESOURCES FOR CHRONIC PAIN MANAGEMENT

CANNABIS FOR PAIN VOL.90 NO.5 June 2017

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE June 2017 Volume 90, Number 5

Pain Medicine: Perspectives and Practices FEATURE ARTICLES

MONTHLY COLUMNS

10 The Opioid Epidemic: A (Not So) Brief History

Medical Insurance Exchange of California

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Membership Matters

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President’s Message Man-Kit Leung, MD

11 First Do No Harm: Changing Tactics in the Opioid Epidemic

Kelly Pfeifer, MD 13 Cannabis for Pain: Substantiating the Evidence

Donald I. Abrams, MD

15 The Hidden Deficiency: Getting to the Root of Pain

Jane Hightower, MD

17 Kids and Chronic Pain: Managing Pain in Children and Adolescents

David Becker, MD, MPH, MA; Cristina Benki, PhD; Lisa Purser, RN;

and Alicia Heilman, RN 20 Integrative Pain Management: SF Health Network Program

Expanding Options for Pain Treatment

Barbara Wismer, MD, MPH 22 Chronic Pain Management: Primary Care Burden to Public

Health Crisis—The CDC Responds

Joseph Pace, MD 24 Pain Management at UCSF: Serving Bay Area Patients

Mario De Pinto, MD; George Pasvankas, MD; Xiaobing Yu;

Lawrence Poree, MD; Sue Gritzner Psy D;

and Mark Schumacher MD, PhD

OF INTEREST

10 SFMMS Advocacy Activities 25 Save the Safety Net

Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfmms.org

SAN FRANCISCO

MARIN MEDICAL SOCIETY

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Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH

26 Medical Community News 27 Upcoming Events 27 Classified Ads

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMMS Members

CHCF Fellowship Applications Are Open

SFDPH Produces Opioid Guide

The California Health Care Foundation (CHCF) Health Care Leadership Program prepares clinically-trained professionals to lead California’s health care organizations, and creates a network of strong and effective leaders. This rigorous, part-time, two-year fellowship addresses essential leadership and management skills, as well as health care trends and policy topics.

Apply by June 30 at http://bit.ly/2pCCpel.

The San Francisco Department of Public Health produced a guide for primary care providers, Opioid Stewardship and Chronic Pain (http://bit.ly/2rj6q00). This practical and informative tool is useful for academic detailing.

CMS Releases Lookup Tool to Help Clinicians Determine their MIPS Participation Status

Unsure of your participation status in the Merit-based Incentive Payment System (MIPS)? Clinicians can now use an interactive tool on the CMS Quality Payment Program website to determine if they should participate in 2017. To determine your status, enter your national provider identifier (NPI) into the entry field on the tool which can be found on the Quality Payment Program website at https://qpp.cms.gov/. Information will then be provided on whether or not you should participate in MIPS this year and where to find resources. To learn more, review the MIPS Participation Fact Sheet at http://bit.ly/2riUnjv.

The Quality Payment Program Service Center may be reached at 1-866-288-8292 (TTY 1-877-715- 6222), available Monday through Friday, 8:00 AM-8:00 PM ET or via email at QPP@cms. hhs.gov.

CMS Publishes Short Videos on Getting Started with MACRA

The Centers for Medicare & Medicaid Services has created several short educational videos on getting started with the new Medicare Quality Payment Program, specifically targeting small, rural and underserved practices. The videos, each only up to 15 minutes long, focus on participation in the Merit-Based Incentive Payment System (MIPS), which was established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Video topics are as follows:

Part 1: Getting started with the Quality Payment Program

(http://bit.ly/2pCu3TX) Part 2: Participating in MIPS (http://bit.ly/2qjJjED) Part 3: How to Participate in MIPS (http://bit.ly/2qknjZV) Part 4: MIPS Reporting Options and Data Submission Methods (http://bit.ly/2qjZjX1) Part 5: MIPS Performance Categories (http://bit.ly/2qnI0mc) Part 6: MIPS Scoring Methodology (http://bit.ly/2qo42Vy) Part 7: Checklist for Preparing and Participating in MIPS (http://bit.ly/2rjiHlg) 4

DHCS Gets Federal Grant to Increase Access to Opioid Treatment in California

The California Department of Health Care Services (DHCS) has received a $90 million grant from the federal government to expand drug treatment services in California, primarily in counties and tribal communities that have higher rates of opioid-related overdose deaths. One key initiative will target those areas with an innovative approach to increase access to medications used to treat opioid addiction. DHCS also will use the grant to fund additional approaches to reduce opioid misuse, such as enhancing the wider distribution of naloxone, which can reverse the toxic effects of an opioid overdose; coordinating local coalitions to act together to reduce opioid abuse; and providing education and training to help reduce the stigma associated with addiction. For more information, visit CMA's safe-prescribing resource page at www.cmanet.org/safe-prescribing.

CMA Joins Partnership to Raise Awareness of Association between Diabetes and Cardiovascular Disease

The CMA has joined the Partnership to Fight Chronic Disease (www.fightchronicdisease.org/issues/diabetes) to raise awareness of the co-occurrence of type 2 diabetes and cardiovascular disease. The program, “Making the Diabetes Heart Connection,” (www.facebook.com/DiabetesHeart/) is a partnership that includes the American Heart and Stroke Association, American Medical Women’s Association, California Chronic Care Coalition, California Health Collaborative, American College of Cardiology (CA Chapter), and the National Association for the Advancement of Colored People. CMA has published a resource page, www.cmanet.org/diabetesprevention, to share tools and resources on diabetes prevention and to help providers connect their patients with evidence-based programs.

Reminder: Failure to Revalidate Medicare Enrollment Information Could Result In Deactivation

Physicians are reminded that Noridian, California’s Medicare Administrative Contractor, is continuing to send revalidation notices to providers who are required to revalidate their Medicare enrollment information. Since the passage of the Affordable Care Act (ACA), in an effort to prevent fraud, all Medicare providers and suppliers have been required to revalidate their Medicare enrollment information under new enrollment

SAN FRANCISCO MARIN MEDICINE JUNE 2017 WWW.SFMMS.ORG

June 2017 Volume 90, Number 5

screening criteria. Once a Medicare enrollment application is validated, the clock starts ticking on a five-year revalidation cycle. Now that five years have passed since the ACA's revalidation requirement took effect, the Centers for Medicare and Medicaid Services (CMS) is continuing its second cycle of revalidation requests. Providers can look up an individual provider or organization to identify the revalidation date through CMS’ look-up tool at http://go.cms.gov/2ridmcQ. Providers due for revalidation in the near future will display a revalidation due date. All other providers/suppliers will see "TBD" in the due date field. For more information on the revalidation process, see MLN Matters #SE1605 at http://go.cms.gov/2rixagd. If you have questions about the revalidation process, visit http://bit.ly/2qJJDxr or contact Noridian at (855) 609-9960.

Anthem Ending Effort to Merge with Cigna

Anthem recently announced that it is ending its effort to merge with Cigna. This is a monumental victory of organized medicine and is the result of twenty-one months of unrelenting advocacy before the U.S. Department of Justice, congressional committees, state attorneys general, insurance commissioners, and federal courts. This action concludes a successful campaign by the AMA and seventeen state medical societies, including the California Medical Association, to stop the Anthem-Cigna merger. CMA has long been concerned with the consolidation of health plans and health insurers, and the reduction of competition. In March 2016, a CMA-backed survey of California physicians revealed an overwhelming 85 percent opposed the Anthem-Cigna merger. When market power is consolidated among just a few companies, insurers contract with fewer physicians, limiting choice for patients, increasing wait times for referrals, and sometimes forcing them to pay more to see out-of-network doctors.

New Out-of-Network Billing and Payment Law Takes Effect July 1

On July 1, 2017, a new law (AB 72) will take effect that will change the billing practices of non-participating physicians providing non-emergent care at in-network facilities including hospitals, ambulatory surgery centers and laboratories. The law, signed in 2016, was designed to reduce unexpected medical bills when patients go to an in-network facility but receive care from an out-of-network doctor. For more information, visit http://bit.ly/2qohMQh.

CMA’s Practice Manager Tip of the Month

Know when you can, and cannot, charge a payor for copying medical records. Most managed care contracts include language that require practices to generally comply with medical records requests at no additional cost. However, if neither the contract, nor payor policies or procedures require you to bear the cost of those copies, there is no law to prevent you from billing the payor for reasonable copying expenses. For more information, see http://cal.md/may-2017-tip.

Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA 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 Toni Brayer, MD Arthur Lyons, MD Chunbo Cai, MD John Maa, MD Linda Hawes Clever, MD David Pating, MD SFMS OFFICERS President Man-Kit Leung, MD President-Elect John Maa, MD Secretary Brian Grady, MD Treasurer Kimberly L. Newell, MD Immediate Past President Richard A. Podolin, MD MMS Officers President Peter Bretan, MD President-Elect Michael Kwok, MD Secretary/Treasurer Naveen Kumar, MD Immediate Past President Jeffrey Stevenson, MD SFMMS 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 Erin Henke Director of Administration Posi Lyon Membership Coordinator Ariel Young SFMMS BOARD OF DIRECTORS Larry Bedard, MD Charles E. Binkley, MD Peter Bretan, MD Irina deFischer, MD Nida Degesys, MD David T. Duong, MD Benjamin L. Franc, MD Steven H. Fugaro, MD Robert A. Harvey, MD Imran Junaid, MD Naveen Kumar, MD Michael Kwok, MD Raymond Liu, MD Todd A. May, MD Jason Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Ray Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD

Monique D. Schaulis, MD Michael C. Schrader, MD Lori Selleck, MD Dennis Song, MD Jeff Stevenson, MD Winnie Tong, MD Matt Willis, MD Joseph W. Woo, MD Albert Y. Yu, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

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PRESIDENT’S MESSAGE Man-Kit Leung, MD

The Pain Pendulum The data is disturbing: ninety-one Americans die every day from an opioid overdose— that’s nearly four deaths every hour. From 2000 to 2015, drug overdoses took the lives of over half a million people.

According to the Center for Disease Control, since 1999 the numbers of overdose deaths, deaths from prescription opioids, and prescription opioids sold in the United States have all quadrupled. So, what happened during the turn of the century that sparked this epidemic?

During the mid- to late-1990s, the public along with multiple state and national organizations were urging physicians to make pain relief a priority in patient care. In 1996 the American Pain Society trademarked the slogan “Pain: The Fifth Vital Sign” and not long after, the Joint Commission for Accreditation of Healthcare Organizations issued standards for hospitals to regularly assess pain as part of patient vitals.

In California, a requirement was made in 2001 for physicians to take twelve hours of continuing medical education on pain management and the appropriate care and treatment of the terminally ill in order to obtain or renew medical licenses.

Around the same time, two verdicts made healthcare providers legally liable for inadequate pain management. In 1991 a North Carolina jury found a nurse and a nursing home guilty of substandard medical care for inadequate pain treatment for a patient who died from terminal metastatic prostate cancer in their facility. The family was awarded $15 million in compensatory and punitive damages. Closer to home, in 2001 Dr. Wing Chin from Castro Valley was found guilty of California’s elder abuse statute for inadequately addressing an inpatient’s pain and penalized $1.5 million. Eden Medical Center settled with the patient’s family before trial in the same case.

As added fuel to the fire, in 1996 Purdue Pharma released Oxycontin which quickly became the most widely used painkiller in America. At one point, annual sales of Oxycontin totaled over $1 billion. Because of its time-release formulation, Oxycontin was marketed as a painkiller with a low risk of addiction and abuse potential. In 2007, however, three executives of Purdue Pharma pleaded guilty to “misbranding” the drug. The drug company and the three executives were fined collectively $635 million. Unfortunately by that time, the damage had been done: the nation was already addicted. In places like West Virginia, for example, between 2007 and 2012 drug wholesalers shipped 780 million hydrocodone and oxycodone pills—equal to over 400 pills per resident—to pharmacies throughout the state. Nine million pills were shipped to a single pharmacy located in a town of 392 residents over a two-year period. Not surprisingly, overdose deaths in West WWW.SFMMS.ORG

Virginia rose by 67% between 2007 and 2012.

As the opioid epidemic continues to blaze, doctors now find themselves feeling the heat. On the one hand, physicians have ethical and legal duties to address patient pain, but on the other hand, the over-prescription of narcotics has been a critical factor fueling this epidemic. While on the one hand, adequate pain control is a core component of patient satisfaction which in turn drives reimbursement, on the other hand, four out of every five new heroin users start out by misusing prescription drugs.

In order to quell the opioid epidemic, physicians and the general public must work together. Physicians must be discriminating gatekeepers of prescription opioids but patients must also be more receptive to non-opioid treatment options for pain control. Focus should be paid not only to decrease the availability of opiates by changing prescribing practices but also to decrease the demand for opioids through public education. State and national agencies should educate patients of the risks of addiction and discourage use of narcotic painkillers when possible. The emphasis should no longer be on pain intensity but on pain tolerability. Whereas pharmaceuticals spend millions of dollars on advertising pain medications that are fast acting and long-lasting, equal attention should be paid to non-pharmacologic treatments for pain management, such as exercise therapy, cognitive behavioral therapy, acupuncture, and pet therapy. Society as a whole must share the burden of the opioid epidemic by understanding that pain may be a natural part of disease or treatment of disease; that tolerable pain should be recognized but may not require pharmacologic intervention; and that the opioid epidemic will be defeated when both the demand and the supply of opiates are curbed.

Man-Kit Leung, MD, is an otolaryngologist in private practice and President of the San Francisco Marin Medical Society.

He welcomes correspondence at mleung@sfmms.org.

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SFMMS ADVOCACY ACTIVITIES AN ADVOCATE FOR PATIENTS, PHYSICIANS, AND THE COMMUNITY As the only medical association in San Francisco and Marin to represent the entire spectrum of medical specialties and interests, the San Francisco Marin Medical Society (SFMMS) has been a champion for community health issues since its inception in 1868.

Our policymaking efforts through collaborations with state/national medical and political leaders, as well as articles in our awardwinning journal, have given us a reputation for being influential far beyond the Bay Area. The SFMMS agenda and activities continue to focus on the community and the following areas of involvement.

UNIVERSAL ACCESS TO CARE: With ongoing, vigilant efforts

to preserve programs and prevent cuts in Medi-Cal reimbursement, SFMS leaders have long advocated that everyone should have access to quality medical care. SFMS additionally joined in the lawsuits to preserve the Healthy San Francisco program, a curriculum designed by those (including our own representatives) serving on the Mayor’s Task Force. SFMS advocated for, and even helped create, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s, and, more recently, argued for preservation of the Affordable Care Act’s best features.

ANTI-TOBACCO ADVOCACY: SFMS advocates were instrumental in the banning of tobacco smoking in San Francisco restaurants, an accomplishment that was ahead of the rest of the state and nation. SFMS advocated for many policies, including ever-stronger protections from secondhand smoke, higher taxes on tobacco products, and the removal of tobacco products from pharmacy settings. SFMS later signed onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco in pharmacies.

SFMS actively worked to pass legislation to tax tobacco products in order to provide additional funding for Medi-Cal. HIV PREVENTION AND TREATMENT/HEPATITIS B:

Having been among the first to push for legalized syringe exchange programs, appropriate tracking and reporting processes, optimal funding, and more, the SFMS was, naturally, at the center of medical advocacy for solid responses to the AIDS epidemic in the 1980s.

SFMS is a partner in the Hep B Free program in San Francisco and helps educate physicians and patients on the prevention and treatment of hepatitis B.

SUGAR TAXATION AND HEALTH: SFMS has long been on record combating overconsumption—and marketing—of sugar and soda, especially where young people are concerned. To help prevent and battle obesity and other associated ills, SFMS has not only endorsed the broad coalition, but is also at the forefront of instituting a landmark local tax on soda with revenue marked for health needs. We have authored policy on this issue for the California Medical Association (CMA) as well.

SCHOOL AND TEEN HEALTH: SFMS helped establish and

staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the San Francisco Unified School District 8

school health service. SFMS has authored a resolution allowing minors to receive vaccines to prevent Sextually Transmitted Infections (STIs) without parental consent.

END-OF-LIFE CARE: SFMS leaders have developed numerous policy and educational efforts to improve care toward the end of life, including promulgation of the Physician Orders for Life-Sustaining Treatment (POLST) medical order. The SFMS was instrumental, after decades of advocacy, in getting the CMA to remove its blanket opposition to physician-assisted dying and to thus allow for legalization of that in 2016.

ANTIBIOTIC RESISTANCE: SFMS leaders have presented national meetings and policy on this topic, including the American Medical Association’s first statement on antibiotic overuse in agriculture and numerous subsequent efforts.

ENVIRONMENTAL HEALTH: SFMS’ many efforts include

establishing the Collaborative on Health and the Environment, a nationwide educational network on scientific approaches to environmental factors in human health, and advocating for reduced exposure to mercury, lead, and air pollution.

REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a

state and national leader in advocating for women’s reproductive health and choice, including access to all medical-indicated services.

ORGAN DONATION: SFMS has been the vanguard in seeking improved donation of organs to decrease waiting lists and deaths due to the shortage of organs through educating the public and proposing new policies regarding consent and incentives for organ donation.

OPERATION ACCESS: SFMS is a founding sponsor of this local

organization which provides free surgical services to the uninsured, and has provided office space, volunteers, and funds.

DRUG POLICY: SFMS has been a leader in exploring and advocating new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, and treatment instead of incarceration. We were integral in the development of CMA’s landmark report on decriminalization and regulation of cannabis, and even in creation of the official subspecialty of Addiction Medicine.

MEDICAL ETHICS: SFMS has developed and promulgated forward-looking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policymakers, and the general public.

PARTNERSHIPS: SFMS works closely with many local specialty and health organizations such as the San Francisco Department of Public Health, Health Commission of San Francisco, San Francisco Emergency Physicians Association, San Francisco Pediatric Council, San Francisco Community Clinic Consortium, West Bay Hospital Conference, Chinese Community Health Care Association, and others.

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EDITORIAL Gordon Fung, MD, and Steve Heilig, MPH

Pursuing Pain with No Harm Pain has always been an integral part of the human condition. For most of history, there was little-to-nothing to be done about it - think of the prehistorical skulls of our ancestors found with holes broken in, theorized to be from a desperate last-ditch attempt at “treating” toothache or headache.

So, in the midst of the current controversies regarding pain treatment and the epidemic of abuse and addiction of pain medications, let’s begin by acknowledging there has been progress.

Pain remains the most common reason for first seeking medical care. For the patient, there is an strong sense of alarm and awareness that something is wrong. For the clinician, pain is a symptom of an underlying disease process. Over millennia, every kind of pain has been described in the lay and medical literature evoking an empathetic and compassionate response in family members, friends, caregivers and health care providers, to relieve and eliminate the sheer suffering of pain. Medical students learn that getting an accurate description of the pain directly from the patient in terms of quality of the pain, radiation of the discomfort, stimulating or relieving factors and the time course (the PQRST of pain) was key to making a diagnosis of many diseases. We learned that in some cases, it was important not to treat the pain until the diagnosis was made or we might miss the diagnosis.

Ironically, tragedies such as war have contributed much to our understanding and treatment of pain. From 1918 to 1946 (during World Wars I and II) there were many advances—especially in cases of trauma such as bomb blasts, gun shot wounds, or fractures. Management of this acute type of pain was also improved for patients with MI, infections, or cancer. This type of pain we have learned is called physiologic pain or eudynia.

Since the 1950’s, there has been a significant increase in chronic illnesses also associated with painful conditions that were difficult to treat because of lack of understanding and knowledge as to the cause of the pain. Sometimes, these patients have frequent episodes of physiologic pain and develop a chronic condition of pain. Sometimes, the pain is associated with a longer illness such as cancer or autoimmune diseases like arthritis or infections such as herpetic neuralgia. Then there are other situations where pain can spontaneous come and go with a chronic disease such as diabetic neuralgia or even post traumatic injuries like phantom-limb pain or cluster headaches. This type of pain has been called pathological pain or maldynia. It is poorly understood and postulate that there are irreversible changes in peripheral pain receptors with nerve and spinal cord and brain changes leading to the possibility that the nervous system itself can begin to generate abnormal pain signals that are resistant to treatment. It wasn’t until the latter WWW.SFMMS.ORG

half of the 20th century that this was recognized as a distinct category of pain and disease entity of its own.

In more recent decades several medical societies and associations devoted to advancing pain medicine have been formed, including the American Academy of Pain Medicine and American Board of Pain Medicine. These organizations were formally accepted as specialty organizations by the AMA in the 1970’s.

The mission of the AAPM is to advance the specialty of pain medicine—algiatry, and the comprehensive care of patients with pain through promotion of the best clinical practices, research, advocacy, and continuing medical education. Currently, pain medicine is a recognized subspecialty within the field of anesthesia. There is currently ongoing efforts to have the American Board of Medical Specialties consider it a primary specialty board and not a subspecialty of anesthesia exclusively to broaden the training by developing a full dedicated residency training in pain medicine with a multi-disciplinary approach.

Managing chronic pain remains a significant challenge due to many factors, including lack of objective test or criteria for the diagnosis of chronic pain, an adequate screening tool, insufficient understanding of the mechanism of disease, insufficient research funding for this condition, insufficient numbers of algiatrists, and poor or limited pharmacologic management options, lack of clear goals of treatment or management. In the literature, from 1990 to 1999, there were more than 105,000 articles written with pain in the title discussing many aspects of this issue including proposed solutions.

In this month’s edition of SFMMS Medicine, we bring together some resources and perspectives we hope are of some value in helping challenging patients with chronic pain - while also minimizing the negative side effects, both clinical and social, of these important efforts. While minimizing pain remains the primary goal, we must also not forget another important dictum: Do No Harm.

Editor and cardiologist Gordon Fung, MD, PhD, is clinical professor of medicine at UCSF with a practice in consultative general clinical cardiology, and is medical director of the Electrocardiography Lab at Moffit/Long Hospitals and of the nation’s first UCSF Asian Heart & Vascular Center located on the Mount Zion Campus. He is a former SFMS President. Steve Heilig, MPH, is Director of Public Health and Education for the SFMMS, and managing editor of San Francisco Marin Medicine.

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Pain Medicine: Perspectives and Practices

THE OPIOID EPIDEMIC A (Not So) Brief History Medical Insurance Exchange of California In the January 2013 issue of The Exchange, we used the analogy of a swinging pendulum to describe the shifting policy regarding pain management and the use of opioid pain medications. Back in 1996, in response to

a perceived undertreatment of pain, the American Pain Society promoted the concept of “Pain as the 5th Vital Sign” to urge physicians to recognize, evaluate, and effectively treat pain both in the outpatient and acute care settings. With the advent of “safe” extended-release opioid formulations such as OxyContin, which came on market in 1996, physicians began to feel more comfortable prescribing opioids for the treatment of chronic pain in the outpatient setting.1 By 2003, state medical boards had updated their guidelines to require the appropriate evaluation and treatment of both acute and chronic pain. Indeed, physicians were disciplined, as well as sued, for allegedly failing to reduce patients’ pain.

Meanwhile the amounts of prescribed opioids in the U.S. soared. Per the U.S. Centers for Disease Control and Prevention (CDC), between 1992 and 2015 total opioid prescriptions increased from 112 million to 249 million. Along with increasing prescriptions, the number of adverse events rose dramatically. From 1999 to 2014, over 165,000 deaths occurred from overdoses related to prescription opioids. The rate of fatal overdoses of prescription opioids has quadrupled since 1999, and there were over 14,000 deaths related to prescription opioids in 2014 alone. By 2014 it was estimated almost two million individuals abused or were dependent on opioids.2 In 2013 we reported that the national policy towards opioids was shifting, partly in response to a November 2011 declaration by the (CDC) that prescription drug abuse had become a “national epidemic.”3 In Spring 2013, the Federation of State Medical Boards (FSMB) released its revised Model Policy for the Use of Controlled Substances for the Treatment of Pain, which in turn led to the updating of state medical board guidelines. The updated guideline, while still recommending that physicians recognize and treat legitimate pain, added several recommendations to minimize the potential for abuse and diversion of narcotic pain medications, and to recognize and prevent the use of them outside legitimate medical purposes.

Meanwhile, authorities were significantly stepping up their discipline, and even criminal prosecution, of physicians for overprescribing opioid pain medications. Beginning in 2013, the DEA Diversion Office, which initially had pursued large-scale pharmaceutical distributors, refocused their efforts on physicians, pharmacists, and smaller organizations.4 As we begin 2017, it is now safe to say that the pendulum has fully swung. The increased prosecution and discipline of physicians has continued. In February 2016, a Southern California physician was convicted of second-degree murder and sentenced to thirty 10

years to life in prison for the deaths of three patients from opioid overdose. This was the first time a physician had been convicted of murder in relation to prescribing pain medications.5 In March 15, 2016, the CDC released its Guideline for Prescribing Opioids for Chronic Pain, which endorses ever tighter restrictions on the use of opioid pain medications outside of active cancer treatment, palliative care, and end-of-life care.

Over the past several years, it has been difficult to read the news without encountering a story about the dangers of opioid abuse and the perceived need for large-scale reform in pain management. Recently, the national discussion has spread from the epidemic of overdose-related injuries and deaths, to the lifelong affliction of opioid addiction.

MIEC Patient Safety & Risk Management Recommendations

In response to recent medical board and CDC guidelines, Medical Insurance Exchange of California (MIEC) has developed recommendations for policyholders: • Be familiar with your state medical board guidelines for using controlled substances to treat pain, and always adhere to state guidelines to avoid civil liability, licensure action, and/or criminal liability.

• Adhere to the CDC Guideline for Prescribing Opioids for Chronic Pain whenever possible, and carefully document your rationale if providing treatment that is not consistent with the recommendations.

• Try non-opioid therapies first for chronic pain, or demonstrate failure of non-opioid therapies before prescribing chronic opioids.

• Conduct and document a full risk assessment before prescribing opioids.

• Focus on and document a functional assessment as well as pain symptoms and physical exam results.

• Develop progress notes specifically for chronic pain patients, which include measures of effectiveness of treatment.

• Have patients sign a pain management agreement and require them to adhere to the agreement.

• Conduct routine urine testing and other standard screening for opioid use disorder.

• Beware the “90-day cliff” and carefully re-evaluate patients before continuing opioids past three months.

• Develop policies to reevaluate patients when increasing opioids past 50 morphine milligram equivalents (MME)/day, and do not exceed 90 MME/day without documented reasons.

• Don’t assume that patients on stable dosages of 50 MME/day or less are being appropriately managed; re-evaluate for efficacy of

Continued on page 12 . . .

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Pain Medicine: Perspectives and Practices

FIRST DO NO HARM Changing Tactics in the Opioid Epidemic Kelly Pfeifer, MD Editor's Note: The California Department of Public Health (CDPH) recently presented the California Health Care Foundation’s (CHCF) Kelly Pfeifer, MD, with the Beverlee A. Myers Award, its highest honor for an individual exhibiting outstanding leadership and accomplishments in public health in California. Pfeifer was recognized for her work leading efforts to address the opioid epidemic, which claims the lives of more than two thousand Californians each year. This article is adapted from Pfeifer’s remarks at the April 4 award ceremony.

I am humbled and frankly shocked by this award. This honor feels like that moment when the Academy Award for best film is given to a producer, and people are watching on TV and thinking, “But what did that person do? Not any real work, like acting or directing.” To acknowledge all those fighting the opioid epidemic in California would be a very long credit reel: county health officers, addiction providers, law enforcement, nurses, doctors, people in recovery, their families, state agency staff, and more—all coming together to turn this epidemic around.

One of my favorite things about working at the California Health Care Foundation (CHCF) is playing this behind-the-scenes producer role: pulling people together and helping them get the resources they need to combat the opioid epidemic. It is deeply satisfying to see progress accelerating across the state, especially since I spent the first several years of my medical career as part of the opioid problem.

As a family doctor in a semi-rural clinic, I saw many people with chronic pain and prescribed a lot of opioids. I wasn’t alone.

The number of opioid prescriptions quadrupled in fifteen years.

Due to marketing from pharmaceutical companies and a misleading study, most physicians believed that long-term opioid use was effective and safe and that less than one percent of our patients would become addicted. We believed we were relieving suffering.

As the years progressed, I saw people get worse instead of better. I had more than one patient die taking the medications I prescribed. Today we know that the percentage of people becoming addicted when taking opioids for pain is anywhere from ten to fifty percent, not one percent. We have learned that pain relief doesn’t last long, and that higher and higher doses are usually needed to get the same effect. With these higher doses often comes hyperalgesia, where people hurt all over—citing constant nine out of ten pain levels—as their bodies stop making the chemicals that regulate pain sensation. We now know about the host of medical problems caused by long-acting opioids: sleep apnea, depression, anxiety, sexual dysfunction—and worsened pain. We didn’t know that once you start long-term opioids, your brain changes and it is very, very difficult to stop. Without curtailing prescribing practices, opioid overdose deaths have continued to climb.

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It may be hard to imagine how a group of smart and highly educated people like doctors could have been misled by pharmaceutical marketing, and by such (now) obvious untruths. The Myers Award is the highest award given annually by the CDPH to the person exhibiting outstanding leadership in public health in California.

Unfortunately, changing prescribing practices will take time and effort. As surgeon Atul Gawande pointed out in the New Yorker, some breakthroughs spread like wildfire, and some take a generation to take hold. Take the discovery of ether as surgical anesthesia. Following its first use in Boston in the 1840s, news of its efficacy quickly spread, and within eight months, surgeons were using ether around the world. Compare that to handwashing and sterile surgical techniques. While these practices prevented fatal infections, they took decades to become standard practice.

What is the difference?

Quite simply, anesthesia immediately makes life better for both the patient and the surgeon. It is difficult for surgeons to perform an operation on someone who is awake and feeling the knife; patients don’t like it much either. In contrast, handwashing combats something invisible (germs), it is painful for the doctor— carbolic acid was the only option in the 1840s—and only benefits the patient through avoided infections.

As Gawande points out, it is very difficult to get clinicians to change their behavior when the change means more work, more pain, and no immediate benefit. This principle is obvious to anyone who has tried to lose weight. Unfortunately, it has become increasingly apparent that opioids are the worst of both worlds: Overprescribing spread as fast as ether, but reversing the trend looks a lot more like handwashing.

Why did we quadruple our opioid prescribing in fifteen years? Simply put: Opioids solved an immediate problem for both patients and doctors. The pills take away pain and suffering almost instantly: Patients feel better, and we health care professionals feel gratified, because diminishing human suffering is one of the reasons we went into this profession. And the suffering caused by opioids? That comes way downstream, far later than a postsurgical infection.

Reversing the opioid crisis, on the other hand, is a much slower process. Changing the medical culture is hard work. We are asking clinicians to change how they treat acute and chronic pain in ways that take more time, more training, without a lot of good alternatives, and without immediate benefit to the patient in front of them. We are telling people with chronic pain to reduce doses of medications they feel they cannot live without and that, as a result, they will feel better and be at lower risk of dying. We are telling people with back pain that they will feel better if they walk

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First Do No Harm Continued from page 11 . . .

The Opioid Epidemic Continued from page 10 . . .

and stay out of bed, and that the pills that could make them feel briefly better now will make them worse later. And we are asking the government and the public to turn around longstanding bias that drug-free addiction treatment is always the right path. The data show that for opioid addiction, sixty percent of people are sober at a year with medication-assisted treatment (MAT), compared to six percent of those using drug-free treatment programs.

The opioid epidemic is a problem that cannot be solved by changing prescribing habits. It is truly a public health epidemic that requires a public health response, and California has led that charge. CDPH director Dr. Karen Smith united more than a dozen state and federal agencies, along with health officers, academia, and community partners, to synchronize efforts, all pointed at the North Star: Zero overdose deaths in California and widespread access to effective addiction treatment.

California’s collective impact in this work will be showcased at the National Rx Drug Abuse and Heroin Summit this month in Atlanta. California is leading the country in redesigning addiction treatment for people in Medi-Cal, a model effort now replicated in other states. And, quite uniquely, we can measure our progress in the California opioid overdose surveillance dashboard. You can compare counties over time with rates of opioid prescribing, opioid-related hospitalizations, overdose deaths, and buprenorphine access.

One of the main principles for CHCF is to find what works and then help spread it across the state. Last year we published papers on successful health plan approaches to opioid overprescribing, complementary pain therapies in the safety net, and medication-assisted treatment options for clinics and emergency departments. We are helping twenty-five community health centers and seven emergency departments start addiction treatment programs, and eight teams of health plans and clinics to build new services for complex patients. We launched Smart Care California—a public/private partnership—to help payers and health plans address overuse, including a focus on the opioid epidemic.

This year we’re planning to look at best practices in addiction treatment for pregnant women and people released from jail.

Our biggest point of pride has been the Opioid Safety Coalitions Network. With Marin and San Diego County coalitions as our model, CHCF, CDPH, and Partnership HealthPlan launched the network eighteen months ago by supporting local coalitions to make local change. Medical societies, county government, health plans, and other local leaders brought people together who typically don’t talk to each other—doctors and police officers, hospitals and health departments, drug treatment and community health centers—all united to look at data, draft a plan, and implement concrete changes to stop overdose deaths in their communities. There has been so much momentum that more than thirty-five counties in California now have active opioid safety coalitions.

These are just a few examples of why I accept this award on behalf of the many people across this work who push this cause forward; the credit reel is long and getting longer every day.”

current treatment and lower dosage if appropriate.

• Register for your state prescription drug monitoring program (PDMP) (Controlled Substance Utilization Review and Evaluation System (CURES) in California) and routinely obtain patient reports prior to, and regularly during, opioid prescription.

• Familiarize yourself with “black box” warnings for all controlled substances you prescribe.

• Know your state’s continuing medical education (CME) requirements, if any, pertaining to education in pain management.

For more information, please see the complete MIEC article online at www.miec.com. You may also contact MIEC at 510-428-9411.

References

1. American Pain Society. “Pain as 5th Vital Sign.” http://americanpainsociety.org/uploads/education/section_2.pdf.

2. CDC statistics. http://www.cdc.gov/drugoverdose/data/index.html.

3. CDC press release November 1, 2011. “Prescription Painkiller Overdoses at Epidemic Levels.” https://www.cdc.gov/media/ releases/2011/p1101_flu_pain_killer_overdose.html.

4. Bernstein, Larry and Higham, Scott. “Investigation: The DEA slowed enforcement while the opioid epidemic grew out of control.”

Washington Post, October 22, 2016.

5. Gerber, Marisa. “Doctor convicted of murder for patients’ drug overdoses gets 30 years to life in prison.” Los Angeles Times, February 6, 2016.

Presented by the Asian Health Institute Department of Medicine University of California, San Francisco

6th ANNUAL

Asian Health Symposium Laurel Heights Conference Center • 3333 California Street • San Francisco, California

COURSE DIRECTORS

Gordon Fung, MD, MPH, PhD Professor of Medicine, UCSF Diana Lau, PhD, RN, CNS Assistant Professor School of Nursing, UCSF

October 6-7, 2017

STEERING COMMITTEE

Peter Chin-Hong, MD John Inadomi, MD Andrew Ko, MD Gene Lau, MD Byron Lee, MD Don Ng, MD Eugene Yang, MD

Reprinted from the California Health Care Foundation.

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Pain Medicine: Perspectives and Practices

CANNABIS FOR PAIN Substantiating the Evidence Donald I. Abrams, MD Surveys of patients accessing cannabis for medical use have consistently demonstrated that chronic pain is the most frequently listed condition for which people are seeking treatment.1,2 State regis-

tries also generally support this finding, although ironically there are some states that do not allow chronic pain as an eligible condition for which cannabis can be recommended. It has been postulated that the main reason that we and other species have cannabinoid receptors and endogenous cannabinoids (endocannabinoids) is to help us modulate the body’s response to pain. Local clinicians caring for patients who have access to medicinal cannabis over the past twenty-one years have likely been impressed with the pain relieving effects they have appreciated.

What does the research say? The Institute of Medicine listed pain as one of the conditions that may benefit from cannabis in their 1999 report, Marijuana and Medicine. More recently, the National Academies of Sciences, Engineering and Medicine (NASEM) conducted a rapid turnaround review of The Health Effects of Cannabis and Cannabinoids to update the earlier study.

The report was issued in January 2017.3 As a result of the November 2016 elections, medicinal cannabis is now legal in twenty-eight states and the District of Columbia.4 In anticipation of these ballot results, a consortium of sponsors commissioned the NASEM to develop a comprehensive, in-depth review of the existing evidence regarding the health effects of cannabis and cannabinoids. In addition, NASEM was asked to make recommendations regarding a research agenda.

The sixteen-member committee, first convened in June 2016, adopted key features of a systematic review process and evaluated meta-analyses and systematic reviews published between 2011-2016 that investigated both the beneficial and harmful health effects of cannabis and cannabinoids.3 If no high quality systematic reviews had been published regarding the eleven prioritized health endpoints, results of high quality primary research published since 1999 were included. The report priorities included therapeutic effects and potential adverse effects in areas such as cancer incidence; cardiometabolic risk; respiratory disease; immune function; injury and death; prenatal, perinatal and postnatal outcomes; psychosocial outcomes; mental health; problem cannabis use; and cannabis use and abuse of other substances.

Of the twenty-four therapeutic areas identified, conclusive research evidence was identified in only two: 1) oral cannabinoids are effective anti-emetics in adults with chemotherapyinduced nausea and vomiting, 2) short-term use of oral cannabinoids improves patient-reported spasticity symptoms in adults with multiple sclerosis.3 This conclusion is drawn when strong evidence from randomized controlled trials supports the effecWWW.SFMMS.ORG

tiveness of the treatment for the health endpoint of interest and there are many supportive findings from good-quality studies with no credible opposing findings.3 The report concluded that there is substantial evidence (strong evidence but few credible opposing findings) that cannabis is an effective treatment for chronic pain in adults. Five good- to fair-quality systematic reviews and two primary literature articles were identified assessing the effects of cannabinoids on pain. Thus, in total, twentyeight pain trials were included in the review. Seventeen of these investigated cannabinoids in peripheral neuropathy pain. Information regarding the effectiveness of cannabis or cannabinoids in other painful conditions is limited.3 Most of the chronic pain studies reviewed were short-term and with small sample sizes limiting the assessment of longterm effects.3 Chronic pain was the only therapeutic area where there was a small body of evidence supporting the benefits of botanical cannabis and not just the isolated cannabinoid delta9-tetrahydrocannabinol in its pharmaceutical preparations.

No studies of the higher potency oral products available from many dispensaries nationwide have yet been conducted as the only legal source of cannabis for investigation continues to be the National Institute on Drug Abuse (NIDA).5 Contributing to the lack of research findings on the effectiveness of cannabis are the significant barriers to research of Schedule I substance.3 This becomes increasingly problematic as the momentum gains for both legalization of medical and recreational cannabis.

Based on the existing evidence, cannabis may be considered prior to initiating opioid therapies in patients with neuropathy and other chronic pain syndromes. Early evidence is promising as states where medical cannabis is legal have reported decreases in opiate prescriptions and opiate-related mortality.6 Animal models and a small human study support decreased pain with no adverse pharmacokinetic interactions between vaporized cannabis and sustained-release opiate analgesics.7 In view of the current significant opiate epidemic, using cannabis instead of opiates for chronic pain and/or to allow opiate-dependent patients to attempt to wean off of their narcotics may be a feasible harm-reduction intervention.8 One question that remains unanswered is the effect of other cannabinoids on pain. Cannabidiol (CBD) has been catapulted to the forefront of attention as perhaps the new most-favored cannabinoid because it lacks the “high� associated with delta-9-tetrahydrocannabinol.8 Many patients seeking relief from pain are not enthusiastic about the mind-altering effects of tetrahydrocannabinol (THC). With the knowledge that cannabidiol is antiinflammatory and analgesic in animal models, more patients are trying products with varying ratios of CBD:THC for pain relief.

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Cannabis for Pain Continued from page 13 . . .

Clinicians may find that they are frequently queried about what is the correct ratio for pain management. Again, there is no answer because there is no data. The ongoing study at Zuckerberg San Francisco General Hospital investigating a 5%THC:5%CBD vaporized cannabis in sickle cell patient appears to be the first trial in the U.S. investigating an inhaled THC:CBD strain. That is not to say that patients are not benefiting from using CBDcontaining products; it is just that the plural of anecdote is still not evidence.

Another issue that remains unclear is what is the best mode of delivery for pain relief? When inhaled—smoked or vaporized—the peak plasma concentration of THC is reached in minutes and declines rapidly. When taken by mouth as edibles, capsules, tincture or oils, the peak plasma concentration can occur as late as two and a half hours after ingestion with a terminal half-life of twenty to thirty hours. When ingested orally, first past metabolism in the liver converts the delta-9-THC into another psychoactive metabolite: 11-OH-THC. This is why people generally get a more deep and prolonged psychoactive effect with oral routes of administration. The pharmacokinetic profile of sublingual preparations available in dispensaries is likely somewhere between inhaled and ingested cannabis but the only available evidence stems from studies of the pharmaceutical whole plant extract, nabiximols, licensed and available in Canada and much of the European Union but not yet in the U.S.9 There may be some populations in which cannabis as an analgesic should be approached with caution if at all. The NASEM report suggests that cannabis is not indicated before the central nervous system is fully programmed and developed at age twenty-five.3 Certainly many Baby Boomers attending college in the 1960’s found eighteen to be a convenient age to begin to experiment with recreational cannabis and appear to be none the worse for the experience. Children and adolescents, however, may not be appropriate candidates for initiation of cannabis as an analgesic. There is a growing body of research on cannabinoid medicines utilized as anti-seizure medications in refractory childhood epilepsies and anecdotal reports of pediatricians finding benefit from the use of oral cannabis-based analgesics, particularly CBD products, but, in general, alternatives should be investigated first.

Older seniors constitute another clinical population in which cannabis as an analgesic should be considered with caution. As cannabis can both elevate and lower blood pressure while increasing heart rate, cardiovascular stress is an issue.

Postural hypotension and risk of falling with an obvious potential for fracture would also be a significant concern. Seniors may also be more averse to inhalation as a mode of delivery and need to be apprised clearly of the delayed onset of edible and oral preparations to avoid excessive dosing.

Currently, there is significant political rhetoric about the role of cannabis in therapeutic care.10 As the NASEM report outlines, there is a need for further high-quality evidence to understand the health risks and therapeutic benefits associated with cannabis. Hopefully further evidence will support individual 14

patient and care provider conversations, advocacy for public health measures, and the development of sound, evidence-informed policy and practice.

Donald Abrams is chief of Hematology-Oncology at Zuckerberg San Francisco General and a Professor of Clinical Medicine at the University of California San Francisco.

He has been conducting research with cannabis since 1996. He was a member of the sixteen-member committee of the National Academies of Sciences, Engineering and Medicine which issued the report on The Health Effects of Cannabis and Cannabinoids in January 2017.

References 1. Reinerman C, Nunberg H, Lantjier F, Heddelston T. Who are medical marijuana patients? Population characteristics from nine California assessment clinics. J Psychoactive Drugs.

2011; 43:128-135.

2. Seton M, Cuttler C, Finnell JS, Mischley LK. A cross-sectional survey of medical cannabis users: patterns of use and perceived efficacy. Cannabis Cannabinoid Res. 2016; 1:131-138.

3. National Academies of Sciences Engineering and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research.

Washington DC: the National Academies Press. 2017. http:// www.nationalacademies.org/hmd/Reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx 4. Steinmetz K. How the 2016 Election Became a Watershed for Weed. Time. 2016;Nov 10:http://time.com/4557472/marijuana-2016-states-legalized/.

5. US Food and Drug Administration. Marijauna Research with Human Subjects. https://wwwfdagov/newsevents/publichealthfocus/ucm421173htm 6. Bachhuber MA, Saloner B, Cunningham CO. Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010. JAMA. 2014;174(10):1668-73.

7. Abrams DI, Couey P, Shade SB, Kelly M.E., Benowitz NL. Cannabinoid–Opioid Interaction in Chronic Pain. Clinical Pharmacology & Therapeutics. 2011;90(6):844-51.

8. Corroon JM, Mischley LK, Sexton M. Cannabis as a substitute for prescription drugs: a cross-sectional study. J Pain Res. 2017; 10:989-998.

9. Tanasescu R, Constantinescu CS. Pharmacokinetic evaluation of nabiximols for the treatment of multiple sclerosis pain.

Expert Opin Drug Metabol Toxicol. 2013; 9:1219-1228.

10. Sifferlin A. Jeff Sessions Says Marijuana Is Only ‘Slightly Less Awful’ Than Heroin. Science Says He’s Wrong. Time.

2017;March 16, 2017.

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Pain Medicine: Perspectives and Practices

THE HIDDEN DEFICIENCY Getting to the Root of Pain Jane Hightower, MD Pain, gastrointestinal symptoms, toothaches, and infertility have been the most common general afflictions plaguing humans. For thousands of years we have con-

tinued to search for the quickest and “best” cures.

Although generalized atraumatic pain is experienced in many diseases, it can also exist without disease. As Grandma soaked her aching tired feet or took a bath in Epsom salts, others sought quicker treatment for pain with opiates, coca leaf, turmeric, cannabis, and alcohol. The pain medication industry has flourished with more potent opiates, from laudanum to fentanyl. And the plethora of analgesics, anti-inflammatory agents, and neurologics is a still-growing multi-billion dollar industry.

For thousands of years, entire industries have been dedicated to a hands-on approach to physically relieve pain in our muscles and joints. This includes massage, acupuncture, chiropractic, physical therapy, and hot mineral springs.

With the opiate epidemic increasing at such a steep rate, we wonder why. It certainly isn’t a new treatment. Human opiate use has been in existence before 5000 BCE. So what are these people treating? Is a higher percentage of humans experiencing pain? Is there something in the water or food? Is there something not in the water or food?

Toxicities versus deficiencies have certainly been looked into in regard to the cause of pain, and both can be inter-related as one influences the other. But when it comes to generalized body, or myofascial pain, so prevalent in our species, a common deficiency could likely be the cause.

With the most common of vitamin deficiencies, there appears to be direct correlations and easy fixes. Examples of which are Vitamin C and Scurvy, thiamine (Vitamin B1) and Beriberi, iron and anemia, iodine and goiter, and B12 and peripheral neuropathy. But one vitamin deficiency is associated with a broad range of many diseases, to include cardiovascular disease, cancer, and autoimmune disease, yet giving this vitamin, which is actually considered a hormone, does not consistently resolve these conditions, if at all.

This vitamin is none other than Vitamin D. Vitamin D deficiency is also associated with myofascial pain, but again, giving supplemental vitamin D has not been consistently effective in resolving this pain.

There are a number of well-known reasons for vitamin D deficiency, such as poor dietary intake, lack of sun, living at latitudes above 37º North, darker skin, older skin, obesity, and vitamin D receptor (VDR) polymorphisms. But one contributor continues to be left out of the equation, and that is magnesium deficiency. Magnesium is vital to the production of the hormone vitamin D. The enzymes, 1- alpha hydroxylase, 24-hydroxylase, and 25-hydroxylase that determine the 25-hydroxyvitamin D and 1 alpha, 25-hydroxyvitamin D concentrations are dependent on magnesium as a cofactor.

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concentrations. Vitamin D and magnesium are both important for deoxyribonucleic acid (DNA) repair and immune system function.

When it comes to myofascial pain, although vitamin D has not been found to resolve this common problem, magnesium has. But it takes a consistent and intensive months-long effort to replete the body’s stores, and resolve tendon tenderness.

Magnesium is important for the body’s function of over six hundred enzymes, regulation of activity of several ion channels, and for stabilization of negatively charged molecules such as Adenosine 5’-triphosphate (ATP), Adenosine diphosphate (ADP), ribonucleic acid (RNA), and DNA. Unfortunately, the most common tests for assessing magnesium levels, such as red blood cell (RBC) magnesium or serum magnesium, do not discern what is in your bones and soft tissues, which is where this intracellular mineral is stored.

Multiple etiologies for magnesium deficiency have been discovered, to include low dietary intake, genetic or acquired aberrations of gastrointestinal absorption, renal or gastrointestinal excretion, and medications that alter any of the above. Diuretics, proton-pump inhibitors, alcohol, chemotherapy, and hormones, are just a handful of agents that can contribute to hypomagnesemia.

It has been shown that magnesium deficiency is common worldwide. The recommended dietary allowance (RDA) for magnesium is about five milligrams per kilogram of bodyweight per day (5 mg/kg BW/day), which is about 320 mg for women and 420 mg for men. The most common food sources are vegetables, dark chocolate, beans, seeds, nuts, whole grains, small fish, and animal protein.

But there is also another important source, poorly recognized by health care practitioners, and that is water.

San Francisco is a soft water municipal district where the average hardness of tap water is 46 mg/L, the average magnesium concentration is 3.9 mg/L, and average calcium concentration is 11 mg/L. For the average woman, consuming about two liters of San Francisco tap water per day, this will only provide about 2.4% of her RDA. In comparison, Bodega Bay, California tap water is about 40 mg/L of magnesium. She will therefore obtain twenty five percent of her RDA just by drinking this water. As a note, cooking in soft water has been found to leach out magnesium from your food.

Drinking soft water has been recognized as an influencing factor for multiple health outcomes. Studies of populations living in soft water municipal districts have concluded that low magnesium in the drinking water increases the prevalence of cancer and cardiovascular disease. Other sources of water such as softened tap water, reverse osmosis filtered, distilled, and desalinated water, along with many packaged or bottled waters, do not contain significant or even measurable amounts of magnesium. In contrast, some mineral waters contain greater than 100 mg/L of magnesium.

So while myofascial pain is associated with magnesium defi-

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The Hidden Deficiency Continued from page 15 . . . ciency, vitamin D deficiency, and a large variety of diseases or conditions, we should be looking for the actual long-term remedy instead of the quick relief.

In my upcoming publication, in the Journal of the American College of Nutrition, I used myofascial pain as a clinical proxy to magnesium deficiency. I then surveyed my patient population and compared myofascial pain and or vitamin D deficiency to any disease and condition. I concentrated on cancer, colon polyps, and tendon rupture. What I found was that myofascial pain or serum 25-hydroxyvitamin D < 30 ng/mL was associated with cancer, colon polyps and tendon rupture. The odds increased when both vitamin D deficiency and myofascial pain were present.

Our bay area patients are living at 37º N, drink soft water that has very low or no magnesium, and may or may not have a vitamin D receptor (VDR) polymorphism. And for many, simply eating magnesium rich food is probably not enough. Supplementation should then be advised, especially when many scientific papers have shown an inverse relationship of magnesium intake and cancers, colon polyps, and cardiovascular disease. And to reiterate, although serum 25-hydroxyvitamin D < 30 ng/mL is associated with many diseases and conditions, to include myofascial pain, supplemental intake has not been consistent in reducing these conditions. Regardless, we know that those who have a vitamin D greater than 50 ng/mL have less cancer and cardiovascular disease. The problem is that it seems to depend on how they got to that level. Taking both vitamin D and

magnesium is more effective in raising vitamin D levels than taking either agent alone.

The World Health Organization has determined that 500 mg of magnesium in supplement form is deemed safe. The only contraindications are renal failure and gastrointestinal obstruction. The main side effect is diarrhea, so divided doses is better tolerated. In patients who are on medications that deplete magnesium, higher doses are in order, to maintain a positive balance to allow accumulation back into the storage spaces. The best magnesium supplements will be chelated with amino acids, or in a liquid ionic form. Other sources are magnesium gels and sprays. And don’t forget Grandma’s remedy for her aching feet and body—that is, Epsom salt. This salt, which is magnesium sulfate, is absorbed through the skin, and magnesium sulfate or mineral springs have been used for body aches and pains for thousands of years. We just have to take the time, to soak it all in.

Dr. Hightower is a board certified internal medicine physician in San Francisco, who has special interest in food and environmental contaminants as it pertains to health, as well as preventive and diagnostic medicine. Dr. Hightower is the author of Diagnosis Mercury: Money Politics and Poison. She is a longtime member of the SFMS. This article includes descriptions of research to be published in the Journal of the American College of Nutrition.

Specialty orthopedic services in San Francisco and Marin.

Whether your patients seek care in the city or the North Bay, you will find comprehensive orthopedic services in convenient locations. Board-certified orthopedic and spine surgeons at California Pacific Medical Center and Novato Community Hospital offer complete orthopedic care, including arthroscopy, joint reconstruction, joint replacement, advanced nonsurgical conservative care and sports medicine.

sutterhealth.org/orthopedics 888-834-1788

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Pain Medicine: Perspectives and Practices

KIDS AND CHRONIC PAIN Managing Pain in Children and Adolescents David Becker, MD, MPH, MA; Cristina Benki, PhD; Lisa Purser, RN; and Alicia Heilman, RN Editor's note: this three part article was written by by the Integrated Pediatric Pain and Palliative Care (IP3) Team at UCSF Benioff Children’s Hospital, San Francisco.

Part 1: Chronic Pain in Children and Adolescents Chronic pain in the pediatric population is a frequently under-recognized and under-treated condition that has been increasing in prevalence for a number of years. In children and adolescents, the most common pre-

sentations are headaches, abdominal pain, and musculoskeletal conditions. Family’s lives can be markedly disrupted with children out of school for months at a time and financial resources severely strapped. These children present unique challenges to primary care providers that are often difficult to address with limited time and training. Specialty programs in chronic pain management have been growing to address this need, but access to high quality multidisciplinary programs has not kept pace with the need. There is broad consensus that chronic pain conditions require multidisciplinary team approaches that include physicians, psychologists, nurses, physical therapists, and additional modalities to address the complex needs of these patients. There are several key concepts that are essential in approaching these cases. We will discuss these concepts and briefly describe our program at University of California, San Francisco Benioff Children’s Hospital San Francisco.

Definitions of chronic pain conditions vary and reliable data on prevalence for most conditions are lacking. In general, pain conditions are considered chronic when they persist beyond three months, but many of the clinical approaches to chronic pain apply to treatment long before this time frame. Studies of the prevalence of chronic daily headache find rates between one and four percent, with the majority not meeting specific criteria for migraine or tension type headaches. Functional chronic abdominal pain conditions are hypothesized to be a dual function of visceral hypersensitivity and motility dysfunction. Estimates of prevalence are in the range of ten to fifteen percent of children and adolescents. The most common musculoskeletal chronic pain conditions in children and adolescents are chronic regional pain syndrome (CRPS; previously called reflex sympathetic dystrophy), and amplified pain syndrome (APS). CRPS has specific diagnostic criteria that include physical exam signs such as temperature asymmetry, localized edema, color changes, muscle wasting or skin trophic changes. APS, on the other hand is a broader term used to describe conditions characterized by hyperalgesia and/or allodynia either without identified inflammation or tissue injury, or that is disproportionate to identified ongoing inflammation or injury. While less common than chronic headache and abdominal pain, CRPS and APS are becoming more prevalent in the pediatric population.

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There are several key concepts regarding the assessment and management of chronic pain conditions that may be helpful for providers. Foremost is putting into practice the understanding that all pain experiences involve a combination of physiologic phenomena as well as cognitive and emotional features. There is no such thing as pain being ‘in someone’s head.’ Even in frank conversion disorders, unintentionally conveying that a patient’s experience is psychologically based invalidates their current experience, risks major rupture in the provider-patient relationship, and more likely delays appropriate treatment rather than facilitates healing. It is hard to over-emphasize this point. One of the ways that mood issues can be addressed in the setting of chronic pain is to discuss the effects chronic pain can have on one’s emotions and thinking. Anyone dealing with life-altering pain conditions is invariably going to experience negative thoughts or emotions. Getting support for these issues doesn’t have to imply that they are the root cause.

Another key management issue is that opiate pain medications are rarely indicated in chronic pain conditions without identified tissue injury or when pain is highly disproportionate to underlying inflammation or injury. Not only are opioids ineffective in these situations, they often prolong the condition, can interfere with engagement in more effective strategies, and are complicated by issues of safety and misuse. In general, while opioid abuse issues are major concerns in the adult population, our experience is that this is much less common in the pediatric and adolescent population. In fact, such concerns may lead to inadequate pain management when opioids are clearly indicated but under-prescribed for children out of unfounded abuse fears.

Finally, how we talk about pain matters. This applies to any situation that involves sensory phenomena—whether acute injury, procedures, or chronic pain conditions. When a child hears “this will only hurt a little bit,” they have a strong tendency to filter out every word of that sentence except “hurt,” priming them to be on guard, frightened and self-protective. A simple alternative phrasing offers the possibility of a very different experience: “I don’t know whether this is going to bother that arm much or not.” Every nurse will tell you that they have had children receive vaccines who have surprisingly said afterward that they didn’t feel a thing! So how could we know what the child’s experience is going to be? Also, depersonalizing painful experiences can help children disassociate from an experience that can feel overwhelming. How long has that headache been bothering you? Reframing pain experiences and how the body works to address them is a key part of the recovery process in chronic pain conditions.

One helpful metaphor is the fire station alarm: When you call the fire department, how do the fire fighters know to get up and rush to the fire? The loud, clanging bell goes off and gets everybody up and

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Kids and Chronic Pain Continued from page 17 . . . going immediately. What happens after the fire’s been put out and they return to the station? Is the alarm still on? Sometimes, after a pain signal in our body has done its job, it gets stuck in the ‘on’ position. Does that leg still need to send that signal? Did you know there are ways to help those nerves settle down and begin to turn down the signal that is no longer needed? Such reframing of chronic pain signals can be very helpful for children and families.

Since pain experiences are so difficult to appreciate and describe, metaphor such as this offer a framework for understanding what is going on in a non-judgmental way. And it lays the groundwork for hope and improvement.

Multidisciplinary approaches to chronic pain management are the standard of care in most cases. Programs around the country usually offer some combination of physician, nurses, physical therapy and psychological care. In our clinic, we also offer acupuncture therapy, massage therapy, nutrition guidance, and a range of mind-body skills on a case-by-case basis. In addition to outpatient consultation and management, we have an inpatient pain rehabilitation program. Our Pediatric Amplified Pain Rehabilitation (PAPR) program is an intensive inpatient program consisting of physical therapy, occupational therapy, creative arts therapy, and psychotherapy to help patients disabled by CRPS or APS regain function.

While we are able to offer the PAPR program to patients for whom outpatient therapy has been ineffective in restoring function and relieving pain, the majority patients we see in our clinic achieve significant improvements in pain and function with multidisciplinary outpatient therapy.

While there is a role for pharmacotherapy in many chronic pain conditions, we have deliberately de-emphasized this here for two reasons. First, medication is utterly ineffective alone. In addition, most chronic pain continuing medical education (CME) offerings tend to focus on medication interventions before getting to the key concepts outlined here.

Dr. Becker is a Clinical Professor in the Department of Pediatrics and has faculty positions at the Pain Management Clinic at UCSF Benioff Children’s Hospital and the UCSF Osher Center for Integrative Medicine.

Part 2: Psychosocial Components of Assessing and Managing Chronic Pain in Children and Adolescents Chronic pain in children is a condition that requires comprehensive assessment and treatment. It is typically

thought of as lasting more than three months, is recurrent and persistent, and can interfere significantly with daily function. Common chronic pain conditions in children include headaches, abdominal pain, and musculoskeletal pain, with prevalence rates varying substantially in the literature. Adolescent girls are disproportionately affected by chronic pain conditions in pediatrics, though we see a number of boys and young adults at UCSF’s Pediatric Pain Management Clinic as well.

Psychosocially, there are a number of factors that contribute 18

to or maintain chronic pain for children and will influence the complexity of treatment. Environmental factors, family dynamics, internal cognitive processes, and psychiatric conditions are important factors to assess in treating pain conditions in pediatrics.

Because of the way pain is processed in the nervous system, children who live in highly stressful environments are believed to be more susceptible to or sensitive to pain because of the constant exposure to activating events stimulating “fight or flight” responses in their nervous system. So, asking about life stressors and exposure to traumatic life events is an important part of a pain assessment. Common life stressors that are seen with pediatric patients are academic pressure, conflict with peers, economic instability, and/or relational conflict between or with parents. Additionally, children who have been exposed to traumatic life events and suffer from chronic illness are uniquely positioned to develop pain syndromes because their body’s threshold for pain is often lower.

Asking about exposure to medical trauma, community violence, domestic violence, sexual abuse or assault, and other life threatening experiences is essential to a comprehensive pain evaluation and will help to identify the need for referral to trauma-informed therapy alongside pain management support.

In addition to learning about life stressors and traumatic events, understanding the child’s beliefs and feelings about their pain as well as any psychiatric co-morbidities such as depression and anxiety helps to alert clinicians of the likelihood that an acute pain crisis might transition into a chronic pain condition. It is well-established in the literature that the way a child perceives their pain will impact the probability that their acute pain may become chronic pain, and/ or their peripheral pain may become centralized pain. Specifically, children who have persistent fears that their pain means something is seriously wrong; children who feel helpless to cope with or manage their pain; and children who perseverate or over-focus on their pain will increase their likelihood of becoming disabled. These children may begin to avoid or withdraw from school, become socially isolated from friends and peers, and in some cases, lose significant physical function. Targeting a child’s beliefs about their pain therefore becomes an important part of treatment. Equally important is empowering the child to feel efficacious and confident in managing their pain, helping them to feel a sense of control over the pain and its impact on their quality of life.

Another central component to a pain evaluation is gathering information on the parent and family relationship to the child’s pain.

Knowing more about the parent and family’s behaviors will help to identify how much parent coaching or behavior management training is needed to undo habits interfering with a child’s function and health. A certain degree of parental distress is expected when a child is in pain because this is the natural empathic response of a caregiver, and with acute pain these automatic responses are quite adaptive. However, with chronic pain, such parental distress can become problematic. A number of studies have examined the impact of parent fears, worries, and anxiety about their child’s pain, and have found that parental distress mediates their child’s pain behaviors and contributes to impaired daily function. With chronic pain in children, a parent’s frequent inquiries about their child’s pain, beliefs that there continues to be something structurally or organically wrong with their child, and a parent’s general distress and anxiety can perpetuate the child’s functional disability. Clear education and reassurance from a primary care provider can really help parents

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to shift their attention and redirect treatment efforts from illness to wellness and can prevent a child’s functional decline. When a primary care physician can spend more time providing information and listening to parent fears and worries, it can help parents to move from searching for another diagnostic label or medical intervention toward helping their child regain function and a better quality of life.

Although the psychologist in our pain management clinic plays a large role in fully evaluating the psychosocial factors contributing to pain and dysfunction, all of the providers in our clinic ask about stressors in a child and family’s life, obstacles to regaining function, and how both the child and their family think about and understand the child’s pain. Learning about these factors helps each of our clinicians to educate families on the importance of psychotherapy, behavior management, and supportive counseling in the comprehensive treatment of pain.

Dr. Benki is a licensed clinical psychologist, who works with children, adolescents, and families as part of the IP3 team at UCSF Benioff Children’s Hospital in San Francisco.

Part 3: Nursing Assessment and Management of Chronic Pain in Children and Adolescents The role of nurses is integral to the interdisciplinary approach to pain management, particularly as the prevalence of chronic pain in children and adolescents increases. With the establishment of the Affordable Care

Act, the medical community has sought to improve patient access to care within the outpatient setting. In order to improve access to services and reduce patient reliance on emergency rooms and hospital admissions for their health-care needs, nurses play a critical role in the assessment and management of patients with chronic pain. Nurses conduct comprehensive pain assessments, offer recommendations, troubleshoot existing issues, and provide education as outlined by established triage protocols, which help prevent escalation to higher-acuity services.

With advancements in medicine, our communities are caring for more and more patients with complex medical histories and conditions. Numerous factors confound the medical picture and pose challenges to our ability to assess our patients’ pain accurately. We encounter discrepancies between a patient’s subjective pain score and their observable behavior. We know that other symptoms such as anxiety, fatigue or depression can be contributing factors to pain. Because of the complexity and difficulty in caring for patients with chronic pain, we are also encountering an increased number of pediatric patients who are opiate tolerant which make controlling their acute-on-chronic pain even more problematic. Moreover, the age ranges that fall under the umbrella of a pediatric patient can pose difficulties for accurately assessing pain if the appropriate validated pain scales are not utilized.

When pain increases or becomes unbearable, nurses are often the first point of contact during these moments of crisis. Appropriate nursing assessment and triage can help patients and families navigate the difficulties of acute-on-chronic pain flares and to support and facilitate their use of effective strategies to help them cope.

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Triage questions are employed to capture a comprehensive history of chronic pain and may include the following regarding a patient’s pain history: etiology, onset and duration, location(s), characteristics and qualities, intensity and severity, alleviating and aggravating factors, medication management history, efficacy of current pharmacologic and non-pharmacologic strategies, and impact of pain on mood and function.

Specific pain-related questions are only one part of a good nursing assessment as nurses utilize the nursing process to develop a plan of care for the patient. With the myriad of medications that patients are often prescribed, nurses diligently conduct a comprehensive pain evaluation, assess for unwanted medication side effects to decipher the signs and symptoms of over sedation, withdrawal, or under treated pain. In order to assess physiological and behavioral signs of unrelieved pain, nurses examine the child or adolescent for the following symptoms: presence of sweating, pallor, skin flushing, unusual changes in behavior, inconsolability, protection of surgical areas, apneic episodes, unusual sleep patterns, extreme irritability or extreme quietness and stillness. The presence of tremors, sweating, flu-like symptoms, vomiting, diarrhea or abdominal cramping would indicate the possibility of withdrawal.

Over sedation would present as drowsiness, somnolence, and even incontinence. Obtaining all relevant information from patients and families help nurses develop a comprehensive pain plan, and make the most informed recommendations while utilizing standardized pain management protocols. .

Such therapeutic relationships and support from nurses help to clarify and educate families on pharmacological and non-pharmacological management instructions given by their physician or specialist. The nursing care plan helps alleviate the patient’s and family’s anxiety, and provides opportunities for securing necessary medical assistance. With the innumerable challenges children with chronic pain face, it is important to support their use of evidencebased pain management tools and to facilitate both appropriate pharmacological interventions and non-pharmacologic integrative modalities. During acute calls with concerned parents, nurses can reinforce the plan of care, use of non-pharmacological strategies such as distraction, guided imagery and deep breathing exercises, as well as support their use of more tactile therapies like massage and acupuncture. Nurses can review and evaluate the strategies that have been effective for the patient in the past, which often helps to reduce anxiety for families in moments of crisis, and empowers them to utilize skills to minimize pain while maximizing function.

Utilizing the nursing process strengthens the therapeutic relationship between the family and their pain management team.

The relationship fosters collaboration, provides opportunities to re-evaluate the pain plan, manages patient and parent expectations regarding acute and chronic pain, and identifies the treatment modalities that best address the patient and parent concerns. More importantly, the relationship promotes and emphasizes the goal of wellness and functional status.

Caring for children with chronic pain requires the coordination of a multidisciplinary team. Here at UCSF Benioff Children’s Hospital Pediatric Pain Management Clinic, we recognize the complex needs of these patients and work collaboratively with physicians, nurse case managers, psychologists, and complementary

Continued on page 21 . . .

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Pain Medicine: Perspectives and Practices

INTEGRATIVE PAIN MANAGEMENT SF Health Network Program Expanding Options for Pain Treatment Barbara Wismer, MD, MPH The San Francisco Health Network is piloting a new pain management program for primary care patients. The program aims to improve patient function and

quality of life, reduce risk from opioids, and improve provider/ staff experience and burnout.

Chronic pain management is often a frustrating experience all around—for patients, for prescribers, and for staff. Chronic pain is a common problem that leads to much suffering and disability, yet there are few treatments that are effective and safe.

Opioids were a mainstay of treatment, but their use has fueled dramatic increases in opioid use disorder diagnoses and opioid overdose/death in the U.S. The evidence base for opioids and many other treatments is inadequate or underwhelming, and non-medication treatments are not always available or reimbursable, especially in the safety net.

Impetus for the program came from local statistics on opioid overdose deaths.1 An analysis of unintentional opioid overdose deaths in San Francisco from 2010 to 2012 revealed that ninety-four percent of the 331 deaths were from prescription opioids. This was 2.2 times the national average, 2.6 times the local rate of vehicular death, and 1.9 times the homicide rate in San Francisco. Deaths were concentrated in areas with high poverty rates and high numbers of single-room occupancy hotels. The response from the San Francisco Department of Public Health was to call for expansion of options for treatment of chronic pain, specifically, non-medication options. The Department also continued measures to improve opioid safety, such as registries and quality improvement efforts; policies and procedures; and education/training, technical assistance, and consultation.

Thus, the Integrative Pain Management Program (IPMP) was born. To develop the program, a Steering Committee was formed. The membership is multidisciplinary, mostly from different parts of the Department of Public Health, and includes leadership as well as front line staff. Most members have an interest and/or expertise in the area of chronic pain.

The committee provides input on and access to the IPMP structure, services, staffing, recruitment, evaluation, and grants. Patient input was also obtained—from interviews, focus groups, and an advisory board. Patients were asked about their hopes and goals, knowledge and experience, and motivation and barriers to chronic pain and its treatment. Patients were found to be knowledgeable and experienced with integrative treatments.

They wanted more options for treatment and felt that community and support from groups would be a plus. Finally, provider and staff input around the referral process and communication were obtained from focus groups and included the following recommendations: Have a uniform message for patients, and 20

have the program recommendation/referral come from the provider. The literature was also used to develop the program.

A multimodal approach to chronic pain management is the standard of care.2 This can include medications, procedures, psychological and physical treatments, and integrative modalities.

IPMP offers the latter three types of treatments (among which there is overlap), with the primary care provider and team managing the first two. IPMP includes evidence based treatments whenever possible, as well as promising practices with little evidence of harm that have not yet been rigorously studied.

Most IPMP services are offered in groups. These can not only be more efficient and allow more patients to be served, but provide social support and build community, reduce loneliness, and improve quality of life.3,4 Many patients in the safety net are isolated, without meaningful or positive connections or contact with family or friends. IPMP promotes active self-care whenever possible, given the importance of the patient’s role in her/his own healing.5 Active self-care allows ongoing treatment beyond the walls and time frame of the program and promote a healthy and healing lifestyle. Finally, IPMP includes health coaching.

Health coaches can assist patients to make behavior changes and are becoming an important component of primary care and chronic disease management. There is some evidence that health coaching can improve outcomes of patients with chronic pain.6 A neuroscience education framework is used. Neuroscience education aims to shift how patients, providers, and staff understand and talk about pain from a tissue oriented biomedical point of view to a nervous system oriented biopsychosocial point of view. Patient education can have positive effects on pain, function, disability, and catastrophization.7 The program also offers medication education to promote safer and more effective use of medications.

The IPMP pilot was launched in 2016 at Tom Waddell Urban Health Clinic (TWUHC). This site was chosen because of its location in a San Francisco neighborhood with high rates of opioid overdose deaths. As well, TWUHC has a large number of patients with chronic pain on opioids. Pilot services were offered weekly for twelve weeks. Services include: a “home” group; acupuncture (group and one-on-one); massage; one-on-one pharmacist visits; and health coaching (by phone). The “home” group provides education, skill building, support, and community, and includes movement and mindfulness components. The group is facilitated by a health educator and program coordinator. Sessions begin with a mindfulness exercise, followed by individual check-ins. There is a movement exercise midway through, then a topic of the day. Sessions end with each participant making a plan to incorporate what was learned and then a blessing. Topics

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include the nature of pain and treatment strategies; medications for pain; nutrition; and self massage. Initially, there is a session at which patients tell their “pain story.” There are several longer sessions for mindfulness and movement. The movement instruction is given by a certified yoga instructor and was developed with a physical therapist. It consists of low impact stretching and strengthening movements. The mindfulness instruction is given by a Zen priest with experience working with underserved populations. Instruction focuses on making mindfulness accessible (i.e., focus on the breath, short meditations, guided exercises) and useable (during movement or eating). Guest speakers at group include a pharmacist, who provides pain medication education, including opioid safety and naloxone.

Pilot objectives were: 1) to determine feasibility and acceptability of the program; 2) to improve patient function and quality of life; 3) to determine the impact of the program on opioid use; and 4) to improve provider/staff experience/burnout. TWUHC partnered with the University of California, San Francisco (UCSF) Osher Center to obtain a grant from the Mt. Zion Health Fund for the evaluation and some of the integrative services. Initial results show the program is feasible and acceptable: 146 referrals were received, and sixteen to twenty-three patients participated in each of the first three cohorts. Most patients tried each modality at least once: ninety-four percent movement; ninety-two percent mindfulness; sixty-nine percent massage; sixty-three percent acupuncture. Patients completing the program had high satisfaction levels, with average ratings of individual program components of 3.7-3.9 (4.0=completely satisfied) for the first three cohorts. Patient comments included: “It’s been remarkable to have this many people with similar issues, with profound suffering from pain and dealing with the side effects & stigma of taking opiates. This was so good for us.” “Over the twelve weeks I’ve learned to deal with my pain.” “I had an overall awesome experience and have made changes I learned in the program which have lessened my pain . . . You have changed me for the better.”

Preliminary survey findings of thirty-eight patients completing baseline and three month interviews show statistically significant improvements in physical functioning, pain interference, pain self-efficacy, satisfaction with social role, and anxiety/depression; there were no changes in fatigue, fear avoidance, or pain catastrophization. Further analysis is underway.

In the meantime, the program has lengthened to sixteen weeks and expanded to include any patient with chronic pain (on opioids or not) either from TWUHC or from a second clinic, Curry Senior Center. A behavioral health clinician has joined the program as a co-facilitator, and the “home” group now includes cognitive behavior and acceptance and commitment therapy.

There is a weekly “graduates group” with ongoing services and support. Planning for a second “hub” of services at Zuckerberg San Francisco General has begun. Our vision is to be able to offer the program to all Primary Care patients in the San Francisco Department of Public Health, and to create a support network of patients living with chronic pain. Ongoing evaluation results will be used to further modify the program to achieve our vision.

ity improvement lead, and currently is the lead physician of the Integrative Pain Management Program. She’s had an interest in chronic pain for many years, and has worked to improve chronic pain care and opioid safety through education, policies, quality improvement, and expanding non-medication treatment options.

References

1. Visconti AJ et al. Opioid Overdose Deaths in the City and County of San Francisco: Prevalence, Distribution, and Disparities. J Urban Health. 2015;92(4):758-772.

2. Dowell D et al. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. JAMA. 2016;315(15):16241645.

3. Geller JS et al. Impact of a Group Medical Visit Program on Latino Health-Related Quality of Life. J Science Healing.

2011;7:94-99.

4. Geller JS et al. Group Medical Visits Using an Empowerment-based Model as Treatment for Women With Chronic Pain in an Underserved Community. Global Adv Health Med. 2015;4(5):27-31 5. Crawford C et al. Effectiveness of Active Self-Care Complementary and Integrative Medicine Therapies: Options for the Management of Chronic Pain Symptoms. Pain Med. 2014;15: S86–S95.

6. Holden J et al. Health Coaching for Low Back Pain: A Systematic Review of the Literature. Int’l J Clin Pract.

2014;68(8):950-962.

7. Louw A et al. The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Arch Phys Med Rehab. 2011;92:2041-2056.

Kids and Chronic Pain Continued from page 19 . . . management and emotional needs are met. IP3 provides comprehensive acute and chronic pain management for pediatric inpatients and outpatients, as well as palliative care consultation and symptom management support. Our team provides expert consultative services across UCSF Benioff Children’s Hospital San Francisco and works collaboratively with providers from all medical specialties. We embrace innovative and integrative approaches to pain management, including biofeedback, massage therapy, guided imagery, acupressure and acupuncture, as well as regional anesthesia, such as epidurals and nerve blocks.

Lisa Purser serves as the Patient Care Manager of Integrated Pediatric Pain & Palliative Care (IP3), Pediatric Prepare and Pediatric Rehabilitation Services at UCSF Benioff Children’s Hospital.

Alicia Heilman is a licensed clinical nurse who serves as the nurse case manager for the Pediatric Pain Management Clinic at UCSF Benioff Children’s Hospital.

Barbara Wismer, MD, MPH has been a physician at Tom Waddell Urban Health Clinic in the SF Department of Public Health for twenty years. She has served as medical director and qualWWW.SFMMS.ORG

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Pain Medicine: Perspectives and Practices

CHRONIC PAIN MANAGEMENT Primary Care Burden to Public Health Crisis—The CDC Responds Joseph Pace, MD From 1999-2014, more than one hundred sixty five thousand people have died from prescription opioid overdose in the US—outstripping deaths from illicit substance

use. This trend mirrors the increased prescribing of opioid medications at high doses over long periods of time to treat chronic, noncancer pain (CNCP). Contributing factors include concerted efforts to answer concerns about the undertreatment of pain; aggressive marketing by pharmaceutical companies attesting to the safety of prescription opioids for long term use; escalating drug doses to address perceived tolerance to the drugs’ analgesic effect; lack of awareness of effective, non-opioid based pharmacologic treatments (e.g., select anticonvulsants and anti-depressants); and lack of access to effective non-pharmacologic treatments (e.g., cognitive-behavioral therapy (CBT)).

In March of 2016, the Centers for Disease Control (CDC) responded to this crisis with a set of Guidelines for Prescribing Opioids for Chronic Pain.1 The document assesses the evidence regarding the risks and benefits of using opioids in the treatment of CNCP in the primary care setting (outside of the setting of end of life). The authors acknowledge that there is insufficient evidence in many areas to guide practice, and, where there is evidence, it is often only of fair quality. Yet the sense of urgency to reverse the trend in prescription opioid-related deaths, the authors believe, outweighs the desire for higher quality data to guide practice at this time.

So what does the CDC conclude from the available science when it comes to the use of opioids in treating CNCP (defined as pain lasting greater than three months or past the time of normal tissue healing)? The document assesses the clinical evidence in five areas:

1. Effectiveness: There is no evidence to support the effectiveness of opioids for long-term therapy (> 1 year) of CNCP when it comes to impact on pain level, function or quality of life.

2. Risk: Long-term opioid therapy is associated with a dose-de-

pendent risk of abuse and overdose. Overdose risk seems to increase dramatically at doses as low as 50 mg morphine equivalents (MME)/day with a hazard ratio as high as 3.73 in some studies compared to doses less than 20 MME/day. Additionally, there is some evidence pointing to increased risk of cardiovascular events when using opioids.

3. Dosing: There is inconsistent evidence about the risk of using extended release/long acting (ER/LA) formulations compared with immediate release (IR) dosing. When compared to extended release morphine, this uncertainty extends to the use of methadone for CNCP therapy with evidence pointing to increased overdose risk, lower overall risk of mortality and no risk difference.

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4. Risk Prediction and Mitigation: Available tools to assess

opioid abuse and misuse tools at the initiation of therapy (e.g., Opioid Risk Tool and Screener and Opioid Assessment for Patients with Pain-Revised) have low specificity and sensitivity. No evidence exists to guide the use of Prescription Drug Monitoring Programs (PDMP), opiate management plans, urine drug testing (UDT), pill counts or abuse-deterrent formulations in mitigating the risk of misuse, abuse or overdose.

5. Acute Pain: There is evidence to suggest that the use of opioids in treating acute surgical pain or pain related to trauma increases the likelihood of ongoing use at one year.

Ultimately, the document’s final recommendations are based on “contextual evidence” in the following areas:

Nonpharmacologic and Nonopioid Pharmacologic Treatments: In studies lasting up to six months, CBT, exercise,

and combined movement and behavioral treatments (compared to single modality therapy) reduced pain and improved function. In addition, the document refers to several other guidelines that indicate non-opioid analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors); select anticonvulsants (gabapentin and pregabalin); and select antidepressants (tricyclics and serotonin norepinephrine reuptake inhibitors) as first or second line treatments. The potential harm of these medications (specifically, acetaminophen and NSAIDs) is considered to be substantially less than the risk of opioids.

Additional Data On Opioid Risk and Risk Mitigation:

Based on the review of additional studies not included in the clinical review, the authors take a firmer position on the disproportionate association of methadone in up to one third of opioid related deaths despite representing <2% of opioid prescriptions outside of opioid treatment programs. They also point to time-scheduled as opposed to as needed dosing of opioids leading to higher daily doses over time. Some additional risk factors for harm or overdose highlighted include: coprescription of benzodiazepines, sleep apnea, renal or hepatic insufficiency, age > 65, depression, and substance abuse/dependence.

When it comes to risk stratification, the authors suggest that PDMP and UDT, while not supported by clinical evidence, may help identify situations that are high risk for harm or overdose. They do, however, acknowledge the limitations of these tools including the cumbersome nature of using PDMPs and the potential for misinterpretation of UDT results potentially leading to inappropriate clinical decisions.

When it comes to risk mitigation, the authors extrapolate from the successes of naloxone distribution in community-based over-

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dose prevention programs targeted to substance users in lowering overdose deaths as a potential strategy for decreasing overdose from prescription opioids. Finally, the authors found little to no evidence at this point to substantiate the concern that changes in opioid prescribing practices may lead to unintended increases in the use of heroin or illicitly obtained opioids.

Provider and Patient Perspective: Faced with the dilemma of trying to address the increase in prescription opioid-related deaths in a setting of little to no high quality data, the authors review provider and patient perceptions about opioid therapy for CNCP. Providers are worried, frustrated, and lack confidence in addressing concerns about opioid risk with their patients. In turn, patients are concerned about “addiction,” report high levels of side effects, and are unsure about the overall benefit of opioid therapy when there is little else is available to treat their symptoms.

Cost: The authors point to the high direct and indirect costs of

prescription opioids including prescription expenses; costs of opioid-related overdose; and costs related to abuse, dependence and misuse compared with costs of non-pharmacologic and non-opioid based pharmacologic therapies.

Recommendations

When it comes to distilling the evidence into recommendations for clinical practice, here, too, the authors feel that the crisis regarding prescription opioid related deaths outweighs the lack of compelling, gold-standard level evidence.

Here is my take on the extensive recommendations:

Providers should have a systematic approach to opioid prescribing: proceeding with caution; identifying a clear and compelling indication to prescribe opioids; and being frank with patients about what we know about the risks and benefits of these treatments. After all, they are worried about the risks of opioids as well.

When providers choose opioids, they should be used at the lowest effective dose. While the guidelines stop short of naming a dose ceiling, the increase in overdose risk at > 50 MME/day is repeatedly mentioned. Furthermore, the recommendation is to avoid increasing dosage > 90 MME/day without clear and compelling justification. IR opioids are favored over ER/LA formulations at the start of therapy.

Methadone and transdermal fentanyl should not be first line choices.

The guidelines raise questions about the use of both ER/LA formulations along with as-needed IR dosing for so called “breakthrough pain.”

For those patients already at high doses, the recommendation is to review the evidence of increased risk and discuss tapering to a safer dose. When tapering, go slow, about ten percent per week, and allow for pauses in the taper if patients are experiencing withdrawal symptoms. Tapers may be accelerated if there is very high risk for overdose. Tapers are not necessary if there is compelling evidence of total diversion. Opioids should be used as part of a multimodal treatment strategy that includes evidence-based non-pharmacologic and non-opioid medications. Clear goals should be established at the outset for assessing risk and benefit of ongoing treatment, along with an “exit strategy” if risk outweighs benefit or if there is no benefit.

As risk of opioid misuse or overdose is hard to predict, providers should take a “universal precautions” approach to monitoring and mitigation strategies that involve frequent and regular followWWW.SFMMS.ORG

up. Here the guidelines recommend follow-up within the first four weeks of start of therapy and at least every three months thereafter.

In addition, the guidelines recommend checking the PDMP before the start of therapy and at least every three months thereafter. UDT should be obtained before the initiation of therapy and at least annually thereafter. One final mitigation approach is the risk based co-prescribing of naloxone (e.g., history of overdose, history of substance use disorder, high opioid dosage (> 50 MME/day), concurrent benzodiazepine use, which should be avoided whenever possible).

When treating acute pain, the recommendation is limit opioids to three days or less, and not more than seven days in rare circumstances. If during the course of therapy, opioid use disorder is diagnosed, providers should offer or arrange for patients to access medication-assisted treatment with buprenorphine or methadone.

Commentary

Depending on one’s clinical setting, these guidelines may align to varying degrees with already established standards. More likely, though, is that current clinician practice varies greatly from these guidelines. As such, greater provider and patient education, awareness, and technical assistance may be needed to successfully transform the use of opioid therapy in CNCP treatment. As overwhelming as continuing to treat CNCP as we have been as a medical community is, changing practice may feel more overwhelming. This will take time.

After all, it took us almost twenty years to come to this point. Whatever you may think of the strength of the arguments for change in opioid prescribing practice, it is clear that change is here. In closing, I offer these thoughts and calls to action as a way to guide our way forward in a process that will overhaul the way we treat CNCP in the years to come—hopefully to the benefit of our patients and communities: • We want to advocate for payors and other stakeholders to support the creation of payment models to support evidence-based non-pharmacologic therapies.

• When we make a change in our practice, we want to be transparent with our patients about why we are making the recommendations we’re making.

• We want to reach out to our colleagues within our practices; acute, specialty and tertiary care settings; and other community stakeholders to craft a consistent, compassionate and comprehensive approach to pain management that focuses on safety and well-being.

• We don’t want to refuse to write another opioid prescription.

Despite the risks, there are still compelling indications for the use of opioids in treating CNCP. • We don’t want to make sudden changes in the treatment plan that leave patients feeling judged, blamed, abandoned, or mistrusted. After all, they didn’t create this problem. We need their trust and they need to know our commitment is steadfast in order for us to back out of this crisis together with the least harm possible.

Joseph Pace, MD, is San Francisco Health Network Director of Primary Care Homeless Services and Medical Director, Tom Waddell Urban Health. He is co-chair of the San Francisco Safety Net Pain Management Work Group. He also co-hosts City Visions, a “thinking person’s talk show” on KALW-FM public radio. This article originally ran in 2016.

Reference Dowell, D.; Haegerich, T.; Chou, R. “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016.” MMWR 65(1):1-49 JUNE 2017 SAN FRANCISCO MARIN MEDICINE

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PAIN MANAGEMENT AT UCSF Serving Bay Area Patients Mario De Pinto, MD, George Pasvankas, MD, Xiaobing Yu, Lawrence Poree, MD, Sue Gritzner Psy D, Mark Schumacher MD, PhD Since opening its doors in 1987, the University of California, San Francisco (UCSF) Pain Management Center (PMC) has been a point of reference for Bay Area’s patients suffering with pain conditions. Under the auspices

of the UCSF Department of Anesthesiology and Perioperative Care, the PMC is becoming one of the most respected centers for pain care in the U.S., offering multidisciplinary care for management of acute and chronic pain to more than eight hundred patients every month.

The Medical Director of the Pain Center is Dr. Mario De Pinto, an Anesthesiology trained physician who trained at the University of Washington, considered the birthplace of modern pain medicine.

Under Dr. De Pinto and Dr. Mark Schumacher’s, Chief of the UCSF Division of Pain Medicine, guidance, the PMC has grown and expanded its services over the last four years thanks to the dedication and expertise of its faculty and staff.

The PMC’s guiding principle is to help patients regain function and improve their quality of life with the minimal amount of medications. We limit the use of opioids as much as possible and try to maximize the use of non-pharmacological and non-opioid pharmacological interventions whenever possible. We work together with referring and primary care physicians in providing guidelines and suggestions for patients who need long term pain management.

The PMC faculty provide a different variety of services that include: • Consultation for comprehensive medical management of acute and chronic non-malignant pain conditions (spinal pain, abdominal and pelvic pain, headaches, neck and facial pain, musculoskeletal and neuropathic pain syndromes, post-surgical pain).

• Comprehensive management of cancer-related pain including post-chemotherapy pain.

• Psychological services including biofeedback, cognitive and behavioral therapies, relaxation techniques, education, and mindfulness meditation.

• Fluoroscopy guided epidural steroid injections, transforaminal nerve root injections, facet joint and sacro-iliac joint injections, sympathetic blocks (stellate ganglion and lumbar plexus), radiofrequency ablation procedures, ultrasound guided peripheral nerve, joint, and trigger point injections.

• Diagnostic and neurolytic visceral plexuses blocks (celiac, splanchnic, superior and inferior hypogastric, ganglion impar).

• Neuromodulation interventions. Neuromodulation is the application of technology at the neural interface. The PMC providers perform trial and placement of implantable devices (Spinal Cord and Dorsal Root Ganglion Stimulation systems, Intrathecal delivery systems). The development of smaller and more effective devices over the course of the last five years has allowed the pain practitioner to treat complex and challenging cancer pain syndromes, post-chemo24

therapy pain, post-surgical pain, complex regional pain syndrome (CRPS type 1-2), post-herpetic neuralgia, and other nerve injury related pain conditions.

Dr. Lawrence Poree, a leader in the North American Neuromodulation Society (NANS), directs the PMC’s effort in neuromodulation. Promising ongoing research in the area of pain biomarkers and closed-loop control of neuromodulation devices will permit an expansion of the number of patients that can benefit from this type of therapy.

Often faced with patient referrals for rare painful disorders, Dr. Xiaobing Yu is a PMC faculty leading a clinical study of patients suffering from Fibrodysplasia Ossificans Progressiva (FOP), a rare autosomal-dominant disorder characterized by sensory hypersensitivity.

He is conducting quantitative sensory testing in these patients with the hope that their underlying genetic mechanism would provide insight into the treatment of neuropathic pain.

The PMC Clinical Pain Psychologists led by Dr. Sue Gritzner, evaluate the emotional, cognitive and social aspects of the patients’ experience with pain and how these factors may impact participation and benefit from various treatments. It is well known that psychological factors (depression, anxiety, PTSD, catastrophizing) are more common in the chronic pain patients than in the general population and will impact the outcome of various treatment modalities. These factors must be identified and addressed in order to obtain the maximum benefit. Pain Psychologists also provide treatment aimed at addressing the psychological factors associated with pain through a range of therapeutic strategies provided both in individual and group settings.

Building on a core faculty boarded and certified in Anesthesiology and Pain Medicine (ABA), we continue to broaden our interdisciplinary approach with the recent addition of pain physicians with backgrounds in Family Medicine and Neurology. Together with the Pain Psychologists we form an integrated team of experts to provide comprehensive pain care.

The UCSF Pain Management Center sponsors one of the premier Pain Medicine Fellowships training programs in the U.S. through the Department of Anesthesia and Perioperative Care. Dr. George Pasvankas serves as the Pain Medicine Fellowship Program Director.

The American Council for Graduate Medical Education (ACGME)accredited Pain fellowship program trains five future pain medicine practitioners and leaders in the field each year. A multidisciplinary training program that includes physical and psychological rehabilitation, complementary and integrative modalities, multi-modal pharmacologic treatments, and different interventional pain management techniques is emphasized. Every year the Fellows in our program are chosen from a pool of highly competitive and diverse applicants. We are very proud that one of the most recent additions

SAN FRANCISCO MARIN MEDICINE JUNE 2017 WWW.SFMMS.ORG

to the PMC Faculty is one of our former Pain Fellowship graduates with background training in Family and Community Medicine. As a leading medical institution, we have also developed a new curriculum to enhance pain education for both residents and medical students. Teaching is provided by a core faculty with backgrounds in anesthesiology and interventional pain management, neurology, family and integrative medicine, and physiatry. Associate faculty within and outside the Division include expertise from Psychiatry, Addiction Medicine, Palliative Care, and Physical Medicine & Rehabilitation, all of which are an integral part of the training program.

In conclusion, the UCSF Pain Management Center represents a unique resource for comprehensive pain care for Bay Area residents. Innovation and integration of care supported by the latest

research allows our dedicated faculty to provide the much-needed hope to some of our most challenging patients. With the unwavering support of the UCSF Department of Anesthesia and Perioperative Care and the Division of Pain Medicine, the PMC will continue to remain a bastion for the relief of pain and suffering for years to come.

Dr. Mario de Pinto was born and raised in Rome, received his MD at the University of Rome in 1985, trained in Surgery, and practiced general surgery for five years. He relocated to U.S. in 1995 and trained in Anesthesiology and Pain Medicine at the University of Washington. He worked at the University of Washington for nine years until 2013 when he moved to SF to become the Medical Director of the UCSF Pain Management Center.

SAVE THE SAFETY NET California Medical Association, California Dental Association and Planned Parenthood of California Call on Governor and Legislature to Keep Promise to Medi-Cal Patients As Washington, D.C., threatens affordable care, California must invest tobacco tax revenues and draw down federal matching funds to protect health care for the state’s most vulnerable.

As the passage of the American Health Care Act (AHCA) by the U.S. House threatens to slash Medicaid funding and defund Planned Parenthood, California’s leading health care providers are fighting to ensure Congress protects patient access to the vital services provided by Medicaid and community clinics.

An equally important battle is being waged here in California.

More than one third of all Californians struggle to access dentists, physicians, and clinics as a result of the state’s underfunded Medi-Cal program.

The California Dental Association (CDA), California Medical Association (CMA) and Planned Parenthood Affiliates of California (PPAC) call on Governor Jerry Brown and the State Legislature to invest tobacco tax revenues (Proposition 56) in a manner that is consistent with the law: to expand patient access to the essential health care services provided by community clinics, dentists and physicians, and draw down the maximum matching federal dollars.

“Now, more than ever, California must act to protect and improve health care throughout our state,” said Kathy Kneer, PPAC President and Chief Executive Officer. “Defunding Planned Parenthood and preventing us from providing preventative and reproductive care to more than 850,000 Californians is a win for the regressive policies of the Trump Administration. By not investing tobacco tax revenues to improve health care access, California is leaving a billion dollars in federal matching funds on the table—and in the hands of the Trump Administration.”

Instead of improving access to care for the 14.3 million Californians served by Medi-Cal, the current budget proposes to use tobacco tax funds to backfill a cut to the state’s general fund contribution to the program. This plan does nothing to improve California’s health; it maintains the status quo and adds more patients to the back of the line in already overflowing waiting and emergency rooms.

“Tobacco tax funds must be used to improve outcomes for the WWW.SFMMS.ORG

most vulnerable patients of our state: like the patient who needs prompt access to chemotherapy but is stuck on a six-month waitlist.

Or the young woman in the Central Valley who has to drive fifty miles for dependable access to family planning services,” said CMA President Ruth Haskins, MD. “As the Trump Administration reneges on its promise of providing affordable health care for all Americans, it’s more important than ever that California fulfill its duty to the voters and apply tobacco tax revenues to help our patients.”

There are well-documented barriers to care within Medi-Cal and Denti-Cal. Sixteen California counties have no Denti-Cal providers or none able to accept new patients. More than fifty percent of Medi-Cal patients have reported difficulty getting in to see a specialist. And increasingly, community clinics are forced to close their doors due to severe underfunding.

“Denti-Cal is chronically underfunded and many Californians have difficulty accessing care,” said CDA President Clelan Ehrler, DDS, MS. “More than a third of California’s population, including sixty percent of children, are enrolled in Denti-Cal, which is why we need to use tobacco tax revenues as voters intended—allowing more providers to participate in the program to ensure enrollees can access care when they need it.”

The California Medical Association (CMA) represents the state’s physicians with more than 43,000 members in all modes of practice and specialties. CMA is dedicated to the health of all patients in California.

The California Dental Association (CDA) is the non-profit organization representing organized dentistry in California. CDA’s membership consists of more than 27,000 dentists, making it the largest constituent of the American Dental Association.

Planned Parenthood Affiliates of California (PPAC) is the state public policy office representing California’s seven Planned Parenthood affiliates. PPAC promotes sound public policy in areas of reproductive and preventive health care, family planning and comprehensive sexual health education.

For more updated information, see CMA.net.

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MEDICAL COMMUNITY NEWS CPMC

Edward Eisler, MD

Kaiser Permanente

SFHN

Arthur Wood, MD

Maria Ansari, MD

The California Pacific Medical Center (CPMC) was among six Sutter Health hospital campuses to earn “A” grades for patient safety from The Leapfrog Group® in its Spring 2017 Hospital Safety Scores. More than 2,600 hospitals nationwide participated in Leapfrog’s Hospital Safety Score program, which grades hospitals on their overall performance in keeping patients safe from preventable harm and medical errors. The letter grades were calculated from thirty evidence-based national measures of hospital safety.

Kerry Egan, best-selling author of the new book “On Living”, gave attendees at a special CPMC presentation a glimpse into her life as a hospice chaplain. Ms. Egan’s inspiring presentation, which was part of the CPMC Ungerleider Palliative Care Lecture Series, took place last month. Her talk included stories from her patients and guidelines on how to act with the same sense of urgency the dying feel. Ms. Egan is a hospice chaplain and a graduate of Harvard Divinity School. Her work has been featured on NPR, PBS and CNN, and her essays have appeared in Parents, American Baby, Reader’s Digest, and CNN, where they have been read more than two million times.

In a recent article published in the New England Journal of Medicine, CPMC Research Institute researchers, Dr. Steven Cummings and Dr. Michael Rowbotham, discuss how electronic informed consent and Internetbased trials can expand the possibilities for broader and more knowledgeable participation in clinical trials. Drs. Cummings and Rowbotham cite studies showing that participants are also more likely to recall key facts with e-consent than with paper-based consent forms. Conducting trials through the Internet also makes them accessible to a broader range of people. By allowing anyone with Internet access to participate, individuals who live far away from research sites can join a study without having to make regular visits.

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The clinicians and staff of the Interventional Pain Clinic at Kaiser Permanente San Francisco manage chronic pain in collaboration with a patient’s primary care provider and the Chronic Pain Department. The Interventional Pain Clinic performs cutting edge procedures to treat chronic pain, one of the newest being a procedure that provides electrical stimulation of the dorsal root ganglion.

Electricity has long been used to treat nerve pain. The ancient Greeks used the electric current of the torpedo fish to treat headaches and the pain of childbirth. Electrical stimulation of the spinal cord has been used for more than thirty years, and spinal cord stimulation is successful in treating cervical and lumbar radiculopathies as well as postlaminctomy syndrome.

Electrical stimulation of the dorsal root ganglion of the nerves innervating these structures provides pain relief superior to spinal cord stimulation. The dorsal root ganglion is the cell body of the peripheral nerve and it plays an integral role in peripheral and central sensory processing of inflammation, somatic pain, and nerve pain.

Targeting the dorsal root ganglion is done via an interlaminar approach using a special stimulating lead, which is steered toward the foramen and over the dorsal root ganglion. Trial leads are first placed and if the trial leads are successful in relieving pain, then permanent leads as well as a battery is implanted. Special training is required to perform the procedure and we are currently are collecting outcome data to determine overall success. At Kaiser Permanente San Francisco, we’re proud to provide this new treatment for our patients coping with chronic pain.

The San Francisco Health Network (SFHN) is expanding treatment options for patients with chronic pain with several new and exciting services. These programs aim to improve safety, patient outcomes, as well as provider and staff experience.

In an attempt to streamline care delivery and offer cutting edge services, Zuckerberg San Francisco General Hospital’s Department of Anesthesia launched the Pain Management Center (PMC) in 2016. The PMC houses a diverse group of providers with training in anesthesiology, internal medicine, palliative care, pharmacy, and nursing. Providers see patients in a newly renovated clinic where they offer consultation for medication management, procedural intervention, physical therapy, and behavioral health. Over the last fifteen months, the clinic has improved wait time for appointments from four months to less than three weeks. In addition, the volume of the clinic has risen from approximately fifteen to seventy patients per month, highlighting the demand for multidisciplinary pain services.

To provide more complete wrap around services, the Department of Anesthesia will also offer a hospital based Acute Pain Service.

Launching this summer, the service will consist of an anesthesiologist, nurse practitioner, and pharmacist that help manage hospitalized patients with difficult to control pain.

Finally, in response to the opioid overdose epidemic, Tom Waddell Urban Health Clinic piloted the Integrative Pain Management Program. This program offers non-medication treatments for chronic pain to primary care (PC) patients. Services include: a weekly group; acupuncture; massage; movement; and mindfulness. Initial results are promising. Further evaluation is underway, and planning for expansion to a second hub has begun. (See related article in this issue for further details.) With these interrelated initiatives, SFHN’s goal is to improve access to non-opioid pain options for some of San Francisco’s most vulnerable patients.

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UPCOMING EVENTS CLASSIFIED ADS Monitoring: What Wellbeing Committees Need to Know June 24, 2017 9:00am – 12:00pm | ACCMA, 6230 Claremont Avenue, 3rd Floor, Oakland, CA You're invited to attend the half-day workshop designed to cover the core information that wellbeing committees need to know about monitoring. CPPPH offers this workshop as a service to those with roles in physician health activities and roles related to peer review, credentialing and privileging in hospital medical staffs, medical groups, specialty societies and county medical associations. No CME credit is offered. Members of the medical and specialty societies that support CPPPH receive a discounted rate.

For more information or to register, visit http://bit.ly/2pD8tyY.

Essentials for Primary Care Pain Management

September 16-17, 2017 | 4610 X Street, Sacramento, CA The UC Davis Center for Advancing Pain Relief is hosting a twoday CME conference for primary care clinicians. The program integrates recent scientific data with current clinic practice regarding pain management. Topics include responsible opioid prescribing, pain and mental health, and pain management essentials. Participants will also learn about the management of co-morbid conditions and the integration and coordination of pain management within primary care. Buprenorphine training available. For more information, or to register, visit http://bit. ly/2qjXSb6.

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Practice for Sale - Fertility Clinic, Santa Rosa.

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Practice for Sale -Psychology and Psychiatry Practice, SF Bay Area. Highly profitable, 3-location clinic providing specialty counseling with an emphasis on Workers’ Compensation issues. Referrals from numerous carriers, employers, occupational injury clinics, and attorneys have supported annual growth in revenue averaging 25% over last few years, now at $1.6 million. Eight professionals on staff in addition to the selling doctor. Seller will stay for smooth transition.

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Practice for Sale - Phlebology – Vein and Cosmetic Dermatology, Walnut Creek. Revenue $1.3

million on 4 MD days/week. Five exam rooms in 2500 square feet in beautiful building close to hospital, freeway, and mass transit. Great potential for growth and expansion. Owner can stay to work part-time and mentor new owner in full range of non-surgical treatment techniques. Committed, knowledgeable staff would like to stay. Third-party appraisal available. Photos available. Offered at only $290,000. info@medicalpractices. com. 800-576-6935. www.MedicalPracticesUSA.com.

Renewed Interest in Biopsychosocial Tx for Chronic Pain

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Insurance coverage still a battle, but that may change given the country's opioid crisis Studies suggest the programs can be quite effective. The Brooks Rehabilitation pain program in Jacksonville, Fla., reports that six months after intensive treatment, nine out of ten patients reported improvements in quality of life and three out of four felt decreased levels of pain. The center reported that just six percent of patients who were weaned off of opioids during the program resumed taking them afterwards.

Reprinted from Medpage Today - by Meghana Keshavan www.medpagetoday.com/painmanagement/painmanagement/65665

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San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133

CALIFORNIA MEDICAL ASSOCIATION FIGHTING TO ENSURE FEDERAL HEALTH REFORM

IMPROVES PATIENT ACCESS TO PHYSICIANS Long before President Donald Trump began campaigning to repeal the Affordable Care Act (ACA), the California Medical Association (CMA) and it’s county medical society partners began fighting for access to health care for all Californians. In fact, access to quality health care has been a core tenet of CMA for many decades.

CMA, which represents over 43,000 physicians across all modes of practice, believes access depends on affordable, quality coverage and reflects the ability of patients to secure appointments with doctors (promptly) for preventative care and when catastrophic circumstances occur.

As Congress embarks on the latest health reform debate, CMA remains committed to working with Congress and the Trump Administration to develop a plan that ensures patients can access doctors to receive high-quality and affordable health care.

CMA is standing by its core health reform priorities, which are to: •

Improve access to physicians

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Protect state and federal Medicaid funding

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Ensure Californians do not lose coverage

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Provide affordable coverage, particularly for low- and moderate-income families

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Eliminate administrative and regulatory burdens in the Medicaid and Medicare programs

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Provide a choice of insurers, HSAs and physicians.

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Maintain reforms on the insurance industry – coverage for preexisting conditions, 85 percent medical loss ratio and no annual/ lifetime limits on benefits

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Stabilize the individual insurance market

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Provide access to affordable prescription drugs

For more information, visit www.cmanet.org.

Medicaid funding must be protected and increased to care for America’s most vulnerable populations, and more work must be done to deliver access to doctors and affordable, quality care.”

Ruth Haskins, M.D., CMA President